Eating Disorders: A Review
20:25 Share

From the JAMA Network, this is JAMA Clinical Reviews, interviews and ideas about innovations in medicine, science, and clinical practice. Hello, and welcome to our listeners around the world. I'm Dr. Kristen Walter, Deputy Editor at JAMA. I'm joined today by Dr. Evelyn Atiyah and Dr. Timothy Walsh. They are both professors of psychiatry at Columbia University Irving Medical Center in New York.

Today, we will be discussing a study that they co-authored titled Eating Disorders, A Review. This article was published online in JAMA on March 6th, 2025. Welcome to you both, and thank you for joining us on this podcast. Thanks. Thank you.

So your article focuses on the three most common eating disorders, which are anorexia nervosa, bulimia nervosa, and binge eating disorder. Before we discuss these conditions individually, can you define what an eating disorder is?

An eating disorder is defined by a disturbance in eating or eating-related behavior. So something is abnormal about the eating. And this is usually accompanied with some impact on functioning. And there are significant related psychological disturbances. And how common are eating disorders worldwide and who is most commonly affected?

The best estimates are that they affect, over their lifetimes, 2 to 5 percent of women. And that underscores the fact that the eating disorders are more common among women than among men, but men do get them. What are some known risk factors for eating disorders, including childhood experiences and gender identity?

Let's be clear that we don't know specifically what causes eating disorders, but we do know some risk factors. Being female is one, particularly for anorexia nervosa and bulimia nervosa. Childhood difficult experiences, including maltreatment, increase the chances of the development of an eating disorder.

And then it varies a bit with the disorder. For example, folks with anorexia nervosa are more likely to engage in activities or professions where concerns about shape and weight are prominent, like ballet dancing. And Dr. Atiyah, can you discuss the gender minority, sexual minority component?

So this is really an emerging field where there's become awareness that individuals in gender minority groups, so folks who don't identify as heterosexual and other associated groups,

appear to be affected at higher rates than the general population. And we don't know the reasons why, but this may have to do with some of the areas of body shape, weight concern, and dissatisfaction that is so common across the eating disorders. And your article also describes how eating disorders often co-occur with other psychiatric disorders, as well as alcohol and stimulant use disorder. Could you discuss this association?

Sure. It is quite clear that individuals with eating disorders have an increased risk of developing other psychiatric disorders, especially anxiety and mood disorders. And particularly for folks who engage in impulsive behavior like binge eating are prone to engage in other impulsive behaviors, including alcohol and substance use disorders.

Suicidal ideation is common among patients with eating disorders. Can you discuss suicidal ideation and the risk specifically of suicide, especially among patients with anorexia?

Suicidal risk is higher in all of the groups who are formally diagnosed with an eating disorder, but the highest risk is in those who carry the anorexia nervosa diagnosis. Individuals with anorexia nervosa are some five to six times more likely to die than age-matched peers without the disorder. About a fifth or so of those deaths are due to suicide.

So we really are concerned with this group and the assessment of these individuals for suicide risk is so important.

And moving on specifically to anorexia nervosa, can you describe the characteristic findings of this condition? Anorexia nervosa is characterized by an individual taking in calories that are insufficient for their body's needs, leading to an individual landing at a significantly low body weight for that person.

So this means a weight that is lower than what's expected in part by population norms, but also specific to that individual's growth history, weight history. And this low weight is connected with a preoccupation with body shape and weight of fear of fat or becoming fat, even though the individual is significantly low in weight.

Those are really the core features of the diagnosis. It's important to be aware as well that among adolescents, what may be observed is a cessation of growth. Rather than continuing to grow normally in height and weight, individuals who seriously restrict their food intake may not lose weight but may fail to gain. And that is a potential indicator of anorexia nervosa.

And what are some other effects that anorexia nervosa can have on the body specifically? Essentially, every organ system can be affected when someone is in that state of malnutrition, essentially, that is a piece of what we see when someone presents with anorexia nervosa. We see changes to vital signs, low heart rate. We see low blood pressure, hypothermia, not uncommonly, and all of those features are

part of the step down in metabolism that's common as somebody gets to and then maintains a weight that's lower than what their body needs optimally. We'll see changes to hormone levels where for females, menstrual activity is commonly interrupted. We'll see changes to blood counts where white blood cell counts will usually decrease as a first sign, but we can see those kinds of decreases across all of the blood cell types for folks who may have

have vomiting as part of their eating disorder behaviors. We'll see decreases in potassium, in sodium, you know, in a number of electrolytes that really can go on to cause important physiological disturbances. Other systems that can be impacted include the liver, especially in the early phases of refeeding when the liver has to get to work to mobilize more calories.

