Eating disorders are serious and often chronic mental health conditions characterised by disturbances in eating behaviours and psychological distress related to eating and body image (Fairburn et al, 2003; Klump et al, 2009). The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association [APA], 2013) specifies three distinct eating disorders:
Additionally, the DSM-5 includes two further categories of eating disorder, namely, other specified feeding and eating disorder (OFSED) and unspecified feeding and eating disorders (UFED) (APA, 2013). OSFED includes atypical anorexia nervosa (anorexia at a higher body weight), subthreshold bulimia nervosa and binge eating disorder (due to low frequency or limited duration), purging disorder and night eating syndrome. UFED encompasses disordered eating patterns that do not meet any of the criteria above. Notably, eating disorders that fall under the OFSED or UFED categories are no less serious than the aforementioned distinct eating disorders (Fairweather-Schmidt and Wade, 2014).
A summary of the diagnostic criteria for anorexia nervosa, bulimia nervosa, binge eating disorder, OFSED and UFED is provided in Table 1.
| Anorexia nervosa (two types: restricting type and binge eating/purging type) | Criterion A: restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than minimally expected |
| Criterion B: intense fear of gaining weight or becoming fat or persistent behaviour that interferes with weight gain, even though at a significantly low weight | |
| Criterion C: disturbance in the way that one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation or persistent lack of recognition of the seriousness of the existing low body weight | |
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Severity grading:
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| Bulimia nervosa | Criterion A: recurrent episodes of binge eating. An episode of binge eating is characterised by eating in a short period of time (e.g. within a 2 hour period) an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances, and a sense of a lack of control over eating during the episodes (e.g. a feeling that one cannot stop eating or control what or how much one is eating) |
| Criterion B: recurrent inappropriate compensatory behaviours to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercise | |
| Criterion C: the binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for 3 months | |
| Criterion D: self-evaluation is unduly influenced by body shape and weight | |
| Criterion E: the disturbance does not occur exclusively during episodes of anorexia nervosa | |
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Severity (episodes of inappropriate compensatory behaviours per week)
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| Binge eating disorder | Criterion A: recurrent episodes of binge eating characterised by both eating in a discrete period of time (e.g. within a 2 hour period) an amount of food that is definitely larger than most people would eat in a similar period under similar circumstances and a lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating) |
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Criterion B: binge eating episodes are associated with three or more of the following:
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| Criterion C: marked distress regarding binge eating is present | |
| Criterion D: binge eating occurs, on average, at least 1 day a week for 3 months | |
| Criterion E: binge eating is not associated with regular use of inappropriate compensatory behaviour (e.g. purging, fasting or excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa | |
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Severity (binge eating episodes per week):
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| Other specified feeding and eating disorders |
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| Unspecified feeding and eating disorders | Symptoms are characteristic of a feeding and eating disorder and cause significant distress or impairment in social, occupational or other important areas of functioning, but do meet all criteria for a feeding or eating disorder |
Causes of eating disorders
The causes of eating disorders are complex and multifaceted. Evidence indicates that genetic, environmental, cognitive and behavioural factors may all play an interactive role in eating disorder onset and maintenance. For example, heritability estimates based on twin studies suggest a genetic predisposition for eating disorders and indicate that genes may account for up to 74% of the variance in anorexia nervosa, up to 62% of the variance in bulimia nervosa and up to 45% of the variance in binge eating disorder (Yilmaz et al, 2015). Meanwhile, sociocultural models of eating disorders have shown that societal pressure to be thin, weight-based teasing and sexual objectification can result in body dissatisfaction, body shame and self-surveillance, which, in turn, can predict eating disorder symptomology (Dakanalis et al, 2016; Moradi, 2010; Stice, 2016). Additionally, negative mood, low self-esteem and perfectionism are often noted as contributing risk factors to eating disorder onset and maintenance (Fairburn et al, 2003; Polivy and Herman, 2002). Finally, dieting is a common behavioural precursor to eating disorders (Stice, 2016). Importantly, it is worth stating that the unique combination of risk factors varies at the individual level and other factors such as trauma are also associated with eating disorders (Polivy and Herman, 2002; Trottier and MacDonald, 2017).
