Eating disorders in adolescents and young adult women: Implications for reproductive health
Eating disorders (EDs) are serious, often debilitating chronic illnesses that typically start in adolescence. About 90% of ED patients are female. In addition to anorexia nervosa (AN) and bulimia nervosa (BN), the most recent Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) has included binge eating disorder.1 Past DSM editions included the category “eating disorder not otherwise specified” (EDNOS), and many young people fell into this group. Modifications of the other ED criteria and the addition of the category “other specified feeding or eating disorder” led to the elimination of EDNOS. Avoidant/restrictive food intake disorder (ARFID) is one more new category; it is especially relevant for children and adolescents. Table 1 outlines the DSM-5 ED criteria.1
The prevalence of EDs has increased in recent decades, likely due in part to better recognition as well as the marked medical and societal focus on obesity and dieting. Current prevalence estimates among adolescents and young adults in the United States are 0.5% to 1.0 % with AN, 1% to 2% with BN, and about 5% with other EDs.2 Of special concern is that ED diagnoses are increasingly being made in preadolescents (<12 years), putting this young population at heightened risk for delayed physical and psychosocial development.3 These prevalence figures are clearly underestimates. The 2011 Youth Risk Behavior Surveillance, a biannual national survey of high school students by the Centers for Disease Control and Prevention, found 61% of females were trying to lose weight, and in the past 30 days 12% of females had not eaten for 24 hours or more, 5% took diet pills/supplements, and 4% induced vomiting or took laxatives to lose or not gain weight.4 Thus, many young women are engaging in unhealthy eating and dieting behaviors, even if they do not meet DSM criteria for an ED.
EDs can affect every organ system; patients may present with any combination of gynecologic, cardiac, gastrointestinal, neurologic, orthopedic, or psychiatric signs and symptoms (Table 2). Young women with EDs are seldom forthcoming about their ED thoughts and behaviors, often leading to unnecessary testing and delayed diagnosis. Because of parental concerns, children and adolescents may be more likely to see a healthcare provider earlier in their course than are older patients.
EDs are multifactorial in origin, with a strong genetic component.3,5 They are not volitional, although dieting often precedes the ED. Patients with AN at low weight show elevated ghrelin, a hunger-stimulating hormone secreted mainly by the stomach and pancreas, and a low level of leptin, a hormone secreted by adipocytes. These abnormalities are likely a physiologic adaptation to a starved state, rather than causal. A constellation of personality and psychologic traits such as perfectionism and low self-esteem are often but not always seen in those with EDs. Comorbid psychiatric conditions, especially anxiety and depression, are common.6 Again, are these factors causative or more a result of the disordered eating and weight changes? Our thinness-obsessed culture influences everyone; young women seem to be especially vulnerable to unrealistic and unattainable “body ideals,” and yet few develop an ED.