e6-10: Eating Disorders in Women

Eating disorders are common in women. Anorexia nervosa and bulimia nervosa are described in detail in Chapter 29-05 and 29-06. The female athlete triad disorder, disordered eating in patients with diabetes, and binge eating disorders are other eating disorders that should be considered.

General Considerations

Female athletes who participate in sports and activities valuing thinness are at increased risk for developing the female athlete triad disorder. The female athlete triad is described as an interrelationship of menstrual dysfunction, low energy availability (with or without an eating disorder), and decreased BMD. The triad includes disordered eating (a spectrum of abnormal patterns of eating, including binge eating, purging, food restriction, prolonged fasting, and the use of diet pills, diuretics, or laxatives), menstrual disorders, and low BMD. Half of all athletes with amenorrhea have BMD at least 1.0 standard deviation below the mean. The BMD is decreased even in those areas subjected to stress during exercise. The diagnosis is made when the female athlete meets the three criteria of the triad.

Clinical Findings

A. Symptoms and Signs

Individuals with the female athlete triad display some pattern of disordered eating and have some menstrual irregularities. Many women have amenorrhea, but others have irregular menses. Typically, the patient has concerns about weight and body image. A history of stress fractures should also raise the clinician's concern.

B. Laboratory Findings

Depending on the severity of the symptoms and whether the patient is binging and purging, the laboratory abnormalities can be similar to those seen in anorexia nervosa or bulimia nervosa. These include electrolyte abnormalities related to binging and purging, metabolic alkalosis due to dehydration and volume depletion, and anemia. BMD, if measured, is decreased.

Differential Diagnosis

The main differential diagnoses include anorexia nervosa, bulimia nervosa, and endocrine disorders such as hyperthyroidism and diabetes mellitus.

Treatment

Little evidence is currently available about treatment of the female athlete triad. Strategies such as counseling, cognitive-behavioral therapy, and possibly exercise restriction may be helpful. A multidisciplinary approach, including consultation with a nutritionist and communication with the coach and trainers (after obtaining appropriate consent from the patient), may enable common goal setting. Working with athletes to develop a "contract" that outlines their responsibilities, and the goals of treatment may be helpful. The desire to participate in sports and the lure of a performance-enhancing diet may motivate some patients to pursue treatment.

General Considerations

Eating disturbances have been estimated to be present in up to one-third of young women with diabetes mellitus. Eating disorders are more common in female adolescents with diabetes than in their peers without diabetes and in women with type 1 diabetes. All-cause mortality is 4–14 times higher in women with anorexia nervosa compared with the general population, and it is even higher in those who have both diabetes and eating disorders. Patients with diabetes and disordered eating have also been shown to have an increased risk of retinopathy.

For diabetes, the dietary regimen emphasizes intense meal timing and consistency. In addition, the hunger associated with hypoglycemia encourages binge eating. Given the emphasis that young women often place on body weight, maintaining optimal diabetes control is a particular challenge. The diagnosis is typically made in a patient with diabetes who has worsening diabetic control, when other causes of worsening control have been ruled out.

Clinical Findings

A. Symptoms and Signs

Patients with diabetes may report polydipsia, polyuria, or weight loss. In addition, upon questioning, they may report disturbed eating patterns. Other symptoms associated with eating disorders, such as disturbance of body image and menstrual irregularities, may be present.

B. Laboratory Findings

The main laboratory finding will be a trend of increasing levels of hemoglobin A_1C.

Differential Diagnosis

The main differential diagnoses are other causes of worsening glycemic control, including infection, or metabolic disease, such as hyperthyroidism.

Treatment

There is currently no evidence to support any particular strategies for the treatment of disordered eating in women with diabetes. Proposed strategies for at-risk women include nutritional counseling to promote healthy eating instead of dietary restraint, regular (instead of fixed) meal and snack times, less intensive insulin therapy to reduce weight gain, and family counseling to improve communication.

No studies have evaluated the optimal treatment of patients with diabetes and established eating disorders. Presumably, strategies that are effective for patients without diabetes, such as cognitive-behavioral therapy and medications, will be effective. In addition, management strategies for diabetes that do not require patients to constantly think about food may be beneficial.

General Considerations

Binge eating disorder, which is more common than anorexia nervosa or bulimia nervosa, is recognized as a diagnosable eating disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) (see Chapter 29-04).

Binge eating disorder is much more common in women and is associated with obesity, although not all individuals with binge eating disorder have obesity. Obesity-related complications are likely to occur, and the disorder may be more common in weight-cycling patients. Psychiatric comorbidities are common.

Clinical Findings

Affected women may present with weight gain or may describe binging episodes. There are no specific laboratory findings for this disorder.

Differential Diagnosis

The main differential diagnosis includes other psychiatric and eating disorders. Other diagnostic possibilities include hypothyroidism and Prader-Willi syndrome.

Treatment

Treatment goals focus on decreasing the patient's binge eating episodes and may include weight loss and treatment of other psychiatric comorbidities. As in bulimia nervosa, cognitive-behavioral therapy is the mainstay of treatment. Interpersonal therapy has also been shown to be effective. Pharmacotherapy with SSRIs is also helpful but does not appear to be better than cognitive-behavioral therapy. In addition, behavioral weight loss therapy (caloric restriction, increasing physical activity), although not specifically targeting binge eating, has been shown to be useful in individuals with binge eating disorder. If the woman does not respond to an SSRI, then topiramate and lisdexamfetamine (a medication typically used for attention-deficit/hyperactivity disorder) have shown some efficacy. Although medications focusing specifically on weight loss are sometimes considered, there is no evidence for this approach. Whether cessation of binge eating disorder has an impact on subsequent weight loss or other obesity-related complications is not clear.