Eating as a problem

By Nicole Schuster / Eating disorders are the most common mental illness among children and adolescents. If left untreated, they can become chronic and even fatal. Depending on the degree of severity, outpatient or inpatient therapy is required. The family should also be involved.

The question of the "right" body weight and the fear of being fat are already preoccupying children. The distorted perception of many adolescents regarding their figure is shown by a look at the Internet. There they uninhibitedly mock friends or celebrities who have a little more on their ribs in a picture. At the same time, questionable trends are emerging, especially among young women, such as the "thigh gap," in which a gap must be visible between the thighs when the person stands up straight with closed legs. In the officially banned pro-ana ("for" anorexia nervosa) and pro-mia ("for" bulimia nervosa) forums, sufferers glorify anorexia and binge-eating addiction and compete on how best to eat as little as possible or how to break food most efficiently. Many children and adolescents become very insecure as a result and no longer know what a healthy body weight actually is.

Anorexia mainly affects young women. <p Fotolia/Westend61</p>

Anorexia mainly affects young women.

BMI and percentiles

Experts use body mass index (BMI) to assess body weight (Table 1). This is calculated by dividing the body weight in kilograms by the height in meters squared: BMI = body weight [kg] : height [m] 2 .

Depending on age, underweight, normal weight and overweight are defined differently and further subdivided into different degrees of severity. A weak point of the BMI is that it does not sufficiently take into account the relationship between fat and muscle mass. Since muscle weighs more than fat, very muscular people can have a BMI in the overweight or even obese range with a low fat percentage.

Instead of the BMI value, the BMI percentiles serve as a guideline for children and adolescents. They take into account the changing body composition as they grow (1, 2).

More and more young people are becoming ill

The obsessive preoccupation with one’s own weight can lead to -disturbed eating behavior. Even if the general perception suggests that eating disorders are on the rise, an increase cannot be confirmed, at least not scientifically.

In 2005, a study showed that from 1988 to 2000, the rate of anorexia cases remained relatively constant, while the incidence of bulimia increased, especially around 1996, but then decreased (3, 4). A Dutch study came to similar conclusions in 2015 (5). It is possible that societal factors play a role in the ups and downs. For example, the increase in -bulimia in the 1990s coincides with the late Princess Diana’s confession of illness (3).

Table 1: Classification of weight

Classification BMI (kg/m 2 )
high degree

It is striking that among the patients there are more and more young people. The highest risk of both anorexia nervosa and bulimia nervosa is in young women between the ages of ten and 19 (4). If the onset occurs before or during puberty, the consequences can be particularly severe, as natural physical development can come to a standstill. As with older patients, the diseases can lead to death, such as circulatory failure or cardiac arrest.

Anorexia: The less the better

The best known eating disorder is anorexia nervosa or anorexia. It is estimated that about 1 percent of adult women and 0.3 percent of men in Germany have the condition (6). Only few data are available for children and adolescents. In 2012, an American study found a prevalence of about 0.3 percent for girls and boys between the ages of 13 and 18 (7). A high number of unreported cases is assumed.

Patients with anorexia compulsively attempt to lose weight and/or maintain severe underweight through restrictive eating behaviors. For the diagnosis, the individual weight must be at least 15 percent below the expected weight based on sex, height and age. In children and adolescents up to 18 years of age, this corresponds approximately to being below the 10. BMI age percentiles and, in adults, a BMI less than 17.5 kg/m 2 (3).

Fit, fitter, sicker

Less well known are anorexia athletica and orthorexia nervosa, a pathological "healthy eating" disorder.

Anorexia athletica manifests with symptoms similar to anorexia, with a strong compulsion for physical activity. The disorder mainly affects competitive athletes who want to become more successful through it. An important difference from anorexia nervosa is said to be that sufferers do not have a body schema disorder and are able to eat normally again after intense periods of exercise. The disturbed eating behavior in combination with extreme physical activity, however, is an immense burden with consequences such as osteoporosis, amenorrhea in women and loss of performance due to lack of energy (15).

A Orthorexia nervosa is characterized by an almost obsessive attempt to eat only "healthy" foods and a real fear of other foods. Malnutrition and underweight are a common consequence. The physical effects can manifest similarly to anorexia nervosa as osteopenia, anemia, hormonal imbalances, and bradycardia, among others (16, 17).

