Eating Disorders: More to Them Than Meets The Mouth
Jason J. Zodda Rochester Institute of Technology
There is no one cause to any eating disorder. There is no one set of individuals that can be diagnosed with any eating disorder. We are all at risk. There are many types of eating disorders, this paper concentrates on the causes and prevalence of the two most common ones, anorexia nervosa, and bulimia nervosa. There are a variety of possible causes that lead to an eating disorder such as culture, socioculture, family life, and genetic disorders. Risk factors are also common in eating disorder cases. There are many victims that have shown a pattern leading up to the disorder; it is a gradual process rather then a simple change in diet. The prevalence is spread across races, genders and creeds; it affects tall people, fat people, and hairy people; no background is omitted and no one can be considered immune. The most common victims are women, however men are affected as well. Age, sexual orientation, and culture show patterns in the prevalence of the disorder. In the end, we are all possible victims.
"Look how thin and beautiful she is!" A common sentence uttered in the fashion industry, not just in the United States but also around the globe. It is safe to say that thin is in, and thinner is always better--aesthetically that is. The growing concern about appearance is not overestimated--disorders such as anorexia nervosa and bulimia nervosa are plaguing our world.
Types of Eating Disorders
Individuals are diagnosed as anorexic (according to the DSM-IV-TR) if they refuse to maintain the appropriate body weight (according to age and height), and have an intense fear of gaining any more weight - even though they are already underweight (Keel & Klump, 2003). Concisely, if patient "X" is significantly underweight, yet does not want to do anything to correct this then patient "X" is anorexic.
Bulimia nervosa, as defined by the DSM-IV-TR, is just as terrifying as anorexia nervosa. The criteria is as follows: Recurrent episodes of binge-eating--consuming an amount of food which is much larger than most would eat during a similar period of time--at least once a week for three months. A lack of control over binge eating. Recurrent and inappropriate behavior aimed at compensating for the weight gain, self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. The subject’s self-evaluation is based on and influenced mainly by body shape and weight. (Keel & Klump, 2003) In short, a diagnosis of bulimia nervosa is if subject "X" eats more then he or she should, and then inappropriately extinguishes the weight because the subject is not the weight he or she fantasizes to be.
These two disorders, anorexia nervosa and bulimia nervosa, are alarming. Do they have particular risk factors? Can culture, socioculture or genetics cause them? What is their prevalence? These are questions which this paper addresses.
What is more effective than curing an eating disorder? Preventing it. The only way this is possible is by knowing what causes the specific disorder. Everything from macro causes, culture, and sociocultural attitudes, to micro causes, substance abuse and genetic relationships are all possible causes of eating disorders.
Causes of Eating Disorders
To determine if an eating disorder is culture bound data must be collected and sorted from various cultures along a timeline of many years. Are Eating Disorders Culture-Bound Syndromes? Implications for Conceptualizing Their Etiology, by Pamela Keel and Kelly Klump did just that. They attained statistics from an assortment of cultures and along a timeline of sixty years. The experiment was done for anorexia nervosa and duplicated for bulimia nervosa. The results were surprising. Anorexia nervosa does not seem to be a culture-bound syndrome. Bulimia nervosa on the other hand does seem to be culture-bound. There has been a significant increase in bulimia nervosa during the later half of the twentieth century. One striking fact is that every non-western nation that had evidence of bulimia nervosa also had evidence of western influence. The authors do not take this to be a coincidence (Keel & Klump, 2003).