Bone is also impacted. So at least after a year, even for previously healthy adolescents, you can start to see a drop in bone mineral density. And this is of particular concern because while almost all the physical abnormalities of anorexia nervosa correct with weight gain, bone density may not catch up if anorexia nervosa occurs during adolescence, during the peak time of accumulation of bone density.

And moving on to bulimia nervosa, can you describe the diagnostic criteria for that condition?

The key abnormality are episodes of binge eating, and those are defined as episodes in which an individual consumes an unusually large amount of food in a short period of time with a sense of loss of control over the eating during the episode. And in addition, individuals with bulimia nervosa engage in inappropriate behavior to try to avoid the absorption of those calories. Most typical abnormal behavior is self-induced vomiting.

And these individuals, like individuals with anorexia nervosa, are overly concerned with shape and weight. But critically, their weights are not low. Individuals with bulimia nervosa have weights that are within or above the normal range. And then just to go on to explain binge eating, because that was a separate category in your manuscript.

So binge eating disorder is a condition where binge eating episodes defined identically to the way we define them for bulimia nervosa, eating more food than would be appropriate for a given situation.

in a relatively short period of time occurs together with that feeling of loss of control. But those binge eating episodes are not accompanied by the compensatory behaviors that we see in bulimia nervosa. And like with bulimia nervosa, when those episodes occur at a frequency of at least once a week for a period of at least three months, we consider that a significant enough pattern to meet criteria for the diagnosis.

And what are some common medical conditions or complications that are associated with binge eating disorder?

Most individuals who present clinically with binge eating disorder have overweight or obesity. So the medical complications that are associated are those associated with overweight and obesity. It is not entirely clear whether folks with binge eating disorder have a higher rate of such complications, but the complications we're talking about are those that are routinely observed among individuals with overweight and obesity.

And so specifically hypertension. That's right. Hypertension, diabetes, lipid disturbances. And can you briefly mention the link between food insecurity and binge eating disorder?

There are some data that suggest that individuals in a community where high-quality food is not available at a reasonable expense may instead consume foods of relatively low quality, so high-calorie, low-food quality, which is sort of a definition of food insecurity. And that exposure to high-calorie foods may increase the chances of engaging in binge eating and the development of binge eating disorder.

When evaluating a patient who's got a suspected eating disorder, what is the differential diagnosis that clinicians should consider?

Well, a number of these eating disorders need to be examined in the context of whether anything else might be happening medically to explain some of the presenting symptoms. So for example, as one is considering the possibility of anorexia nervosa, we're looking at other kinds of medical conditions that might lead to low intake of adequate energy to maintain normal. So gastrointestinal disorders, neoplasms,

Endocrine abnormalities such as thyroid disease would be something that often needs to be ruled out when confirming the diagnosis of anorexia nervosa. For bulimia nervosa, there may be other issues. So taking a look at stomach motility and other possible causes for the symptoms would be important. So that leads to my next question. When should clinicians be thinking about eating disorders and why is it important to identify eating disorders early?

Clinicians ought to be thinking about eating disorders because they're common enough and they can be missed enough of the time that having a better awareness that a few basic questions around weight history and concern about body shape and weight might lead to proper diagnosis and appropriate referral procedures.

sooner. And we do know that earlier identification and shorter duration of illness is associated with better outcomes. Our adolescent patients who get identified early are the most likely to have a lasting positive outcome. So we have the sense, with some data to back it up, that

The disturbances in eating behavior that are the defining characteristic of eating disorders, the longer these disturbances in behavior persist, the more ingrained they become and the more difficult it is for individuals to stop engaging in them. And that, I think, underlies the importance of early recognition and referral for definitive treatments.

Yeah. And so moving on to treatment for anorexia, what are the goals of treatment and what are acute treatment options for anorexia nervosa?

So treatment usually emphasizes weight restoration and improvements in eating behavior so that eating returns to a more normal pattern with adequate meals and snacks so that stable weight is achieved and maintained. These treatments are delivered in lots of different settings depending on the severity of that initial presentation.

So generally, the treatment has these behavioral elements, but may be offered on an outpatient basis or using a more structured outpatient approach where some meals are supervised and overseen so that people have that additional level of assistance as they make changes. Some individuals need 24-7 settings, residential or hospital-based settings, so that the

medical complications can be adequately monitored and all of the meals can be properly supervised and some

groups, activities, and other pieces of psychological management can be delivered in those kinds of more intensive settings. Patients will often have some preference about where it is that they wish to receive treatment, and medical teams will work with them to make decisions about what seems to be the safest and most likely to be effective setting to begin and carry out some of these treatments.