Both social factors, such as the ideal of thinness in Western countries, and a genetic predisposition favor the development of anorexia nervosa. Patients are often perfectionistic and have low self-esteem. On a biological level, there is evidence for possible disturbances in the reward system and affect regulation. In addition, triggers within the family could play a role. The disease possibly breaks out so often during puberty, as adolescents try to separate themselves through it, exercise self-control and form their own identity.

Problems with puberty-associated physical changes can also play a role. Sports that are aesthetically influenced, such as gymnastics, figure skating, or ballet and dance can increase the risk of disease, as can those such as boxing or judo, where there are weight restrictions depending on the class, or endurance sports (1, 3). There is even a disorder called sports anorexia (Box).

Fixated on (non-)eating

Eating as a problem

Among the most important symptoms is that patients’ thoughts revolve non-stop around food, calories and weight, and their interest is greatly reduced. Their eating plan is usually restrictive; high-calorie, high-fat, and high-sugar foods are prohibited. Rituals such as ex-tremely slow chewing or eternal delaying of eating are added. Food deprivation causes a -feeling of euphoria, lightness, and elation, while they perceive eating as failure.

In order to lose weight and avoid gaining weight, patients often engage in excessive (endurance) sports, induce vomiting or abuse laxatives (Table 2). There are overlaps here with bulimia nervosa. Experts therefore divide anorexia nervosa into a restrictive and a bulimic type (1, 2, 3).

Massive malnutrition causes children to delay or halt pubertal development. In girls, menstruation is absent or does not start at all. The bones lose substance and the risk of later developing osteoporosis increases. Heart rate and metabolism slow down, blood pressure and body temperature drop, sufferers freeze constantly, become more susceptible to infections, and even lose brain matter. Gastrointestinal complaints, such as constipation, and disturbed regulation of the feeling of hunger and satiety are other frequent consequences. Signs of severe malnutrition are the formation of lanugo hair, which are small downy hairs on the back, while the hair on the head tends to fall out, as well as brittle nails and dry skin.

Possible psychological consequences include a strong need for control, increased anxiety and a compulsion to constantly compare oneself with others. Avarice, self-hatred and guilt, and depressive moods may also occur (1, 3, 8).

Anorexia is difficult to cure

Not eating an ounce too much and keeping everything under control: That is the most important thing for many anorexia patients. <p Shutterstock/Mihai Simonia (left),Fotolia/Westend61</p>

Not eating an ounce too much and keeping everything under control: This is the most important thing for many anorexia patients.

Photos: Shutterstock/Mihai Simonia (left),Fotolia/Westend61

The therapeutic limits and possibilities are described by Professor Dr. Tanja Legenbauer from the LWL University Hospital Hamm for Child and Adolescent Psychiatry in Bochum, Germany. "In order to get well, patients must do the very thing that scares them the most and that they partout to avoid – eating and gaining weight."

Psychotherapy is the treatment method of choice. For children and adolescents, the family should be involved in therapy. The effectiveness of psychotropic drugs in anorexia is not proven. The atypical antipsychotic olanzapine is sometimes used (temporarily and off-label), for example in cases of excessive urge to move and severe brooding.

Without a clear understanding of the illness and the will to get better, doctors cannot help sufferers in the long term. Even if they are aware of how threatening their condition is, recovery is difficult. A body schema disorder, i.e. the feeling of being (too) fat even in an emaciated state, has a disease-maintaining effect.

"One goal of therapy is to work on the negative irrational beliefs about food and the body and reward weight gain," explains the expert. "The shorter the duration of the illness, the better the chances of success, in general."Factors such as a very low weight, comorbid mental disorders, or severe family stress are prognostically negative," he said.

Weight gain is most important for treating most of the physical effects of being underweight. Comorbid mental disorders, however, usually require separate therapy. "There may even be a shift in symptoms. If the eating disorder improves, obsessive-compulsive symptoms, for example, can increase," says the expert. This is because underlying problems have not yet been worked through and skills for coping with everyday life are lacking.

Relapse prophylaxis is necessary because patients often do not remain stable for long after outpatient or inpatient therapy. Only 50 to 75 percent recover in the long term. In about 14 percent, the disease becomes chronic. Within 20 years, almost 15 percent die. Mortality in anorexia nervosa is thus the highest among mental illnesses (1, 3, 9).