Cashel, Cunningham, Cokley, and Muhammad, in Sociocultural Attitudes and Symptoms of Bulimia: Evaluating the SATAQ with Diverse College Groups, tested the affect of sociocultural attitudes on eating disorders. The method was to question an array of students from a Midwestern University in the United States. The participants consisted of both men and women. The procedure consisted of having the subjects fill out a structured questionnaire, the Sociocultural Attitudes Towards Appearance Questionnaire (SATAQ). After the questionnaire was finished a correlation between Caucasian women, all men, African American women, Hispanic American women, Caucasian sororities and Caucasian non-sororities to body dissatisfaction, drive for thinness, and bulimia was calculated.. SATAQ Internalization was significantly correlated with EDI-2 (a self-report measure developed to assess a variety of symptoms reflective of eating disorders), Body Dissatisfaction and Drive for Thinness. SATAQ Awareness scores were extensively correlated with the Body Dissatisfaction and Drive for Thinness scales for the Caucasian American and Hispanic American female groups. The SATAQ Awareness scores for African American women and men were not considerably related to scores from the EDI-2. The extent of the correlations with eating disorders was the strongest for Caucasian and Hispanic American women (Cashel, Cunningham, Cokley, & Muhammad, 2003). To get to the point, this study proves that there is an affect of sociocultural attitudes on eating disorders.
A third possible cause for eating disorders is substance abuse by the parents. Von Ranson, McGue, and Lacono (2003) tested 674 females and their parents. Daughters underwent assessment of eating disorders while their parents underwent assessment of substance abuse. The results of this study show no correlation between parents with past substance abuse problems and their daughters’ eating disorders.
Another possible cause for eating disorders is heredity. If a mother has an eating disorder does it mean her child will as well? Von Ranson et al. (2003) tested this possibility. The findings were chilling. The results show a high correlation between mothers that have eating disorders and daughters that have eating disorders. This strengthens the theory that eating disorders can be passed down from generation to generation.
Genetic relationships could be a cause of eating disorders. The most accurate way to study this hypothesis is by examining monozygotic and dizygotic twins. Monozygotic twins have identical genes, while dizygotic twins do not. The higher the correlation between monozygotic twins points to greater genetic causes and less environmental causes. A study by Klump, K., McGue, M. & Lacono, W titled: Genetic Relationships between Personality and Eating Attitudes and Behaviors was undertaken. The study showed an extremely high correlation between genetic influence and eating disorders for the monozygotic twins and a low correlation for the dizygotic twins. Data can be viewed in Chart G in Appendix I. This strengthens the idea that there is a significant genetic influence in eating disorders.
As presumed, there are many things that can cause an eating disorder. Sociocultural attitudes, heredity, and genetics are much stronger influences then substance abuse and culture causes. This is not enough. Factors such as parent-child bonds, economic status, and intelligence must be studied. Unfortunately they have not. In light of this, we seem to know very little about what actually causes eating disorders.
Prevalence: The total number of cases of a disease in a given population at a specific time. Is it important to know how many people have a specific disease? Without a doubt, yes. Having an accurate number of the population with a certain disease along a timeline will help to determine trends. It will also help scientists to alienate specific "hot zones", or places where the disease tends to occur more frequently. Knowing the prevalence of a disease can only help to cure it. The following will investigate the prevalence of eating disorders on three sublevels – gender, age, and sexual orientation.
Prevalence of Eating Disorders
Table 1 shows the point prevalence (1 year) of adolescent males and females. Table A-2 shows the lifetime prevalence of the same adolescents (Andrews, Hops, Roberts, Seeley & Lewinsohn, 1993).
The data in tables A-1 & A-2 was collected by interviewing 10,200 adolescents (under the age of 18) and their parents that lived in a population of 200,000. They were interviewed two times by clinical psychologists or certified social workers. The second interview was about one year (13.3 month mean) after the first. The results of the experiment are divided into anorexia nervosa and bulimia nervosa and further broken down by gender.
Focusing on the point prevalence (Table A-1), neither the adolescent males nor females were diagnosed with anorexia. With regards to bulimia nervosa, a significant number of females in interview one were diagnosed (Andrews, Hops, Roberts, Seeley & Lewinsohn, 1993). During the second interview, just one year later, the amount of females with bulimia nervosa rose.
