Eating Disorders During Adolescence

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Consequences of disturbed nutrition during a vulnerable period

Adolescents must be adequately nourished to ensure their growth and development progresses normally and continuously.  Monitoring and modifying the wide swings in nutritional status during the course of eating disorders in order to maintain normal growth and development requires specific knowledge. The most sophisticated techniques available to the physical health and social sciences today must be applied to help teenagers change disturbed eating behaviors that impair their nutritional health;  behaviors not included in diagnosable syndromes as well as those which are included.  Knowledge and expertise regarding treatment for these complicated problems is expanding.  Principal nutritional aspects of anorexia nervosa and bulimia nervosa, documented through research and practitioner consensus, are reviewed here. 

Eating Disorders:  Prevalence 

The number of adolescents with diagnosed anorexia nervosa or bulimia nervosa is growing and many adolescents with various eating disorders and disordered eating behaviors remain undiagnosed and untreated.  Uncounted teenagers preparing to be models, entertainers, dancers, gymnasts, jockeys and other athletes who manipulate their weight also suffer from long-term effects of chronic malnutrition, whether they do or do not meet the criteria for anorexia nervosa or bulimia nervosa.  They may be categorized as having an “Eating disorder not otherwise specified” when they have combinations of symptoms that do not fit the exact criteria of the other described eating disorders.

Eating Disorders:  Characteristics

Spectrum of physical characteristics seen among adolescents with eating disorders.  Those with acute anorexia nervosa are usually among the thinnest and the developmentally obese* among the heaviest.  Adolescents across the spectrum are affected by various underlying psychosocial disturbances.  While the physical aspects may obviously require treatment, interventions should be directed to all aspects of these complex conditions, not solely the physical symptoms.
(Modified from Rees JM: Eating disorders.  Copyright Mahan LK, Rees JM Seattle, Wash, 1989. Originally published in Mahan LK, Rees JM: Nutrition in Adolescence, St. Louis, 1984, Times Mirror/Mosby.)
*Note:  The developmental obesity referred to develops through specific family interaction from birth (described by Hilde Bruch in 1973 – Eating Disorders: New York, Basic Books).  It is one of the many types of obesity, a condition with many etiologies.

Physically, adolescents with eating disorders form a spectrum, from the extremely thin to the extremely heavy, as the drawing above illustrates.  Between the extremes are various types of  physiques.  Along the spectrum, adolescents with disordered eating behaviors have underlying problems interfering with normal nourishment; they use food inappropriately.  Food related behaviors and associated deviation in body weight are two obvious characteristics of these disorders.  These outward symptoms are obvious to the affected adolescent, the public, and  health professionals. Understanding the underlying neuro-physical and psycho-developmental issues is essential to dealing adequately with the disorders.

Background:  Physical growth and development. 

Rapid physical growth and development in adolescence constitute the unique background for development of eating disorders at this stage of life. Self-esteem problems intensify in many normal young women in the process of doubling their body weight, increasing the percent of body fat, gaining about 4 inches in height, developing breasts and acquiring other features of the mature female body, as well as experiencing menarche.  Given that this development occurs within a 6-8 year period, the rapidity of change contributes to the difficulty of the task of acceptance.

The intensity of physical growth and development also accounts for the vulnerability of any adolescent to long-term consequences if they experience semi-starvation.  All organisms are subject to the greatest harm from food deprivation at periods when they are synthesizing tissue;  they need nutrients to build into tissues and food energy to fuel the process.  Human teenagers are no exception to this basic biological rule.

Background:  Body image and psychosocial development

Adapting a mental image of one’s unique body (the body image) is a basic feature of adolescent development.  Body image distortion is a core characteristic of anorexia nervosa and bulimia nervosa.  Thus, these disorders are commonly seen in adolescence, the period when young people are vulnerable to body image problems. Whether as cause or effects, progress in adopting adult body image is interrupted for the teenager with an eating disorder. 

Teenagers with severe eating disorders also fail in varying degrees to accomplish other psychosocial developmental tasks of adolescence. The most striking of the developmental problems first described by Hilde Bruch in 1973 (Eating Disorders.  New York, Basic Books) is a struggle to develop autonomy.

  • Inability to develop and use formal operational thought processes, especially in reference to themselves.
  • Inability to experience bodily sensations originating within themselves as “normal” and “valid”.
  • Unrealistic perceptions of body size.
  • Preoccupation with weight and food, reflecting dependence on social opinion and judgment.
  • Failure to normalize eating and exercise patterns.
  • Unrealistic expectations for themselves.
  • Failure to develop autonomy.
  • Difficulty in accomplishing the normal psychosocial tasks of adolescence.

Background:  Etiology 

For many adolescents disturbed eating has developed slowly throughout earlier life, though seeming to appear suddenly in adolescence.  The origin of eating disorders is very complex. Individual and familial, biological and psychological characteristics contribute.  Cultural values combined with eating habits common in modern societies create a milieu that is said to foster eating problems.  To reflect the multiple influencing factors, eating disorders are said to have a multi-factorial etiology.