Eating disorder outcomes
Eating disorders warrant attention as they are associated with numerous adverse health and quality of life outcomes (de la Rie et al, 2007; Hudson et al, 2007). Physical and psychological health consequences of eating disorders are well documented and include cardiovascular, endocrine and gastrointestinal complications, dental problems, osteoporosis, nutritional deficiencies, marked psychological distress and comorbid psychiatric disorders, such as anxiety or depression (Westmoreland et al, 2016). Significantly, as the result of medical complications or suicide, eating disorders can be fatal, and anorexia nervosa is associated with the highest rate of mortality across all mental disorders (Arcelus et al, 2011). Beyond adverse health outcomes, eating disorders are also associated with impaired cognitive and emotional functioning. Research has found that eating disorders can significantly interfere with decision-making, concentration, emotional regulation, social communication and inter-personal relationships (Roberts et al, 2007; Harrison et al, 2010). Importantly, as eating disorders are often protracted, their burden on the individual's quality of life is substantial and wide reaching (Price Water house Coopers [PwC], 2015; Eddy et al, 2017).
Beating the stereotypes
Contrary to the common stereotype that eating disorders are an affliction limited to thin, Caucasian adolescent women, eating disorders can affect anyone regardless of age, gender, race/ethnicity, weight or socio-economic status. For example, research has shown that, while eating disorder onset often occurs during adolescence (Hudson et al, 2007), eating disorders can emerge at any age (Gagne et al, 2012; Baker and Runfola, 2016). Furthermore, studies have shown that men account for up to 25% of those with an eating disorder, while transgender people are at greater risk of developing an eating disorder compared to cisgender peers. Evidence also suggests that eating disorders are also present across different racial and ethnic groups (Hudson et al, 2007; Marques et al, 2011; Diemer et al, 2015).
Barriers to treatment
Despite the severity of eating disorder outcomes, research has underscored that eating disorders are often under-diagnosed and undertreated (Hart et al, 2011). Factors such as shame, denial and an ambivalence to recovery are recognised barriers for individuals with eating disorders to present for help (Hart et al, 2011). Financial costs, geographic location and a lack of specialist treatment provision are also widely noted systemic barriers to eating disorder support (PwC, 2015). For instance, individuals who fall outside the narrow stereotype may not recognise themselves as someone with an eating disorder, may view themselves as less deserving of treatment, and/or may fear that health providers will dismiss their symptoms (Räisänen and Hunt, 2014; Sonneville and Lipson, 2018).
» Universal screening and appropriate referral pathway systems in aesthetic procedure settings are recommended to help improve eating disorder outcomes through early detection and intervention «
Given the extant evidence supporting the advantages of early intervention for eating disorder recovery (Grange and Loeb, 2007), researchers have highlighted the need for greater awareness and education among health professionals, including aesthetic practitioners. Dentists, hygienists and nurses have also been identified as healthcare professionals who may be instrumental in supporting the early detection of eating disorders, but among whom researchers have similarly observed gaps in knowledge and training (DeBate and Tedesco, 2006).
Link between aesthetic procedures and eating disorders
Veale (2006) argued that patients with eating disorders, like patients with body dysmorphic disorder (BDD), should be contraindicated to aesthetic procedures. However, little attention has been paid to eating disorders in the context of aesthetic procedures in academic literature. For example, it is unclear how many people with eating disorders present for aesthetic procedures and what the outcomes are for patients with eating disorders following aesthetic procedures, particularly in relation to their eating disorder symptoms, eating disorder trajectory and interest in recovery. The few studies examining eating disorders and aesthetic procedures have found that individuals with eating disorders report a higher interest in and tendency to seek liposuction, in line with body image concerns with weight and shape (Jávo and Sorlie, 2010; Jávo et al, 2012). Additionally, one study surveying women who had received inpatient treatment for an eating disorder found that 12% reported to having had at least one aesthetic procedure, with 4% reporting that they had had multiple aesthetic procedures (Coughlin et al, 2012). Notably, the authors found that those who had undergone aesthetic surgery tended to be older, had a higher BMI and were more likely to have a purging diagnosis (specifically, laxative and diet pill use), compared with those who had not undergone any aesthetic procedures.
In contrast to the scarcity of research investigating eating disorders and aesthetic procedures, numerous studies have considered BDD in relation to surgical and non-surgical aesthetic procedures. For example, evidence from Veale et al (2016) documented that individuals with BDD are overrepresented in aesthetic procedure settings (13.2% compared to 1.9% in community populations). Research also found poor post-aesthetic procedure outcomes for those with BDD. Specifically, individuals with BDD were more likely to report heightened psychological distress and dissatisfaction, which could lead to unwanted legislative action (Sweis et al, 2017). Furthermore, evidence suggested that aesthetic procedures rarely alleviate BDD symptoms (Bowyer et al, 2016), as they are unlikely to address the underlying core psychological symptomatology of the condition (Crerand et al, 2006). As eating disorders are also mental health disorders, it stands to reason that, as with BDD, aesthetic procedures will not help alleviate eating disorder symptoms in the long term.