The results of the lifetime prevalence show that during the one-year gap between the interviews the number of adolescent females diagnosed with anorexia nervosa almost doubled. The adolescent males show no signs of anorexia nervosa. Bulimia nervosa, just as anorexia nervosa, nearly doubles for the female subjects. For males, a small portion were diagnosed with bulimia nervosa; and had a small rise in one year (Andrews, Hops, Roberts, Seeley & Lewinsohn, 1993).
Assessing these results shows the researcher that adolescents are at risk of developing an eating disorder. Females are obviously more at risk (Table A-1 & A-2), but males cannot be omitted. This also shows that adolescents were diagnosed with bulimia nervosa two times more then with anorexia nervosa.
Table B-1 shows the lifetime prevalence of adults with anorexia nervosa (Zhang, & Snowden, 1999). The full chart can be viewed in Appendix I Chart J. The results come from a study of 18,151 American adults (18 years and older). They are broken down into four groups of white, black, Hispanic, and Asian. The results show that white Americans are more vulnerable to be diagnosed with anorexia nervosa then minority groups.
Table C-1 shows the lifetime prevalence of adults with bulimia nervosa divided by sexual orientation. (Siever, 1994) 250 adults participated in the study. The full chart can be viewed in Appendix I Chart K. The results of these findings show that homosexuals, both male and female are at a higher risk of being diagnosed with bulimia nervosa.
In contrast of these prevalence findings you can conclude that anyone is at risk for becoming diagnosed with an eating disorder. In all cases women are at more risk then men. However, men should not be overlooked as victims, as they usually are. The "Eating Disorder Information Board" says that one out of six people with an eating disorder is a man (http://www.eatingdisorderinfo.org/men_eating_disorders.htm). Therefore, eating disorders should be taken very seriously by men, women, and parents of adolescents. Conclusion Do you know someone that has ever had an eating disorder? You answer is more then likely yes. This paper has proved that no sets of people are immune, and that there is a wide variety of ways to contract this disease. There are many causes of eating disorders – genetics, and sociocultural factors are the most relevant. Anyone is at risk for being diagnosed with an eating disorder, however adult women face the highest risk. In contrast, be aware. Learn if you are at high risk for catching this disease. Study the symptoms. If you are experiencing any of them, seek professional help. "Knowing is not enough; we must apply. Willing is not enough we must do" (Johann Wolfgang von Goethe).
Table 1. Point Prevalence of Eating Disorders in Adolescents
Disorder Interview 1 Interview 2 Male Female Male Female Anorexia nervosa 0.00% 0.00% 0.00% 0.00% Bulimia nervosa 0.00% 0.34% 0.00% 0.39%
Table 2. Lifetime Prevalence of Eating Disorders in Adolescents
Disorder Interview 1 Interview 2 Male Female Male Female Anorexia nervosa 0.00% 0.45% 0.00% 0.74% Bulimia nervosa 0.12% 0.90% 0.14% 1.60%
Table 3. Lifetime Prevalence of Anorexia Nervosa in Adults
Diagnosed White Black Hispanic Asian Total % 0.9 0.4 0.4 0.6 2.3
Table 4. Lifetime Prevalence of Bulimia Nervosa in Adults by Sexual Orientation
Diagnosed Lesbians Gay Men Heterosexual Women Heterosexual Men % 15.4 14.2 16.2 12.2
Zodda did an excellent job of introducing readers to the topics of anorexia nervosa and bulimia nervosa. His first sentence does much to emphasize the socio-cultural pressures to be thin that young women face in Western culture. Certainly, this causes many young women to obsess about their weight, because they want the men and women of our society to view them as attractive, but more can be said about the socio-cultural factors that influence eating disorders. As one looks at the cultural influences that young women encounter, one can find many examples of inappropriate physical models. At an early age, many girls are offered a Barbie doll to play with. It has been long known that Barbie’s dimensions are all but impossible for a woman to achieve, but even though there have been many alternative dolls produced that are more affirming of a normal woman’s body, Barbie continues to be the best seller in this category. Another example of inappropriate body images for young women is the fashion models that advertisers use to promote their products. Many of these models are too thin compared to an average woman’s body type and do not even look healthy. Young women encounter these images as they shop and read popular publications, and these images serve to reinforce the notion that women must change their body to be attractive.
