Women get the message early in life. To be thin is to be beautiful, valued and successful. Pre-schoolers play with Barbie with the long, slim legs and incredibly tiny waist. For adolescents and teens standards of beauty are dictated by TV stars, singers and fashion models–almost all of whom are thin, some emaciated.

The gap between this rigid cultural ideal of beauty and the reality of developing into a normal woman’s body creates conflict and a negative self-image in many young women.

Modern culture has developed a love-hate relationship with food. We eat to satisfy our senses, in response to hunger signals but also at the urging of non-stop advertising in magazines and on television. In a society where high-calorie food is both cheap and effortlessly available, eating for many of us has become a battleground. Consequently, eating disorders are becoming increasingly common, according to the Office on Women’s Health of the US Department of Health and Human Services.

Anorexia nervosa, bulimia nervosa and binge eating disorder are increasing at all socioeconomic levels and among all ethnic and cultural groups. Eating disorders are seen more often in women and are now estimated to affect more than five million women, a figure that has doubled in recent decades. Eating disorders range from extremes of self-denial and starvation in those with anorexia to uncontrolled binge eating, now recognized as binge eating disorder, or bulimia, where bingeing is followed by purging.

Binge Eating Disorder

Binge eating disorder (BED) is the most common eating disorder, affecting an estimated two to five percent of the population. While anorexia and bulimia are more common in young women, BED affects men and women in roughly equal numbers. Binge eating disorder is defined as frequently eating very large quantities of food within a relatively short period of time, such as a two hour period. A diagnosis of BED requires that the binges are frequent, at least twice a week, for a period of six months or more, and involve larger than normal amounts of food consumed at one time. Binges can vary in size–a smaller binge may involve taking in 1,000 calories at one time; a larger binge might account for as many as 10,000 calories.

The difference between BED and bulimia, which also involves binge eating, is the element of purging. Persons with bulimia tend to be of normal weight and compensate for the effects of a binge with self-induced vomiting, use of laxatives, excessive exercise or strict dieting between binges.

By contrast, those with BED are more likely to be obese. Almost one third of Americans who seek treatment for obesity suffer from BED. These patients tend to have a poor quality of life and are more likely to have related emotional and psychological problems such as anxiety and depression.

Although overeating is a relatively common occurrence, a distinguishing factor for those with BED is a feeling of loss of control. Most people who overeat are aware that they are overindulging but could stop if they really wanted to. This is not the case for those with BED who feel controlled by the binge episode.

Binge episodes occur frequently for a period of six months or more and typically involve:

• eating more rapidly than normal,

• eating alone, often because of embarrassment about the amount of food consumed,

• eating large amounts of food when not hungry,

• feelings of guilt, depression and self-disgust about the amount of food eaten.

Women with BED have high rates of anxiety and depression. Studies of twins show that BED tends to run in families. Genetic factors are estimated to be involved in about 40 percent of binge eating behaviors.

Body signals related to hunger and fullness are distorted in those with BED. Studies show that abnormal hormone levels have a negative influence on appetite in BED.

Like other eating disorders, BED is difficult to treat. Because it has both psychological and physical dimensions, BED needs to be addressed in a number of ways.

Cognitive behavioral therapy has been used with some success, sometimes in tandem with either weight loss drugs or psychiatric medications.

The goal of cognitive behavioral therapy (CBT) is to increase the patient’s understanding of the disorder and the mechanisms that trigger binges. Patients can then develop coping strategies to resist binges and develop more healthy eating strategies. CBT can also help patients identify underlying reasons for binge eating patterns such as anxiety or depression and create a treatment plan for those issues.

One study found that adding the weight loss drug orlistat (Alli) to cognitive behavioral therapy helped control binge eating episodes and increased weight loss.

BED is difficult to treat because it is often accompanied by other emotional or psychiatric problems. Obesity and other related health problems magnify depression and a negative self-image, so it’s important for persons with BED to seek treatment to gain control of the bingeing behavior.

Persons with BED should try to find a physician experienced in treating the disorder, someone who is non-judgmental and willing to work with the patient for an extended period to treat not just the bingeing but any underlying problems such as depression or anxiety. It’s a complex problem that requires compassion, patience and persistence with a good dose of encouragement.

Bulimia

Eating disorders are known to be difficult to diagnose and treat. Most patients don’t willingly seek treatment; some may hide or deny the problem. Cultural pressures to be thin are believed to be at least partly responsible for bulimia, an eating disorder characterized by episodes of binge eating followed by purging, either by vomiting or use of laxatives.

Bulimia nervosa affects up to three percent of young women and is about 10 times more common in women than in men. A much larger percentage of young women suffer from a milder form of the disorder.

A clinical diagnosis of bulimia requires that binge eating episodes occur frequently (at least twice a week) for three months or more. Eating binges are then followed by self-induced vomiting, use of laxatives, excessive dieting or extreme exercise to counter the excess calories. Bulimics often engage in binge eating in private, viewing it as shameful .Attempts to purge are also usually carried out in secret.

About one quarter of women with severe bulimia have a history of anorexia and some women cycle between the two. Anorexia is a serious eating disorder that involves severe calorie restriction in response to a distorted body image. Bulimics also have higher rates of depression, obsessive compulsive traits and low self-esteem.

Because of the secrecy and the fact that bulimics often maintain a normal weight, bulimia can be difficult to detect.

Repeated vomiting and abuse of laxatives can lead to a number of health problems including erosion of dental enamel, bleeding and ruptures in the esophagus and stomach, heart arrhythmias and low blood pressure. It’s important for young women with symptoms of bulimia to recognize the long-term damage and to seek help.

Bulimia is normally treated either with medication, psychological therapy or a combination of the two. Fluoxetine (Prozac) or other SSRIs are often a first choice as they are considered safe and relatively effective, at least over the short term. Studies show a 50 to 75 percent improvement within six to eight weeks.

Although antidepressants may provide short-term relief, experts point out that bulimia is not a short-term illness and recommend psychological therapy in addition to drug treatment. Cognitive behavioral therapy is the standard of care for bulimia. Patients work on issues related to self-esteem and on recognizing the unrealistic ideals of thinness fostered by the media.

There is no one known cause for bulimia. As well as cultural pressures to be thin, there are a number of other risk factors. Conflict with parents, a family history of eating disorders, low self-esteem and a history of anorexia all increase a woman’s risk. A history of anorexia is seen in 40 percent of women with severe bulimia, and some researchers speculate that dieting may set the stage.

A large percentage of teens and young women diet frequently. Strict diets that create feelings of deprivation and food cravings can’t be maintained and lead to uncontrolled binge eating. Women become locked in an unhealthy binge/purge cycle that has a negative effect on mood, self-esteem and health.

Rather than hide their symptoms, women with eating disorders should seek professional help that ideally includes therapy to counter self-defeating thoughts and behavior related to food and body image. The best chance of success lies in a combination of medication and therapy.

Michelle Herbert, PharmD, CDE