Eating disorders and BDD
Eating disorders and BDD are clinically distinct disorders. BDD involves the preoccupation with a perceived appearance ‘deficit’ that is associated with shame, depression, marked distress and a compromised quality of life (Veale et al, 2016). As detailed above, eating disorder symptomology involves unhealthy eating behaviours and rituals, such as restriction, binging and purging, as well as body dissatisfaction and preoccupation with body shape and weight (Fairburn et al, 2003; APA, 2013). However, there is some overlap in symptoms related to body image, including body dissatisfaction and (over) investment in appearance, in addition to a degree of comorbidity between the two conditions (Ruffolo et al, 2006). Few studies have compared body image among those with eating disorders and those with BDD. One study found that those with BDD and those with eating disorders reported comparable levels of overall body dissatisfaction compared with gender-matched controls. However, differences emerged on the foci of the dissatisfaction (Hrabosky et al, 2009). Specifically, those with BDD reported more facial dissatisfaction than all other groups, while those with anorexia or bulimia reported greater dissatisfaction and preoccupation with their weight and body shape compared with the BDD group (Hrabosky et al, 2009).
Identifying eating disorders in aesthetic procedure settings
Body dissatisfaction and appearance investment are common among those with eating disorders and those seeking aesthetic procedures (Sarwer, 2019). Acknowledging that eating disorders are often underdiagnosed and undertreated, combined with the increasing normalisation, popularity and accessibility of aesthetic procedures promising to ‘improve’ a person's body, there is a potential for individuals with (potentially undiagnosed) eating disorders to present at aesthetic practices and clinics (Hart et al, 2011; Sarwer, 2019). Indeed, it is possible that aesthetic practitioners may be a first point of contact for individuals struggling with an eating disorder. To this end, universal screening and appropriate referral pathway systems in aesthetic procedure settings are recommended to help improve eating disorder outcomes through early detection and intervention.
Screening tools
Eating disorder experts have developed several short eating disorder screening tools designed to help a practitioner determine whether more detailed assessment of a possible eating disorder is required. Importantly, these tools are not diagnostic instruments. The SCOFF questionnaire (Morgan et al, 1999) was co-developed by clinicians and experts by experience comprising five questions, which address core features of anorexia nervosa and bulimia nervosa. At least two positive responses are required to raise suspicion of an eating disorder:
In both the UK and internationally, the questionnaire has been validated in primary care settings, with good specificity and sensitivity (Solmi et al, 2015). It has also been tested in community settings, although here, findings indicated that the tool had high specificity (i.e. good at ruling out an eating disorder, since false positives are rare), but low sensitivity, suggesting that a substantial number of individuals with an eating disorder were not identified (i.e. high rate of false negatives) (Solmi et al, 2015). Therefore, the authors suggested caution when using the questionnaire in the general population, as a proportion of people with eating disorder symptoms may be overlooked when using the SCOFF questionnaire alone (Solmi et al, 2015).
The eating disorder screen for primary care (ESP) (Cotton et al, 2003) is an alternate screening tool designed for primary care settings and comprises four questions, also requiring at least two positive responses:
Notably, the ESP includes an item assessing the core cognitive psychopathology of eating disorders—weight-based self-worth (Fairburn et al, 2003), which is not assessed in the SCOFF questionnaire. Analysis comparing the SCOFF questionnaire and ESP found that there was no difference in correctly ruling in an eating disorder, but the ESP questions were found to be better at ruling out possible cases (Cotton et al, 2003). However, neither the SCOFF questionnaire or the ESP were developed to capture binge eating disorder, and researchers have suggested that more work is needed to improve the validity of the more widely used SCOFF questionnaire to address some of its current limitations (Solmi et al, 2015). Furthermore, as both the SCOFF questionnaire and ESP are limited by design to raising suspicion of a likely eating disorder case, an accompanying referral process is also required for further investigation and formal assessment. In the UK, referrals for eating disorder diagnosis and treatment are made by GPs, and charities such as Beat offer free support services, including helplines and online support groups (National Institute for Health and Care Excellence, 2017; Beat, 2019).
Conclusion
Eating disorders are serious, complex mental health conditions that are frequently underdiagnosed and undertreated. As body dissatisfaction is a common risk factor in eating disorders and in motivation to seek aesthetic procedures, it is possible that people with eating disorders who are not receiving treatment and may not have an eating disorder diagnosis present at aesthetic procedure settings. While more research is needed in this area, it has been suggested that aesthetic practitioners should be trained and informed about eating disorders. Furthermore, universal screening with accompanying referral pathways is recommended to help support early detection and intervention of eating disorders.