Eating Disorders: Additional Insights
David E. Chinander
Rochester Institute of Technology
Zodda needed to go further in discussing the issues of control present in both anorexia nervosa and bulimia nervosa. Typically, persons suffering from anorexia nervosa struggle with issues of over-control and anxiety. Some have areas of their life where they do not feel that they experience enough control. By controlling their weight, they are able to feel that they have complete mastery over something in their life. This need for control is expressed by others who are perfectionists who set unrealistic goals for themselves. When they experience failure as a result of their expectations, they compensate by succeeding in the area of weight control.
Bulimics, on the other hand, struggle with issues of under-control, recalling Zodda’s definition of this disorder: “A lack of control over binge eating.” Bulimics share the perfectionist tendencies with anorexics. Further, they tend to be more impulsive, and some sufferers also have troubles with substance abuse and over-spending.
When evaluating the prevalence of these syndromes, Zodda might have highlighted some additional information. These disorders most often occur between adolescence and adulthood, and it is rare for a person to develop an eating disorder after the age of 25. Although everyone should be concerned about this societal problem, the data indicate that prevention efforts should be focused on adolescents and college students.
Finally, I believe Zodda could have gone further in discussing why this problem is so severe. It is true that persons suffering from eating disorders struggle with psychological problems like obsessive thoughts, feelings of anxiety, and feelings of helplessness stemming from their perceived lack of control, but they often suffer from physical problems as well. They have higher risks for developing problems related to their heart, kidneys, liver, and stomach. Although treatments for these disorders can be effective, some sufferers remain focused on their weight, and spend a considerable amount of time and energy avoiding weight gain. Anywhere from 5% to 10% of people with eating disorders die either from physical complications resulting from their behavior or from suicide, which further impresses upon one that the danger from these disorders can neither be underestimated nor overlooked.
Although Zodda's conclusions on the causes of eating disorders used some evidence to corroborate his claims, not enough evidence was used to substantiate these claims. Culture, socioculture, family life, and genetics were all possible causes of eating disorders presented by Zodda. Not only did Zodda fail to present enough convincing evidence, but also he failed to highlight other potential causes of eating disorders. These points will be discussed in detail.
Good Enough for a Snack, But Not for a Four-Course Meal
Brian A. McManus
Rochester Institute of Technology
One test was provided as evidence for no correlation between parents with past substance abuse problems and their daughter's eating disorders. One test surely does not cast all doubt from my mind. What other roles do parents play in their children's onset of eating disorders? Do parents' high expectations help drive the onset of eating disorders in their children? What role does socioeconomic status play? Do women in a higher socioeconomic class have a greater prevalence of eating disorders? Other factors besides substance abuse by parents must be considered and explained.
Although evidence was given linking heredity with eating disorders, more research should be highlighted. The possible link with parents' attitudes and expectations needed to be discussed. The Von Rason, Iacono, and McGue (2003) study and twin studies need to be reconsidered with this in mind. A mother who had or still has an eating disorder may drive the same weight expectations into her children, conditioning them to have the same expectations. These points need to be considered before jumping to the conclusion that eating disorders must have a genetic component.
Comorbidity with other disorders was not taken into account. Various studies have linked substance abuse, compulsiveness, depression, and perfectionism with eating disorders (e.g., Stice, Presnell, Bearman, & Kate, 2003; Von Ranson, Iacono, & McGue, 2002). The effects of these other disorders on eating disorders must also be discussed. Zodda's claim that we are all possible victims of eating disorders may not be valid at all once a comprehensive collusion of potential causes is presented.
This paper, "Eating Disorders: More to Them Than Meets the Mouth," was a review of several studies on anorexia nervosa and bulimia nervosa that showd primarily that the disorders may be more prevalent than popular belief reflects. Presumably, the paper might have demonstrated common belief to be that certain age groups, genders, and cultural groups would be at more risk than others; in fact, it did not at any point state the definition of "common belief." Because of this, the paper did not exactly compare the true risk factors to anything else; it simply reviewed the risk factors and the prevalence of the disorders across varying groups.
