Eating disorders: types, diagnosis and treatment

A family member who constantly refuses to share a meal with you in the evening and says they’ve already eaten. A school friend who’s obsessed with exercise, takes it to the extreme and weighs every gram of chicken. A colleague who can only go half an hour without snacking and posts all her meals on Instagram. Harmless habits? Or a step on the way to developing an eating disorder?
 
“Be it among friends, in news reports or on social media, there currently seems to be an obsession with diet and nutrition”, says Professor Gabriella Milos, president of the Swiss association for eating disorders and senior consultant at the clinic for consultation-liaison psychiatry and psychosomatic medicine at the University Hospital of Zurich, who has worked in this field for over 20 years.

“It’s common nowadays to work out, read all about specific nutrients, and encourage each other to lose weight on Instagram. But there’s so much information out there, it’s sometimes hard to know what’s healthy and what’s not,” says Milos. “How, what and how much people eat is largely determined by their lifestyle, and obsession with diet has become normalised. This makes it harder to spot an eating disorder early on.”

What is an eating disorder?

Of course, not every person who eats too much suffers from a serious disorder. Just like every successful diet isn’t a sign of anorexia. But the slide from normal to slightly conspicuous eating habits and then to a serious disorder is often gradual.

At what stage can a person be said to have an eating disorder? As there are many different types, it is hard to provide a general definition. “One thing that those affected have in common is that they have an unhealthy relationship with food and their body,” says Milos. “These people spend a great deal of time thinking about what they eat. They eat either too much or too little, cut out major food groups or vomit after a meal.”

Frequency

In Switzerland and other industrialised countries, around 3.5% of the population will develop an eating disorder during the course of their life.

“Atypical eating disorders are also on the rise,” says Milos. “These people don’t have normal eating habits, but don’t fit into the narrow definitions of classic eating disorders. They often have mixed or weakened forms.”

Around 13% of people living in Switzerland have some kind of problem with eating (OBSAN report 2023). In addition, obesity, often triggered by unhealthy eating habits, is a growing global health problem in industrialised nations and developing emerging countries.

Gender differences

More women are affected by eating disorders than men. The differences between the genders also extend to the type of disorder, with women more likely to suffer from anorexia.

“Recent studies reveal that this is probably also due to a woman’s metabolism,” says Milos. “The female body is subject to complex hormone fluctuations. For example, many women experience cravings before their period.” The metabolism has to constantly balance out these fluctuations, thus making women more susceptible to eating disorders.

Studies have also highlighted metabolic anomalies in people with anorexia, even before the onset of the disorder. As a result, researchers now assume that anorexia is not purely a psychiatric or psychological condition but is also driven by problems with metabolism.

A new research project on the topic by Professor Milos is testing the influence of artificially produced leptin (a hormone produced in the body) on women with anorexia. “Preliminary studies indicate that the substance could have a positive effect on depressive moods and other symptoms of anorexia.” A new glimmer of hope for a disorder that is hard to treat.

Men are more likely to fall into the trap of excessive exercise and abuse of anabolic steroids, which is similar to an atypical eating disorder. But they can also suffer from traditional eating disorders.

Age

There are also differences between age groups. Anorexia tends to start in adolescence, while bulimia and binge eating often develop in later adolescence or young adulthood – and even extend into a person’s 40s.

Types of eating disorders

There are many different types of eating disorders: people eat too much, too little or irregularly, or make themselves throw up after meals. The boundaries between the different types are often blurred.

Causes and risk factors

There’s no single cause of eating disorders. In most cases, various factors have to come together to result in unhealthy eating behaviour. But perfectionism, anxiety, issues with self-esteem, depressive moods, experiencing psychological or physical abuse and difficulties regulating feelings all seem to play a role in the development of eating disorders.

Elite athletes at greater risk

People who are training at a high level and worrying a lot about their appearance are often more susceptible. They want to shape their bodies to fit their ideals. Particularly with anorexia or bulimia, however, patients have a disturbed body perception and a false body image – they perceive themselves to be fat, even though they aren’t.

It’s hardly surprising, therefore, that eating disorders are particularly common in circles that focus on performance, weight and beauty, such as elite sports like ballet or gymnastics or in the world of modelling.

Unrealistic ideals of beauty

Associating beauty with being extremely thin is particularly dangerous. Many children and young people base their expectations on unrealistic (and often edited and filtered) pictures shown in the media, advertising and on social media platforms. So those affected have often tried many diets at an early age before the actual eating disorder begins.

But experiences such as sexual abuse or neglect can also lead to eating disorders. And since eating disorders are more common in some families, it is suspected that genetic factors also play a role.

Diagnosing an eating disorder

If an eating disorder is suspected, the patient should be referred to a psychiatrist or psychologist. This is usually done by an attentive doctor. In addition to physical abnormalities, such as being underweight or severe weight fluctuations, interviews and self-assessment questionnaires are key tools for diagnosis.

What to watch out for:

• Young women with a low body weight
• Underweight and normal-weight patients who worry about their weight
• Women with menstrual disorders or amenorrhoea
• Patients with symptoms of malnutrition
• Patients with digestive problems
• Patients with recurring vomiting
• Children with growth disorders

Body mass index gives initial indication

The World Health Organization’s body mass index (BMI) is usually used to determine whether a person is overweight or underweight. It is a statistical figure indicating the ratio of height to weight. Even though the BMI is often criticised for not providing sufficient information on body composition, it is useful as a guide.

For example, particularly muscular people (e.g. athletes) can still be classified as normal weight, although their body composition – due to the lack of fat – displays a conspicuous hormonal metabolism. This can result in brittle bones or missed periods.

What treatments are available?

All eating disorders are serious illnesses and it is important that they are treated as early as possible. Anorexia, for example, has the highest mortality rate of any psychiatric disorder. The faster this eating disorder is diagnosed, the higher the chances of recovery.

So it’s important for friends, relatives and colleagues to be alert and act quickly: “If someone stops eating with other people, is obviously underweight or always eats and throws up after meals, it’s high time to seek help,” says professor Milos. “Regular psychological counselling with a trusted therapist is particularly useful in cases like these. And it’s important not to do battle with the person affected but to see the eating disorder as an illness.”

Compulsory treatment only in critical cases

Compulsory treatments such as force feeding are fortunately rare and are only carried out when it is a matter of life and death. “By then, the disorder is already well advanced,” says Milos.

The Swiss association for eating disorders explains how those affected can be helped:

Alongside psychological counselling, self-help groups can also provide valuable support for those affected and their relatives.