• 10 million females and 1 million males have life threatening eating disorders
• 87 percent are children and adolescents under the age of twenty
• By age 13, 10% of girls had reported the use of self-induced vomiting

Risk Factors for Different Groups

• Teens: Early puberty is a primary risk factor for the onset of eating disorders among teens.
• Males: The number of males with eating disorders has doubled in the past 10 years, certain sports, homosexuality
• Women: Increasing numbers of women aged 20 – 50 seeking help for eating disorders they have harbored secretly for twenty or thirty years.

Health Consequences of Eating Disorders:

Eating disorders are the most lethal of all mental health disorders, killing or maiming between 6 and 13 percent of victims who die of:

• Infectious diseases
• Stroke
• Heart attack/failure
• Seizures
• Liver or kidney failure
• Diabetic Coma

• 1 in 3 Americans is overweight
• 1 in 5 or 129.6 million are obese
• 70% of Americans dieted in 2007
• 95% of all diets fail if exercise is not part of the program
• Yo-yo dieting leads to eating disorders and may be the single most common “cause” of disordered eating
• In a recent study, young girls were quoted as saying that they would prefer to have cancer, lose both their parents, or live through a nuclear holocaust than to be fat.
• 80% of girls in grades 3 to 6 displayed body image concerns and dissatisfaction with their appearance
• 81% of 10 year olds say they are afraid of being fat
• By the time girls reached the 8th grade, 50% of them had been on diets, putting them at risk for eating disorders and obesity.
• 25% of first graders admit to having been a diet.

In my practice, I often see patients that were overweight as children and experienced such self-hatred or shame that their eating disorder is a conscious attempt at avoiding that situation again.

For others, a family member, perhaps a father or mother or even a grandmother or an aunt with a weight problem triggers intense anxiety about weight gain.

Check out the chart for percentages of individuals reporting the type of Eating Disorder from which they are suffering.

The survey has been up for approximately two years.  The number of people reporting being Bulimarexic has tripled in that time. One year ago the percentage for Bulimarexia was only 24.9%, now it is nearly 48%! (Part of this is likely due to increased familiarity with the term.)

The question is why? According to our survey at the Norton Center of more than 200 individuals who report having been in treatment for an eating disorder, 16% of those suffering exclusively from Anorexia upon entering an inpatient program report being discharged with symptoms of Bulimia that they acquired during their inpatient stay. Likewise, 11% of those surveyed, report that they entered in-patient treatment suffering exclusively from symptoms of Bulimia and exited with symptoms of Anorexia as well.

Anyone treating this population knows that the most difficult group to treat by far is the group suffering from symptoms of both Anorexia and Bulimia, or Bulimarexia.  Likewise the risk of mortality is greater with this group than that of either group alone. If it isn’t apparent, the medical consequences of cycling between restricting sufficiently to be at an extremely low weight, followed by periods of bingeing and purging, are dramatic and often deadly. Thus, a treatment approach that may actually increase the likelihood of the development of Bulimarexia is a serious problem.

Obviously not all patients with Bulimarexia have developed the disorder while in an in-patient program. However, I am finding that an alarmingly high number of individuals “graduating” from inpatient treatment end up with Bulimarexia. Since I often see patients that other practitioners will not take into their practice because they are so sick, the number of Bulimarexic patients I see is probably higher than it would be in most practice settings.  None-the-less, this issue doesn’t appear to be on the radar of researchers and many practitioner groups which is a serious problem in my opinion.

To date, there is not even a diagnostic code specifically for Bulimarexia in the Diagnostic and Statistical Manual, Fourth Edition (DSM IV).

In the DSM-IV, the closest thing we have is a code for two types of Anorexia:

Restricting Type: During the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behavior (self-induced vomiting or misuse of laxatives, diuretics, or enemas).
Binge Eating/Purging Type: During the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior.

These definitions do not capture the nature of Bulimarexia. For example, whether the individual started as Anorexic or Bulimic makes a difference in terms of their current symptoms.  The more Anorexic Type restricts most of the time and may or may not binge, but purges almost everything she does eat.  In other words, she is more likely to have “subjective” binges, i.e. a small amount of food seems like a binge to her so she is forced to purge it.

