By Megan Flaherty
Illustration by Malcolm Garris/PhotoDisc
February 11, 1999

Is "Ally McBeal" star Calista Flockhart anorexic? Does waif-model Kate Moss set a bad example? Do young gymnasts and ballerinas starve themselves—or regularly binge and purge—to keep their competitive edge?

Our society’s obsession with these questions reveal a growing public awareness of anorexia nervosa and related eating disorders, which affect between 5 million and 8 million Americans. Unfortunately, awareness alone is not enough to eliminate or diminish the impact of these sometimes deadly disorders, experts say.

"The prevalence of eating disorders continues to rise even though there is a lot of information about the warning signs, prevention, and treatment," said clinical nurse specialist Joan Petty, RN, a psychiatric nurse practitioner in New York who treats patients with eating disorders. "Society still embraces thinness as a top priority."

However, health professionals have come a long way in understanding eating disorders. Most health professionals had not even heard of anorexia 25 years ago; now many—but perhaps not enough—are able to spot the signs and symptoms of eating disorders in their early stages. Anorexia is usually identified in patients who have lost about 15 percent of their normal body weight for their height over a short time period. Most anorexics claim they feel overweight even when emaciated. Health professionals generally used to believe that only young, white women suffered from anorexia; now it’s widely recognized that eating disorders strike men, too, and all ages and ethnic groups.

Control issues

Researchers have studied the causes of anorexia and related eating disorders extensively. One popular conclusion is that "it’s all about control," said Paula Levine, PhD, director of the Anorexia and Bulimia Resource Center in Miami. A young person could be reacting against an overprotective family or reacting to rejection from peers, for example. "They just need something that says, ‘I’m in charge, I’m in control,’" Levine said.

According to Vivian Hanson Meehan, RN, president of the Highland Park, Ill.-based National Association of Anorexia Nervosa and Associated Disorders, people with eating disorders use food exactly as they use drugs and alcohol—as a means of escape. "By focusing on food or lack of food, you avoid life’s problems. No one can control how much a person eats or how her body appears, except herself," she said.

The causes of eating disorders differ for everyone, but they are often triggered by major life changes, Meehan said. She has worked with a young woman on the verge of graduating from college who developed an eating disorder because she feared failing in the real world. She’s also worked with a male karate expert who gained a little weight around his stomach, went on a diet, and ended up with an eating disorder that was difficult to recover from. Other studies show a genetic component to eating disorders, links between physical or sexual abuse and eating disorders, and many more possible causes.

Spotting the disorders

Nurses who have ongoing patient contact—especially school nurses and nurses who work in direct primary care offices—are in the best position to spot a person with a potential eating disorder, experts say.

Warning signs can be more subtle than large weight fluctuations. If a patient is uncomfortable getting on the scale or evasive about answering questions related to food, eating, or exercise, it’s important to dig a little deeper, said Margo Maine, PhD, director of eating disorders at the Institute of Living, a research, education, and outpatient care facility in Hartford, Conn. Nurses should ask whether the person takes laxatives to lose weight and ask what health food products a patient buys. Some over-the-counter drugs advertised as "fat burners" or "natural phen-fen" may be dangerous, Maine said. Nurses sometimes don’t understand that excessive exercise and amenorrhea can lso be linked to eating disorders, she said.

"It’s relatively easy to identify anorexia, but sometimes we’re not as attuned to normal- or higher-weight people who also have eating disorders," Maine said. Even patients who are right where they’re supposed to be on the height and weight charts should be asked what they do to maintain their weight. They could be bingeing and purging, exercising excessively, or avoiding food. "Anorexia will eventually become visible, but bulimia can be very secret for a long time," Levine said.

Gentle treatment

At the time they notice a weight fluctuation or suspect an eating disorder, it’s best for nurses to express their concerns directly—to the patient in the case of an adult or to a parent in the case of a child, Maine said.

"Usually when we first ask a person, there is a fair amount of denial," Maine said. But just asking the questions lets patients know that you care and that they can turn to you for help and referrals to resources, she said.

It’s tougher for staff nurses and others who don’t have ongoing relationships with patients to identify a potential eating disorder and approach a patient about it, Meehan said. "Nurses can spot a problem, but unless the people they work with are alert or are willing to do something, their hands may be tied," Meehan said.

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