What doctors wish patients knew about eating disorders

In a society that has long celebrated the idea of the perfect body, the dark reality of eating disorders continues to cast a haunting shadow over countless lives. This silent epidemic affects people of all ages and backgrounds, striking at the core of their physical and mental well-being.

Despite its widespread impact, the gravity of eating disorders often remains concealed behind closed doors, leaving many patients with the condition to battle silently while society grapples to understand the magnitude of the issue. Knowing more about eating disorders is key.

Eating disorders affect millions of people in the U.S. at any given time—most often women 12–35 years old—and primarily develop in adolescence and young adulthood. They are behavioral conditions that are characterized by severe and persistent disturbance in eating behaviors, which are often associated with disturbing thoughts and emotions, according to the American Psychiatric Association.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

For this installment, AMA member Theresa Rohr-Kirchgraber, MD, an internist in Athens, Georgia, and past president of the American Medical Women’s Association, discussed what patients need to know about eating disorders. Dr. Rohr-Kirchgraber also is member at-large of the AMA Minority Affairs Section and a professor of medicine at the Augusta University/University of Georgia Medical Partnership, a four-year medical school campus of the Medical College of Georgia.

“When thoughts about food or your body cloud your mind such that it disrupts your daily living, it is disordered,” Dr. Rohr-Kirchgraber said. “You angst about that extra serving that somebody placed on your plate and it gives you pangs of anxiety or you look at food as a panacea in place of interactions with others.”

For example, if you avoid going out with others because you don’t want them to see you eating or you’re afraid you are not going to be able to eat, “then that should also strike warning bells,” she said. “But it’s definitely more than just ‘I shouldn’t have had that cookie.’

“If you’re thinking I shouldn’t have had that cookie, let me go throw up, let me overexercise and then it destroys the rest of your day … that very disordered thought process is what should alert you that there’s something not quite right and that this is disordered,” Dr. Rohr-Kirchgraber said.

“We call it the trifecta” because it includes a genetic predisposition as well as psychological and sociological factors, Dr. Rohr-Kirchgraber explained. “There is a genetic predisposition for eating disorders, but having the genetic predisposition doesn’t necessarily mean you will have an eating disorder.”

“Having a genetic predisposition does put one at risk, but it is the combination of the psychological and sociological factors that influence the development,” she said. “What makes one start down that path of an eating disorder? Perhaps it was the initial ‘I want to look like the people I see in the media’—without realizing that a lot of those have all been touched up and Photoshopped.”

Some body-related shifts taking place in the mass media are positive, such as including “people of multiple different sizes and colors” as models for fashionwear, in glossy magazines and on TV. But that welcome change “doesn’t necessarily change one’s own perception,” Dr. Rohr-Kirchgraber said. “For adolescents, eating disorders can manifest around puberty—your body changes and you can’t do anything about it.”

“It’s interesting because we also see another blip in eating disorders for women during perimenopause, and the same thing happens—you go from being curved to being straight up and down because you have increased distribution of fat around your midsection,” she said. “Again, the body changes and it is not under one’s control.”

Eating disorders are “definitely more common in women than men,” but they are growing more prevalent among boys and men, “which is not a good thing,” Dr. Rohr-Kirchgraber said. “And how many of them are we missing because we as physicians ask about and look for eating disorders more commonly in women, and we don’t always ask the right questions?”

“With men, we see a bit more of the ‘exercise bulimia’ where it’s overworking out, especially with our younger adolescent boys,” she said. “Exercise can be a good thing when it’s done in the context of healthy living but when it interferes with other activities of daily living, or it becomes obsessive, it is disordered.”

The eating disorder “most people think of is anorexia nervosa—which is severe restriction of caloric intake. In this disorder, instead of viewing food as nourishment, food is seen as an enemy,” Dr. Rohr-Kirchgraber said. “One can see their body as being overweight and every jiggle looks like fat.”

“A significant weight loss—like a weight loss of over 25% of your body weight—even if you have a normal BMI, that degree of weight loss in a short time, should be a warning to attend to,” she said. “And we need to ask about the reasoning that caused the restriction—about the idea behind it of not liking the way your body looks and always feeling like there’s more that you could lose.”

For girls and women, anorexia is “usually also associated with amenorrhea—or not having periods—because you lose so much of your body weight and your body fat content that your hormones aren’t able to work properly,” Dr. Rohr-Kirchgraber said. “It can also be associated with body aches and pains, difficulty sleeping, constipation and fatigue.”

“If you don’t have enough caloric intake, if you're not eating enough, your body has to get the energy from someplace,” she said. “So, it breaks down your muscles, it breaks down your tissues. And as it's breaking down, it hurts all over.”