The more Bulimic Type of Bulimarexic can keep some food down, and/or has more flexibility in terms of what she allows herself to eat, i.e. she may eliminate fat altogether from her diet but allow foods with carbohydrates. She will have some criteria that she uses to establish a “good” day versus a “bad” day.  “Bad” days trigger the need to binge and purge whereas a “good” day allows her to skip this part of the cycle. These distinctions may not seem important, but they are critically important when it comes to treatment effectiveness.  The therapist that does not understand such subtleties is going to be much less effective treating these disorders and could end up doing more harm than good.

More attention needs to be paid to this problem, we need better in-patient alternatives and we need more research on outcomes in general, i.e. we need to look at the impact that both inpatient and outpatient therapy has on the incidence of Bulimarexia. Graduate students looking for research opportunities contact me at drnorton@eatingdisorderpro.com.

My experience treating this population has been that treatment effectiveness is driven by customizing strategies to the individual and not using a One Size Fits All © approach. In general, I believe that inpatient approaches have tended to lump all eating disorders together in terms of treatment. The upshot is often an increase in the type of symptoms during or following discharge, or crossover from one disorder to another.  This is a serious problem given the increased medical and psychological complications that result.

Excerpt from Dr. Norton’s upcoming book One Size Fits All Copyright Dr. J. Renae Norton 2010 All rights reserved.

It is estimated that over 6 million Americans are affected by Night Eating Syndrome (NES) or Sleep Related Eating Disorders (SRED), yet most of us have never heard of either of these disorders.  Essentially they involve consumption of large quantities of high carb foods during the night. Because NES and SRED share  the characteristics of other eating, mood and sleep disorders they can easily be misdiagnosed and mistreated.  Those affected by NES or SRED often feel misunderstood, isolated and hopeless.  These feelings can exacerbate other eating disorders and perpetuate a cycle of disturbed eating patterns during the day as well as during the night.

How are NES and SRED different?

While they are similar in as which they involve uncontrolled night eating that interferes with sleep and daytime activities they are fundamentally different. Those with  NES have a difficult time falling asleep and wake frequently with an intense urge to eat, sleep is  prevented until the urge is satisfied.  This syndrome usually occurs when the individual is battling stress and depression. SRED is the act of preparing and eating food while sleep walking, these individuals will awake with no memory of eating the night before.  This disorder is very common in those who suffer from restrictive eating disorders.

Is Treatment Available for NES and SRED?

Yes, treatment is available.   NES and SRED are a combination of disorders so each disorder must be addressed.   The most effective treatment involves a combination of psychotherapy and behavior therapy, in some cases medication may also be necessary.  When seeking treatment it is advised that you find a health care provider that has experience with NES and SRED.

Anorexia, a potentially life-threatening eating disorder characterized by self-starvation and excessive weight loss, has seen a threefold increase over the past 40 years among women in their 20s and 30s. The percentage of teens afflicted has remained about the same with the exception of male teens. Whereas males used to represent only 5% of the ED population, they now represent closer to 10% and are over-represented among wrestlers, professional ice-skaters, jockey’s and the male homosexual population.

Anorexia is usually characterized by resistance to maintaining a body weight sufficient for normal functioning and/or for survival. In a small proportion of cases, the individual is not resisting weight gain, nor is she consciously trying to lose weight. Instead she is simply unable to eat enough to maintain a normal weight as a result of excessive anxiety. The eating disorder for this relatively small group develops partly as a result of a defense mechanism called Obsessive Compulsive Disorder (OCD) which drives her to restrict more and more in order to control the number of calories she is ingesting. Eating less and less becomes an obsession.  Unlike the majority of Anorexics, whose goal it is to loose weight, her goal is to control her calorie intake. Obviously, the outcome is the same, but it is important to understand the difference, otherwise she will be mislabeled and may end up being or feeling mistreated.

In most cases, the fear of weight gain or being “fat” is so intense that the individual consciously restricts to achieve a lower and lower weight.  For such individuals, the number is never low enough.  Suffers grossly distort the shape of her body, believing that she is “fat” in the face of deathly thinness. This condition is known as body dysmorphia and is a common symptom. In terms of personality, the anorexic tends to be a perfectionist, judging others and herself harshly.