We don't have medications that are as helpful as we wish in anorexia nervosa. Medications have been considered for assisting in weight restoration and improvement in some of the psychological symptoms. And they're notably less effective than we might expect.

At improving mood, anxiety, and some of the weight features, we have a little indication that the atypical antipsychotic medication olanzapine can be modestly helpful with some weight improvements, not usually as a standalone treatment, but maybe something that is needed adjunctively to some of these other behavioral approaches.

I'll just say that in our younger patients, in adolescents with anorexia nervosa, there's good evidence that involving the family makes a big difference in helping individuals use an outpatient setting to normalize weight and move to really lasting recovery. There's a treatment that

is called family-based treatment for anorexia nervosa that really engages parents to be helpful partners in helping their child achieve weight restoration that has very good success across a number of studies. And that usually is a place to start for younger patients with anorexia nervosa.

Years and years ago, it was kind of thought that some kind of psychotherapy might deal with some kind of underlying issue, and then the person with anorexia nervosa would start to eat more normally. That approach has been abandoned. The need to gain weight is so critical for both physiological and psychological improvement that it is part of the treatment, not the end result of successful treatment.

And the other thing I would mention is the family-based treatment, which is the first choice treatment for adolescents with anorexia nervosa, particularly since COVID has become more available remotely. So there are a number of programs that are able to deliver really first-class psychological treatment using the internet, using Zoom or related technologies.

The psychotherapy is an important treatment option. What types of behaviorally focused therapies are helpful for these conditions? That varies with the condition.

For anorexia nervosa, we have good evidence that treatment helps. People do gain weight and they improve psychologically with good, solid treatment. But there is no one specific treatment that can be recommended. Cognitive behavioral therapy, which is standard across the field for many conditions, is useful. But so is interpersonal psychodynamic psychotherapy. And so is well-administered supportive psychotherapy.

So we don't have a specific form of psychotherapy for anorexia nervosa, but therapy helps. For bulimia nervosa, cognitive behavior therapy is very effective and is typically the first line psychological treatment. For binge eating disorder, cognitive behavior therapy is also very effective, as is interpersonal psychotherapy.

For bulimia nervosa, SSRIs are quite effective in reducing binge eating. And fluoxetine at 60 milligrams a day, a larger dose than typically used to treat depression, is FDA approved for the treatment of bulimia nervosa.

The medication lisdexamphetamine, a CNS stimulant approved for the treatment of ADHD, is also FDA approved at a dose of 50 or 70 milligrams per day for the treatment of binge eating disorder. Before closing, is there anything else you'd like to mention that we haven't previously discussed? I would just note that there are two other disturbances in eating behavior that were noted in DSM-5.

One is what's called atypical anorexia nervosa. This describes individuals who lose a significant amount of weight, say 10% of their starting body weight, and then develop many of the psychological and some of the physiological disturbances characteristic of anorexia nervosa, but whose weights remain atypical.

in the normal range or above. So somebody may lose from 200 pounds to 175 pounds and develop a lot of the symptoms and signs of anorexia nervosa, but never get underweight. The other category that's worth mentioning is a label called avoidant restrictive food intake disorder.

We often use the acronym ARFID to describe that group. So these are individuals who may avoid or restrict their food intake for reasons including being afraid of an aversive consequence of their eating, or maybe they've got an increased sensitivity to a sensory feature of eating. The food feels too thick or too scratchy or smells a certain way, and that leads them to not want to eat. This also includes the possibility of individualism.

individuals who have a very different kind of appetitive drive. They've never really been interested in food and we'll hear from families that maybe since a very young age, they had to be reminded around eating. Eating was never something that they did with ease. And if these individuals get into some significant

trouble where there is social impairment or nutrient deficiency or significant weight loss, they meet for this new category, ARFID. We don't describe much about ARFID in the JAMA review because ARFID was first described formally in DSM-5 in 2013, and we're just learning more about the kinds of treatments that work for this group and more about the course and outcome.

Thank you so much for sharing your thoughts with us about this interesting and important topic. I'm Dr. Kristen Walter, and I've been speaking with Drs. Evelyn Atiyah and Dr. Timothy Walsh from Columbia University. You can find a link to this article in this episode's description. To follow this and other JAMA Network podcasts, please visit us online at jamanetworkaudio.com or search for JAMA Network wherever you get your podcasts.

This episode was produced by Daniel Morrow at the JAMA Network. Thanks for listening. This content is protected by copyright by the American Medical Association with all rights reserved, including those for text and data mining, AI training, and similar technologies.