“Then the less subcutaneous tissue you have—the less muscle and tissue you have between your bones and the outside world—the more, when you're lying and sitting, it hurts because you don't have as much cushion,” said Dr. Rohr-Kirchgraber.

Also with anorexia, “if you don’t have enough nutrition, your body slows down,” Dr. Rohr-Kirchgraber said, noting that she frequently hears “complaints of constipation with my patients with anorexia.”

“The lack of nutrition causes less energy leading to the slowing down of normal body functions, like intestinal movement,” she explained.

This is “overeating to the point where you feel uncomfortable. It’s not just to be full. It’s more for a psychological need rather than a physiological need,” said Dr. Rohr-Kirchgraber.

“And it can be restricting, restricting, restricting and then you’ve restricted so much that you really have to eat and then you pour it all in,” she added. “Any kind of disordered eating is to be a concern, but binge eating is a problem as it is less well recognized.”

“There’s also bulimia, which is probably something that most people would recognize as an eating disorder,” said Dr. Rohr-Kirchgraber. Bulimia is “significantly overeating and then purging or throwing up. Purging can also be by exercise.”

What patients with the disorder may not “realize is that they might be getting rid of the food that they just ate, but they also are really losing a lot of electrolytes and water,” Dr. Rohr-Kirchgraber warned. “So, they can get extraordinarily constipated, have lack of energy, burn their esophagus by all the acid that’s coming up, and develop arrhythmias—abnormal heart rhythms—due to the electrolyte disturbances.”

Some “adults don’t realize that the way that they’ve been dealing with food is disordered,” Dr. Rohr-Kirchgraber said. She encourages adults to ponder whether “if there is something about being in a situation where there’s a lot of food that makes them anxious or irritable.”

And amid the appropriate focus the disease of obesity, “we have to be a little bit careful in terms of how it’s discussed and how it’s brought up because you don’t want to just substitute one problem for another,” she added. “Getting to how that person feels about who they are and where they are and being healthy in general is the right track.”

“The treatment programs really vary significantly by which eating disorder is being treated. The most important thing is to recognize the eating disorder as early as possible—either telling somebody about it, talking to your physician about your own personal concerns or having our physicians ask more questions,” said Dr. Rohr-Kirchgraber. “But the earlier an eating disorder is treated, the better.”

“When somebody has had a significant eating disorder—especially if it was anorexia—because of that lack of nutrition that affected the growth of the brain, there were some things that just don’t come back,” she said. “For example, we know that when you had an eating disorder during your adolescent years when all your bone growth is occurring, you can develop osteoporosis or thinning of the bones that can persist even after your eating disorder is resolved.”

When it comes to eating disorders, “there’s such a significant mental health component to it, especially however it got started, such as I want to look better or I need to numb myself,” said Dr. Rohr-Kirchgraber. “With binge eating, for example, I’ve heard from a number of patients where they had a history of trauma earlier in life and that trauma either made them want to be bigger so that they wouldn’t have to experience that kind of trauma again—or so little that nobody would see them.”

Trauma comes in many different ways. Whether it is a childhood trauma that is measured and discussed as an Adverse Childhood Event (ACE) or a personal trauma later in life, trauma can have a major impact on one’s mental health.

“Now, not everybody who has an eating disorder had a major trauma, but if they have that misperception about the way that their body looks, then it would be useful to work on that,” she emphasized. “Delving into why I am doing what I’m doing and is there something else that I could do in place of this behavior—whether that behavior is restricting, overeating or cutting—there definitely is a significant relationship between the psychological component and disordered eating.”

“This isn’t only a problem with little white girls in junior high. It crosses all ages, all socioeconomical status. It’s everywhere,” said Dr. Rohr-Kirchgraber, noting that “our focus should be on what is healthy eating.”

“There is no bad food, though most of us have this list of what is bad and what is good. It’s not the food that’s bad. It’s what we’re doing with it. It’s how we’re interacting with it,” she explained. “If you want to have chips, have chips. Just do it in a manner that says: I’m enjoying this and it is in moderation.”

“There are so many diets, myths and nutritional nonsense in the public domain. Don’t go for all the funky diets. Instead, fruits and vegetables are always going to be a good choice,” Dr. Rohr-Kirchgraber said. “I always try to stick to lean proteins—and proteins don’t have to be meat. Lentils and beans do a great job.”

“One of the best ways that we can enjoy food is having a mindfulness about eating. With each mouthful, we recognize the good that the food is doing for us—the nutrition and energy it is bringing to our bodies, and the joy that comes with appreciating the care and work that others have put into bringing that nutrition to us,” Dr. Rohr-Kirchgraber said.