Warning Signs of Anorexia

*Dramatic or persistent steady weight loss.

*Preoccupation with weight, food, calories, fat grams, and/or dieting.

*Refusal to eat certain foods, progressing to severe food restrictions.

*Frequent comments about feeling “fat” or overweight despite weight loss.

*Denial of hunger.

*Development of food rituals.

*Consistent excuses to avoid mealtimes or situations involving food.

*Excessive, rigid exercise regimen-despite weather, fatigue, illness, or injury.

*Withdrawal from friends and activities.

*Life revolves around weight loss, dieting, and control of food.

A more accurate or relevant measure is the glycemic load (GL) which reflects both the quality and quantity of dietary carbohydrates. This is important because, to put it very simply, blood glucose levels determine whether or not and how much fat your body stores.  Understanding GL allows us to maintain a healthy weight for our size. Because most foods with a low GL are whole foods (came out of the ground or had a face) instead of processed foods, this means that we will be eating more fruits and vegetables and healthier proteins.

To calculate the glycemic load of a food, divide the GI by 100 and multiply by the grams of carbohydrate in the serving size.  GL=GI/100 x # Carb grams per serving

Examples of How to Lower A Meal’s GL:

GI = 60    GL = 48                   GI = 42    GL = 31

A cereal with fiber plus a fruit, which also has fiber lowers the GL.

GI = 83    GL = 19                   GI = 14    GL = 1

Pretzels are made from bleached white flour, salt and a little sugar. Peanuts, even with the fat, are a much better snack because of the fiber.

So What is High, Medium and Low in Terms of the GL for a food

Low 0-10

Moderate 11-19

High 20+

What Should I Shoot for During the Course of a  Day?

Low: less than 80

Moderate: less than 100

High: greater than 100

How to Increase Consumption of Low GI Foods

*Eat high-fiber breakfast cereals, especially oats, bran and barley OR

*Add berries, nuts, flaxseed and cinnamon to high GI cereals

*Choose dense, whole grain and sourdough breads and crackers OR

*Add a heart healthy protein and/or condiment to high GI breads and crackers.

*Include 5-9 servings of fruits and vegetables every day

*Replace white potatoes with yams or sweet potatoes OR

*Eat smaller portions of high GI potatoes

*Eat less refined sugars and convenience foods OR

*Combine nuts, fruits, yogurt with commercial sweets – just watch portion sizes

It is important that one does not eat only low GL foods.  The result could be a calorically dense, high fat, low fiber, low carb diet (such as the Atkin’s Diet).  It is best to aim for a well balanced diet that includes low GL carbohydrates, such as fruits and vegetables and hi fiber grains and use the glycemic load as a guide for increasing these foods and for keeping blood sugar levels stable.

Objective and Subjective Binge Eating

An objective binge consists of  as much as 20,000 calories in one episode (which may last from minutes to  many hours) or huge amounts of low calorie foods, such as 6 heads of lettuce with no fat butter.  Binges generally have a function or serve a purpose such as procrastination, avoidance, or relieving anxiety and boredom.  The binge is usually thought out and requires a block of time and privacy.

A subjective binge is the intake of normal foods in normal amounts that the individual feels uncomfortable eating.  The person may feel uncomfortable because it contained a taboo such as fat, sugar or carbs.  Or it may have been “healthy” but they ate too much.  The most common reason for a purge is that the individual feels too full.  Research shows that Bulimic’s and Bulimarxics are unusually sensitive to the sense of fullness.

Situational Binge Triggers:

Meal Preparation, a person with an eating disorder can often be triggered into a binge by preparing a meal, as they are preparing the food they will begin to nibble on the ingredients used to prepare the meal.  The amount of food they consume during the preparation of the meal can be as much as the meal itself, the result is consuming twice as much food as intended.  This may lead to purging, depending on the type of eating disorder.