Comorbidity of Depression and Anxiety With Eating Disorders
Andrew P. Ochtinsky
Rochester Institute of Technology
The paper showed positively that both anorexia nervosa and bulimia nervosa are prevalent across age groups, gender groups, span of time, race, and sexual orientation. Perhaps common belief is that only young females in western culture are at risk; this was not explicitly stated, but it may be the truth. Thus, the paper showed that the common belief understates risk factors for other groups.
Given that the paper cannot show a comparison between actual prevalence of the disorders and culturally assumed prevalence, it cannot decide any particular point. It may have been advisable to propose recommending some sort of change in the diagnosis or treatment of the disorders based on the analysis of research. One possibility was to examine the comorbidity of the disorders; assuming a highly comorbid disorder correlated with anorexia nervosa or bulimia nervosa, that may then become a risk factor, possibly allowing better diagnosis of the disorders in question.
According to Kaye, Weltzin, and Hsu (1993), persons with anorexia nervosa also often meet criteria for clinical depression; for those with the restricting type of anorexia, obsessive-compulsive disorder is also comorbid (Halmi et al., 1991). Comorbid personality disorder (Axis II) diagnoses, especially those in the anxious-fearful range, are also common in anorexia nervosa, particularly the restricting subtype (Skodol et al., 1993). Bulimia nervosa has some comorbidity with depression and anxiety disorders, either generalized anxiety or social phobia (Carson, Butcher, & Mineka, 2002).
Clearly, anorexia correlates with depression and anxiety, as well as with some personality disorders. It may be that the symptoms of these disorders are more visible than symptoms of an eating disorder--perhaps because major depression has far greater lifetime prevalence overall than eating disorders--and there is a strong focus on that particular disorder in modern medicine. Thus, diagnosis of major depression, and various other disorders comorbid with anorexia and bulimia, could serve as risk factors for eating disorders, as opposed to, say, being a young female in a Western culture. Such a point is definitely worth expounding upon.
I appreciate the peer commentaries--they were very clear and well thought out. The main argument given in all of the commentaries was that I did not discuss enough factors that cause eating disorders or that I did not go in-depth enough to satisfy the audience. I originally wanted to focus only on socioculteral and genetic factors in eating disorders. I found such a vast amount of information on these two factors, however, that I did not see why I should regurgitate it again. Thus, I chose to give a significant amount of information on a few select factors that could possibly cause either bulimia nervosa or anorexia nervosa.
More to the Peer Commentaries Than Meets the Mouth
Jason J. Zodda
Rochester Institute of Technology
I want to thank Chinander for his input on the difference between over- and under-control for the two eating disorders. This is a very interesting issue. Additionally, Chinander stated that I was not blunt enough in describing the severity of eating disorders. I apologize--readers must understand that eating disorders are one of the most severe problems in society.
McManus insisted that I did not discuss enough factors and did not present the ones I presented in enough depth. I would need to write a paper for each factor to satisfy McManus. Further, to list every factor that could possibly lead to an eating disorder would be a waste of time on behalf of both the author and the reader. There are hundreds of theories on what causes eating disorders; I chose a few factors that I believed important. The thesis of this paper was that there is no one cause of any eating disorder; the purpose was not to write a summery of every factor that causes eating disorders.
Ochtinsky made the same mistake as McManus. The paper was not intended to summarize all factors that cause eating disorders but to use a few select factors to demonstrate that there are indeed many factors. I agree with Ochtinsky that comorbidity is very important when dealing with eating disorders. Depression and anxiety both go hand-in-hand with each type of eating disorder and should be studied much more closely.
I again thank all the peer commentators who took the time to respond to my paper. I accept all the criticisms as constructive and hope that I have answered all of the concerns completely.
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