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Am Fam Physician. 2001;64(3):367-369

See article on page 445.

Eating disorders are a complex group of illnesses that often are seen in the adolescent female population. During the past three decades, the prevalence of eating disorders has increased dramatically; currently, the overall incidence is approximately 5 percent.1,2 Although eating disorders generally occur in adolescents, they are now seen much more often in children and adults, including the elderly.3 Initially, eating disorders were believed to affect only socioeconomically advantaged white women; however, this stereotype has not held true. These diseases affect persons of all social classes and both sexes.3 The increase in the prevalence and incidence of eating disorders is multifactorial.4 Increased awareness among patients and physicians is partly responsible for the increase, but the media, the fashion industry and changing societal norms are equally responsible.

This rise in the incidence of eating disorders can be best illustrated by tracing recent history. In the 1940s and 1950s, the movie star Marilyn Monroe, whose figure was curvaceous and somewhat Rubenesque, exemplified the ideal woman's figure. However, by 1967 a 92 lb British teenager, “Twiggy,” was the most famous fashion model and her “ultra thin” prepubescent body was perceived as the ideal figure for women. In the 1970s and 1980s, eating disorders finally received media attention with the death of singer Karen Carpenter, who died of cardiac complications of anorexia nervosa. This was the first time the media focused on the fact that eating disorders can have life-threatening consequences and are not simply a group of “benign” psychiatric illnesses. Since then, public awareness and understanding have continued to grow as more and more celebrities and athletes disclose their personal battle with these diseases. Unfortunately, icons such as the late Princess Diana of Wales may have romanticized these illnesses and made them appear less serious and life threatening than they are.

As evidenced by this historical account, the initial battle involved gaining recognition of the serious nature of eating disorders, first by the medical community and much later by the lay population. Despite a 200-year medical history and a detailed classification and description of these diseases, the National Association of Anorexia Nervosa and Associated Disorders has recently stated that “many physicians and other health professionals have not been trained to recognize or treat anorexia.”6 Given the current prevalence and incidence of eating disorders, all of us need to become more knowledgeable and comfortable with the recognition and treatment of this complex group of illnesses.

Health care professionals who routinely screen and treat patients with eating disorders recognize that another battle must be faced. The current challenge is not in understanding these illnesses but in providing comprehensive medical services to affected patients. It is incomprehensible that most insurance companies only allot a life-threatening illness such as anorexia nervosa “30 days per year” of inpatient hospital coverage when such limitations do not apply to other serious illnesses, such as ischemic heart disease. Medical complications of eating disorders create a significant risk of mortality as well as long-term morbidity. Limiting care for patients with eating disorders is a shortsighted and economically driven decision that will ultimately have a negative impact on future health care costs.

To address the inequities surrounding eating disorders, it is important that physicians continue to document the medical complications of these illnesses in reputable journals. In this issue of American Family Physician, Kaplan Seidenfeld and Rickert5 provide an excellent review of the morbidity faced by female adolescents with eating disorders.

By stressing the medical complications of eating disorders, the focus may shift from the psychiatric to the medical, possibly altering how these illnesses are viewed by the insurance industry and, ultimately, how treatment services are offered.

And finally, what about prevention? We are a nation obsessed with dieting and thinness, yet, as a nation, we are becoming more overweight with each passing year. The multibillion-dollar “diet food industry” has produced numerous nutritionally empty low-fat foods, of which a large percentage of American children are consuming. Obviously low-fat foods are not the solution and, in fact, growing evidence suggests that dieting itself may be the initiating factor in the development of eating disorders.7 Furthermore, the media and the fashion industry play a significant role in establishing society's body image norms. Is there a way to shift some of their efforts and resources into nutritional education, a nationwide exercise encouragement program and education geared at healthier body norms? While better education and increased activity throughout the lifespan may be part of the solution, we need to encourage physicians, especially primary care physicians, to head research studies specifically focused on prevention. For a chronic disorder such as anorexia, prevention is more cost-effective than treatment after the fact.

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