Dining out with a Group, this is usually very difficult for a person with an eating disorder.  The person with the eating disorder will usually consume an appropriate amount of  “healthy” food while those around them are eating “taboo” foods.  This often angers the person with the eating disorder and can lead the person to binge on those “taboo” foods when they get home in private.

DID YOU KNOW?

According to Dr. Norton’s online survey, in which over 130 people responded, over half of those that binge often find themselves fantasizing about foods to binge on while grocery shopping.

Occurrence by Eating Disorder

* Bulimarexia – 57.1%

* Bulimia – 53.3%

* Emotional Eaters – 53.3%

Participants in Dr. Norton’s Survey rated their forms of treatment as follows:

Out-Patient Psychotherapy

*39.7% found Out-Patient Psychotherapy to be Very Therapeutic and

*36.2% found it to be Somewhat Therapeutic

*3.4% felt that this therapy did more harm than good

In-Patient Residential

*20.9% found In-Patient residential treatment to be Very Therapeutic and

*33.9% found it to be Somewhat Therapeutic

*18.3% felt that In-Patient Therapy did them more harm than good

Limitations of In-Patient Treatment

The learning taking place often does not  generalize to the home environment.  Patients are put on meal plans and are monitored 24/7 by staff such that they are not really learning to make new choices.  Also the daily stressors of family dynamics, school/work pressures and social demands are not present.  The patient has been removed from daily triggers that may have contributed to the eating-disorder in the first place.  Finally this treatment can also be very costly and often results in no insurance coverage as many HMO’s will not cover once the person has been in-patient.

Pro’s of Out-Patient Treatment.

Out-Patient Treatment, especially if it includes Family Treatment, allows the individual to deal with the eating disorder in their everyday setting and provides an atmosphere conducive for family involvement which can be key to recovery.  This method also involves persistent effort for the person with the eating-disorder to get better on their own.  Finally Out-Patient is more cost effective when compared to In-Patient treatment.

Our Strategy: We approach the problem by aligning with the patient rather than colluding against her, blaming her, or casting her in the role of someone who is incapacitated.  While those suffering from an eating disorder do have severe and/or debilitating distortions regarding food, weight and body image, they will ultimately have to choose for themselves whether or not to face their fears and change their relationship with food.  Taking away control only delays that decision and may have serious side effects.

1.  It can help create healthy habits. On average children age 8 – 18 spend 3 hours a day either watching t.v., playing video games or on the computer.  The responsibility of a household chore would get them away from the t.v. and up and moving.  Vacuuming, mopping, mowing the lawn and gardening are all good ways to increase your heart rate.  Children need at least 90 minutes of moderate to strenuous physical activity a day, chores are a great way to get your child moving.

2.  It can help reduce stress and family tension. A messy, cluttered house can cause a lot of tension and resentment within a family.  Often parents just complain or yell at their children for not helping.  This can create feelings of failure and anger for both the parent and the child.  A sedentary lifestyle combined with feelings of shame, failure and anger can lead into emotional eating habits.

3.  Allows parents more time to spend with their children. Why should parents spend their evenings and weekends doing all the housework?  When the kids pitch in the work could be done in half the time.  This time could be used to go for a family bike ride, walk or maybe even a game of chase or hide and seek.  Remember ” a family that plays together stays together”.

The prevelance of childhood obesity in the United States is increasing at an alarming rate.  According to the Center for Disease Control (CDC), the percentage of overweight children 2-5 years of age has doubled, with one in four pre-schooler’s being overweight or at risk for obesity.  Fifty percent of these children will become obese adults.  For more information about this study you can visit the CDC’s website at http://www.cdc.gov/HealthyYouth/obesity/#1

I don’t know of many people who actually enjoy the mundane task of going grocery shopping but for those who suffer from an eating disorder it can be an absolute nightmare. For them going to the grocery can be time consuming, mentally exhausting and costly.  Check the results we collected from Dr. Norton’s Online Survey concerning grocery shopping.

• 75.2%  debate whether or not to purchase each particular item
• 44.4% find themselves fantasizing about binging on certain foods while grocery shopping
• 30.1% spend more than they can afford on food

These statistics, which are from a sample of over 125 respondents, are good examples of why Dr. Norton provides the service of shopping coach.