Eating disorders, which include anorexia nervosa, bulimia nervosa, and binge-eating disorder, are psychological disorders where people experience abnormal or disturbed eating habits. People who have anorexia nervosa typically view themselves as overweight, but they are actually dangerously underweight. Anorexia nervosa may lead to several medical complications including abnormally slow heart rate, low blood pressure, scoliosis, osteoporosis and/or severe dehydration, and women may experience amenorrhea, or an absence of period. People of any age, race, gender, and social-economic status can be affected by anorexia. The disorder most frequently begins during adolescence, but children and adults can be diagnosed as well. Hudson, Hiripi, Jr, & Kessler (2008) found the lifetime prevalence estimate of anorexia nervosa to be 0.9% among women and 0.3% among men in the United States. A 2011 meta-analysis found that mortality rates among those with anorexia nervosa are higher than the general population, and higher than mortality in patients with other eating disorders (including bulimia nervosa and eating disorder not otherwise specified; Arcelus, Mitchell, & Wales, 2017).
While there is a growing body of research on treatment for anorexia nervosa, the research on the prevention of anorexia is limited. Some research has suggested that individuals who have anorexia are more likely to experience adverse health risks, compared to their peers without eating disorders. This data snapshot further explores some of those adverse health risks among adolescent girls in Utah.
To better understand the magnitude of eating disorder behaviors on the adolescent population, Youth Risk Behavior Surveillance System (YRBSS) data from 2011 and 2013 were used. YRBS is a collaboration between the Centers for Disease Control and Prevention and the Utah Department of Health. The YRBSS surveys students in grades 9-12, across Utah every two years. The questionnaire includes sections for chronic disease prevalence, alcohol, tobacco and drug use, safety, violence-related behaviors, physical activity and nutrition, depression, and suicide ideation.
To look at health risks due to potential anorexia among the adolescent population in Utah, we used two constructs – Body Mass Index (BMI) based on age and sex growth charts, in addition to diagnosis of an eating disorder behavior. To determine if an adolescent had potential anorexia, we identified students below the 15th percentile BMI and those who had one or more of the following eating disorder behaviors: (1) trying to lose weight; (2) fasting for 24 hours or more to lose weight during the past 30 days; (3) taking diet pills to lose weight during the past 30 days; and (4) vomiting or using laxatives to lose weight during the past 30 days.
To understand the magnitude and consequences of eating disorder behaviors among underweight adolescents, we looked at rates of various health risks for adolescents with potential anorexia compared to those without potential anorexia. These findings highlight the burden of anorexia and associated health risks on the female adolescent population in Utah.
In 2011 and 2013, 3.9% of female students and 1.4% of male students met the BMI and eating disorder behavior criteria for potential anorexia. For girls, the most commonly reported eating disorder behavior for those with potential anorexia was trying to lose weight (22.8%), followed by fasting to lose weight (11.8%), vomiting to lose weight
(7.0%), and taking pills to lose weight (4.8%). Overall, these percentages estimated that nearly 3,000 girls and more than 1,000 boys were potentially anorexic in Utah. For females, this number was approximately equal to the number of female student who currently smoke cigarettes during the same time period.
Additionally, we applied these two criteria for potential anorexia to 2013 national YRBSS data. We found that rates of potential anorexia among all adolescents (2.6% and 1.5%) and rates of potential anorexia among girls (3.9% and 2.1%) are statistically higher in Utah compared to the U.S. adolescent population. This further magnifies the severity of these findings and demonstrates the magnitude of the issue within Utah.
Anorexia has been shown to be associated with numerous adverse health risks. The prevalence of potential anorexia among girls was associated with higher rates of the health risks shown on Graph 1 and Graph 2. Compared to those with no potential anorexia, girls with potential anorexia had statistically higher rates of: suicide ideation (36.6% vs. 16.1%); making a suicide plan (31.4% vs. 13.0%); attempting suicide (18.7% vs. 6.3%); electronic bullying (34.3% vs. 21.0%); being in a physical fight (30.3% vs. 14.7%); and intimate partner violence (physically hurt 22.0% vs. 6.3%; forced to do sexual activities 35.5% vs. 13.2%).
