Official reprint from UpToDate® Back | Print www.uptocate.com Author Section Editor Deputy Editor Sara F Forman, MD Amy B Middleman, MD, —H Nancy Sokol, MD MPH, MS Ed Last literature review version 17.3: September 2009 | This topic last updated: May 13, 2009 (More) INTRODUCTION — The current United States culture is obsessed with weight loss. Women's magazines typically have a cover highlighting a story about weight management, dieting hints, or how to tighten specific muscle groups Models and actors display an unattainable level of thinness. Some athletes relentlessly pursue a leaner body for performance enhancement. Our culture's obsession to achieve lower weight conveys an unavoidable message to maturing adolescents. According to the 2005 Youth Risk Behavior Survey, 32 percent of adolescent girls believed that they were overweight and 61 percent were attempting to lose weight [1] . In the 30 days before questioning, 6 percent of adolescent girls reported that they had tried vomiting or had taken laxatives to help ccntrol their weight. The epidemiology, pathogenesis, and clinical features of eating disorders are reviewed here. Treatment and outcomes of these conditions is discussed separately. ( See "Eating disorders: Treatment and outcome"). DEFINITIONS Anorexia nervosa — A diagnosis of anorexia nervosa requires four diagnostic criteria as defined in the DSM-IV ( show table 1 ) [2] : * Refusal to maintain weight within a normal range for height and age (more than 15 percent below ideal body weight) + Fear of weight gain + Severe body image disturbance In which body image is the predominant measure of self-worth with denial of the seriousness of the illness * In postmenarchal females, absence of the menstrual cycle, or amenorrhea (greater than three cycles).Adolescents with anorexia nervosa may drop 15 percent below ideal body weight without losing weight if they do net gain appropriate amounts during their pubertal growth spurt. There are two subtypes of anorexia nervosa: restricting; and binge eating/purging ( show table 1 ). Patients with the restricting subtype primarily use restriction of intake to reduce their weight, while those with the binge/purge subtype may either binge or use purging (eg, vomiting, laxatives, diuretics) to control their weight. Thus, a patient with anorexia may induce vomiting, yet can still be considered anorexic (rather than bulimic) if he/she Is 15 percent below ideal body weight and meets the other physiologic and psychologic criteria. Either subtype may also use compulsive exercise as a means to reduce weight. Bulimia nervosa —The DSM-IV criteria for bulimia nervosa include the following (show table 2 ) [2] : * Episodes of binge eating with a sense of loss of control * Binge eating Is followed by compensatory behavior of the purging type (self-induced vomiting, laxative abuse, diuretic abuse) or nonpurging type (excessive exercise, fasting, or strict diets). * Binges and the resulting compensatory behavior must occur a minimum of two times per week for three mnths * Dissatisfaction with body shape and weight In addition, the disturbance does not occtr exclusively during episodes of anorexia nervosa. Other — The DSM-IV also includes a definition for Eating Disorder Not Otherwise Specified (ED-NOS) [ 2] . This category includes patients with clearly aberrant eating patterns and weight management habits who do not meet the criteria for anorexia nervosa or bulimia nervosa. Binge eating disorder —Although it is only a research diagnosis, there has been significant interest in binge eating disorder (BED). Its role in the current obesity epidemic is being defined. According to the research criteria, BED involved binge eating (eating, ina discrete period of time, an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances) two days per week for a six month duration [ 2] . The binge eating is associated with a lack of control over the eating, and with distress over the binge eating. The binges associated with BED must have at least three of the following five criteria: * Eating much more rapidly than normal* Eating until uncomfortably full * Eating large amounts of food when not feeling physically hungry * Eating alone because of embarrassment «Feeling disgusted, depressed, or very guilty after overeating The mean lifetime duration of BED in one study was 14.4 years, longer than for bulimia nervosa (5.8 years) or anorexia nervosa (5.9 years) [ 3] . EPIDEMIOLOGY — Trends in the epidemiology of eating disorders are difficult to assess because of changes in the diagnostic criteria over time, and because detection by self-report may not be reliable in an illness characterized by secrecy and denial [ 4] . Most studies report increased prevalence over the past 50 years [ 5] , although trends over the past 10 years are debated. One study among college students in California noted a decrease in binge/purge behaviors from the 1980s to the 1990s[ 6] . However, most clinicians believe that incrzased numbers of eating disordered patients are presenting to their practices. The lifetime prevalence of anorexia nervosa in women is estimated to be 0.3 to 1 percent [ 7] . Rates for men are significantly lower. Data from the National Comorbidity Replication survey indicate a lifetime prevalence of 0.9 and 0.3 percent for women and men respectively [ 8] . Data from a Finnish birth cohort study suggest a higher lifetime prevalence (2.2 percent), with inclusion of untreated cases Identified by screening [ 9]. Bulimia nervosa has more stringent criter'a in the DSM-IV than earlier DSM diagnoses. This, combined with the shorter length of time that this illness has been identified, clouds interpretation of epidemiologic data. Prevalence rates of 1 to 1.5 percent of women have been reported [ 8,10] . Rates for younger adolescents are generally lower than those for college students. ED-NOS occurs in approximately 3 to 5 percent of women between the ages of 15 and 30 in Western countries [ 11] . Eating disorders have become more common among minority culture groups as these groups become assimilated into American society [ 12] . An estimated 1 to 2 million women in the United States meet criteria for bulimia nervosa as defined in the DSM-IV; 500,000 women meet diagnostic criteria for anorexia nervosa [ 13] . Many more have disordered eating and meet criteria for ED-NOS. There are two peaks of the onset of anorexia nervosa, at ages 14 and 18, though patients may present from late childhood through adulthood. Prevalence data for binge eating disorder (BED) are quite variable depending on the population surveyed, ranging from less than 2 percent of a community sample to over 30 percent among patients in a weight loss clinic[ 14] . Lifetime prevalence in the US National Comorbidity Replication survey was 3.5 percent