Bulimia: life between the refrigerator and the toilet

Data from America are available on the frequency of binge eating among adolescents between the ages of 13 and 18; according to these data, about 0.9 percent of girls and 0.3 percent of boys are affected (7). Patients are often perfectionistic, but at the same time suffer from severe self-doubt. The suppression of physical needs and a family environment in which conflicts are handled in a dysfunctional manner can also promote the development of the disease.

Table 2: Frequent counteractive measures (purging behavior)

Measure Specificity
Vomiting After meals
Purging Non-indicated use of laxatives
Sports excessive physical exertion, for example, jogging, sit-ups, push-ups, bicycling, stair climbing
Other behaviors Examples: Performing activities while standing and cold instead of sitting and warm; carrying heavy; only chewing caloric foods, for example, sweets, but not swallowing them but spitting them out ("chew and spit")

Very many of those affected are women, mostly normal or only slightly underweight or overweight – and thus clinically inconspicuous. Characterized by eating in a very controlled, often restrictive manner most of the time, avoiding foods high in carbohydrates and fats. Constant abstinence and prohibitions result in regular -eating binges, sometimes several times a day and in secret.

The attacks differ from normal cravings in that patients compulsively eat immensely large amounts of food in a short period of time, losing control and being unable to stop. Anger, resentment, or boredom may trigger binge eating; however, these may also be planned. Affected persons then wait for times when they are alone and undisturbed.

After the attacks, they try to "undo" the eating again. Induction of vomiting is typical (Table 2). Parents may become aware of the disease if their offspring disappear to the toilet immediately after meals. Sometimes they discover traces of vomiting (1, 2, 3).

Hamster jaws and tooth erosion

Secret eating attack in the bathroom <p Shutterstock/</p>

Secret eating attack in the bathroom

Similar to anorexia, bulimia damages the body in many ways. The stomach acid that rises during vomiting gradually destroys the tooth substance. Adapted dental care is important (box). The parotid glands swell and "hamster cheeks" form. Calluses on the fingers may reveal that patients stick them down their throat to induce vomiting.

A dangerous and potentially life-threatening consequence is that the electrolyte balance becomes unbalanced, which impairs the function of the heart and kidneys, among other things. The filling behavior and transport of food in the stomach as well as the feeling of hunger and satiety also become confused. Mental consequences or concomitant disorders may manifest as depression, anxiety or obsessive-compulsive disorders, self-injurious behavior, and sometimes abuse of other substances, such as alcohol or drugs.

Seizure-like devouring of large amounts of food leaves one feeling disgusted with oneself, guilty, and is also a financial burden (1, 3, 8, 10). To finance eating, adolescents often spend all their savings, sometimes steal money from their parents or commit shoplifting. In addition to concealing and denying the illness, this is another breach of trust within the family (11).

Dental care in bulimia

During vomiting, the rising gastric acid attacks the tooth enamel. There is a risk of permanent damage due to tooth erosion. The risk of tooth decay increases.

Patients with bulimia should not brush their teeth immediately after vomiting to avoid removing the top softened layer. It is better to rinse the mouth with a neutralizing liquid, such as a solution with sodium bicarbonate, baking soda or antacids. Fluoridated mouthwash and fluoride gel once a week protect teeth. Whitening toothpastes or bleaching methods, on the other hand, attack them. Acidic drinks and foods also put a strain on teeth.

First warning signal can be an increased sensitivity. Even if it is difficult, bulimic patients should confide in a dentist (1).

"For the treatment of bulimia, cognitive behavioral therapy is the treatment of choice," explains Legenbauer. The goal is to learn a healthier way of dealing with the triggers of the eating attacks. Dietary behavior outside of seizures should also change. Instead of restrictive eating, those affected should return to a regular and sufficient intake of food and acquire a moderate and enjoyable approach to the "forbidden" foods (1, 3).

Treatment with antidepressants can have a positive effect. Approved is -fluoxetine, which can also improve concomitant -depression. A combination of -psychotherapy and antidepressant medication is said to be most effective.