Discussion: Domains of Health, Girls, Potential Anorexia, and Health Risks
Physical & Reproductive Health
Anorexia nervosa, while a mental health condition, also manifests itself physically. Individuals who have anorexia nervosa can be at risk for numerous consequences, including death due to the development of arrhythmias (abnormal heart rhythms) or electrolyte imbalance. Anorexia has the highest mortality of any mental illness. Physical symptoms of anorexia include extreme weight loss, bluish discoloration of fingers, thinning hair, lanugo (soft, downy hair covering the body for warmth), and dehydration. Physical complications as a result of some of the aforementioned symptoms of anorexia include anemia, bone loss, gastrointestinal problems, and kidney problems.
Additionally, females may experience amenorrhea (absence of a period) and men may experience a decrease in testosterone. Despite menstrual irregularities, women with anorexia nervosa are getting pregnant at similar rates to those found in the general population. The demands of pregnancy on a person with anorexia nervosa may present additional challenges and considerations, but for mothers with adequate gestational weight gain, the occurrence of delivery complications and rate of birth defects was no different from that of the general population (Hoffman, Zerwas, & Bulik, 2011). In addition, potential anorexia in young people was associated with other adverse risk behaviors, including physical and sexual assault.
Occupational and Financial Health
Higher health-care costs and treatment costs present financial burden for individuals with anorexia. One study demonstrated nearly $2,000 higher annual health-care costs among individuals with eating disorders compared to the general population (Samnaliev, Noh, Sonneville, & Austin, 2015).
Eating disorders are a disorder of the mind and body. They are not a fad, diet, or lifestyle choice. Those with anorexia nervosa maintain a starvation diet despite being significantly underweight. Often, the individuals feel a sense of control when engaging in abnormal eating habits and losing weight. Once they are at an unhealthy body weight, they still see themselves as overweight and refuse to regain healthy weight. Eating disorders, including anorexia nervosa, must be recognized as a mental health issue and must be treated as such. It is common for eating disorders to co-occur with other psychiatric disorders. This makes diagnosis, treatment, and recovery even more difficult. The earlier a person seeks treatment, the greater are the chances of emotional and physical recovery.
Our results demonstrate the lack of attention and resources anorexia has received compared to other health conditions with a similar burden among the same population. Based on the findings of this analysis, recommendations include a deeper dive to better understand the problem, as well as development and implementation of prevention strategies and interventions for adolescents with potential anorexia. Current efforts by healthcare providers to screen for eating disorders, as well as current efforts to prevent interpersonal violence and suicide in youth, should be evaluated. School nurses or school counselors may play an important role in screening for or identifying eating disorders, violence, mental health, and other associated health risks, and providing support for affected youth. Prevention resources and partnerships should be aligned to incorporate these findings. The magnitude of potential anorexia among adolescent girls in Utah, and the association with multiple health risks, demonstrate the need to recognize and address eating disorders as a part of adolescent health. Awareness of these issues is critical, among school staff and providers as well as parents and all youth.
- Arcelus, J., Mitchell, A. J., & Wales, J. (2011). Mortality Rates in Patients With Anorexia Nervosa and Other Eating Disorders, Arch Gen Psychiatry 68(7), 724–731.
- Hoffman, E. R., Zerwas, S. C., & Bulik, C. M. (2011). Reproductive issues in anorexia nervosa. Expert Review Obstet Gynecol, 6(4), 403–414. https://doi.org/10.1586/eog.11.31.
- Hudson, J. I., Hiripi, E., Jr, H. G. P., & Kessler, R. C. (2007). NIH Public Access, 61(3), 348–358.
- Samnaliev, M., Noh, H. L., Sonneville, K. R., & Austin, S. B. (2015). The economic burden of eating disorders and related mental health comorbidities : An exploratory analysis using the U . S . Medical Expenditures Panel Survey. PMEDR, 2, 32–34. https://doi.org/10.1016/j.pmedr.2014.12.002
Friedrichs M, Waters M, Ferell D. (2019). Potential Anorexia Among Adolescent Girls in Utah. Utah Women’s Health Review. doi: 10.26054/0KZCZSHTDF.