Anorexia Nervosa: Symptoms

The term anorexia nervosa is actually a misnomer.  Affected adolescents ignore and even lose their hunger sensations.  The motivation to be thin apparently keeps these adolescents from eating.  Since an early description (in 1689), a combination of symptoms has come to be regarded as characteristic of anorexia nervosa, although certain of these symptoms may be seen in other disorders.  The unique combination of symptoms in anorexia nervosa has been defined by the American Psychiatric Association (APA)
A description appears below, including considerations suggested by adolescent eating disorder specialists (in brackets and capital letters), making it applicable to most adolescents.

  • Refusal to maintain body weight at or above minimal normal weight for age and height
  • Loss or failure to gain weight with maintenance weight 15% below expected [FOR AGE APPROPRIATE DEVELOPMENTAL STAGE]
  • Disturbed experience or evaluation of body weight, size, or shape 
  • Absence of three consecutive menstrual* cycles not relying on estrogen in post-menarcheal females [OR FAILURE TO ACHIEVE MENARCHE* AND ESTABLISH MENSES* AT AN APPROPRIATE AGE]
    * In all cases females are considered amenorrheic when menses do not occur unless induced by estrogen replacement.

“A relentless pursuit of thinness” and “a misuse of the eating function in efforts to solve or camouflage problems that otherwise would appear insolvable” underlies these symptoms as pointed out by Hilde Bruch in her classic description in 1973 (Eating Disorders.  New York, Basic Books).  In summary, the adolescent with a severe eating disorder suffers from arrested physical and psychological growth and development. (Because most patients are females, the feminine pronoun will be used in this discussion.)

Anorexia Nervosa:  Overall prevalence

Although recent precise figures are not available, as many as 1% of American teenaged females, 15 – 19 years of age, are said to suffer from anorexia nervosa.  The majority of persons with anorexia nervosa are adolescents, although the disease affects young adults and other age groups.  The disorder is supported by a cultural paradox:  food is abundant and used lavishly for purposes other than survival and on the other hand slimness is highly valued.  These cultural values are strong internal messages for many in the modern world.  The impact is great on a young adolescent who has not developed autonomy.

Anorexia Nervosa:  Prevalence in females 

About 1% of average high school aged girls in the US and England are thought to be affected.  It must be recognized, however, that accurate data are difficult to obtain because of the secretive nature of the disorder and the fact that many do not seek treatment. 

Anorexia Nervosa:  Prevalence in males 

The disorder is not common among males, with only about 5% to 10% of diagnosed cases being males less than 14 years.  Of cases diagnosed in older adolescents, 19% to 30% are in males.  Males with anorexia nervosa seem to have the same sort of disorder as females. The traditional lack of value on extreme slimness in males adolescents probably puts them at a somewhat lower risk for the disorder.  Celebrities with excessively thin and/or muscular bodies are beginning to influence the ideals of young males, however.  Obsessive muscle building and exercise to the point of harming their bodies, may be the equivalent of anorexia nervosa in vulnerable male

The physical manifestation of anorexia nervosa may be sudden, although unrecognized underlying characteristics may have been present prior to manifestation of an identifiable disorder.  Intervention strategies should simultaneously address the psychological and physical issues of the adolescent.

Onset: Progressive development 

From the family’s point of view, the teenager with anorexia nervosa has traditionally been a “model child”.  She fits into the family and meets her parents’ high expectations, working extremely hard at school and being satisfied only with excellent grades.  Suddenly she displays a compulsive attitude about her weight and food consumption.  The family erupts in crisis as response to her extreme eating behavior.

Onset: Psychological characteristics 

The teenager with anorexia nervosa is troubled about her life. She finds it difficult to  mature psycho-socially and clings to the rigid patterns of childhood. She is unable to sustain peer friendships and isolates herself.  Life appears to be out of her control. She is conflicted about living as her parents direct, is hurt by their critical comments and begins to realize that she must assert herself but finds that difficult. She feels too fat and thinks she has to be slim to be a worthy person. She takes an uncompromising stand about her eating and exercise habits.  Increasingly preoccupied and angry when her family interferes, she denies her illness.

Onset: Distorted perceptions 

A range of distorted perceptions has been noted, often related to body size and shape, hunger, satiety, physical endurance and the need for rest.  Distorted perceptions characteristic of anorexia nervosa may be exacerbated during episodes of crisis level starvation and will vary from time to time as well as adolescent to adolescent.  Anorexia nervosa should not be ruled out on the basis of lack of specific distortions if other symptoms are present.

Onset: Motivation 

The adolescent with anorexia nervosa has been described as wishing to stave off adulthood.  The question is whether she tries to avoid maturation or whether maturation eludes her.

Onset: Family characteristics

Many families of adolescents with anorexia nervosa list no problems until the manifestation of the disorder.  They need assistance from family specialists on the health care team to deal with the unexpected crisis of an eating disorder.  As treatment progresses they require guidance while developing a family system to support their adolescent as she learns to regain her healths.


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