Binge eating: binge eating without countermeasures

Binge eating disorder has been considered a separate diagnosis since the current fifth edition of the Diagnostic and Statistical Manual of Mental Disorders -(DSM-V) classification system. Eating attacks without hunger are characteristic – similar to bulimia nervosa – but no countermeasures are taken. After overeating, patients suffer from shame, guilt, guilty conscience or disgust – even with themselves. Diet outside of seizures is usually normal and rarely restrictive. Sufferers inevitably gain weight and are often overweight.

Binge eating is estimated to affect between 1 and 5 percent of adolescents. In addition to a lack of affection in the parental home, genetic predispositions are said to increase the risk.

In psychotherapy, patients can learn to control their eating behavior and cope with triggers for binge eating in other ways. In adults, drug approaches are also possible, study data for adolescents are not yet available. Prognosis is considered more favorable compared to other eating disorders (1, 3, 13, 14).

Addressing affected individuals: How to do it right?

If pharmacy staff suspect that a young person may have an eating disorder, it is advisable to first discuss the suspicion with the team. If the decision is made to approach him, this should be done by the colleague who has the best contact to him. The conversation should not start with direct questions such as "Do you have anorexia??" begin. Instead, pharmacy staff should report from the first person that they have noticed changes they are concerned about. Warnings or even threats should be avoided.

Many of those affected initially react dismissively and deny that there is a problem. At this point, it is good to refer to local counseling services and encourage the adolescent to involve parents. In cases of severe emaciation, duty of care may require the pharmacy to approach the parents.

It can be helpful to point adolescents to new techniques such as apps – which, of course, cannot replace psychotherapy. However, the small programs can support a healthier approach to eating through constant reminders and motivations. Internet offers, such as self-help forums or professionally guided online therapy, are suitable for exchanging information with other sufferers and experts.

Despite initial rejection, many of those affected are grateful when they receive -attention and help (19).

Are anorexia and co. Addictions?

Opinions differ on the question of whether eating disorders are addictive disorders. There are many commonalities, for example in neurobiology. "Brain studies show that there are similar activation patterns in heroin addicts as in people with eating disorders," explains Professor Dr. Felix Tretter, second chairman of the Bavarian Academy for Addiction Issues in Research and Practice e. V. in Munich. In both types of illness, patients feel driven by an inner urge, feel ashamed of their behavior and deny their problem to others.

Nevertheless, most experts classify eating disorders neither as substance-related addiction nor as behavioral addiction. Thus, at least in anorexia, the pleasure aspect, which is typical for a dependence disease, is missing. "One difference from typical sub-stance addiction is that eating does not trigger a serious change in consciousness like psychoactive substances," according to psychiatrist and neurologist.

Another common feature: in addiction disorders, as in eating disorders, a not insignificant number of patients cannot be cured. Then one has to find a way to come to terms with the disease, to keep the health consequences as low as possible with medical help, and to be able to lead a reasonably satisfying life despite the limitations. This is not a glorification of the eating disorder as in the pro-ana and pro-mia community, Tretter emphasizes. Rather, he says, it’s about understanding that some illnesses are so persistent that they have to be part of life at some point.

Loving the body

Because it is so difficult to cure an eating disorder, prevention is particularly important. Because of the multiple triggers of the diseases, prevention must also start in different areas.

A positive culture of conflict in the family and an open approach to negative feelings such as anger or sadness can prevent children from looking for other ways to cope with strong emotions. Parents should also set an example of a relaxed approach to their own body and weight and not constantly diet themselves or criticize their own figure. Children and young people should learn to question common ideals of beauty and know that the stars they admire usually only look so great because their photos have been heavily edited.

A loving and appreciative approach to one’s own body is just as important as a positive body awareness. Dance or movement therapy, for example, can contribute to this. Benefits should not be overstated in families. If children think that they have to be perfect in order to be loved, they can also relate this to their figure. Only seemingly banal: A good eating culture with regular, balanced meals together is important (1, 3, 12). /

Literature by the author

The author

Nicole Schuster studied medicine for two semesters in Bonn, then pharmacy and German studies in Bonn and later in Dusseldorf. During her studies, she did internships at various scientific publishing houses. After her second state exam and licensure in 2010, Schuster completed postgraduate studies in the history of pharmacy in Marburg and has since been working on her dissertation on traditional herbal remedies.

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