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A recent study sought to understand the relationship between dietary patterns of children and their 

Investigators examined 2 different age groups of children from Spain: 259 preschoolers aged 3 to 6 years old (57 with ADHD and 202 controls) and 475 elementary-school-age children, aged 10 to 12 years old (213 with ADHD and 262 controls). ADHD was assessed in accordance with the DSM-5. Eating data were collected using a food consumption frequency questionnaire. Three types of eating patterns were identified: Western-like, sweet, and healthy.

Western pattern consists of eggs, processed meat, seafood, savory cereals, potatoes, legumes, sodas, and cooked vegetables. Sweet pattern consists of dairy desserts, sweet cereals, preserved fruit, and sweets. 

 consists of nuts, fish (white and oily), raw vegetables, fresh fruit, and olive oil.

The children and adolescents with ADHD were negatively associated with the healthy pattern (p < 0.001) and positively associated with the Western-like diet (p = 0.004). Furthermore, children with inattentive presentation showed lower adherence (12.2%) to a healthy pattern than that of the control group (39.9%) (p < 0.001). The control group had the highest adherence to the Healthy pattern. However, the two groups had a similar adherence to the sweet dietary pattern.

Previous research explored the association between 

 and the Mediterranean diet—a dietary pattern that includes fiber-rich food such as fruits and vegetables, healthy fatty acids, proteins, and more.

 According to 2 studies, there was less healthy eating and lower adherence to the Mediterranean diet in children and adolescents with ADHD than that in controls.

“We hypothesize that children with ADHD have a low-quality diet with a lower intake of fruits and vegetables than that of their peers without the disorder, and that this shows up specifically in children with combined or hyperactive–impulsive (H–I) ADHD presentations. Moreover, we hypothesize that food consumption generally differs from the established recommendations by dietary guidelines,” wrote the authors.

The authors concluded that there is an association between ADHD and dietary habits, and children with inattentive presentation may be at increased risk of unhealthy eating habits.

1. Rojo-Marticella M, Arija V, Alda JÁ, et al. 

Do children with attention-deficit/hyperactivity disorder follow a different dietary pattern than that of their control peers?

2. Rios-Hernandez A, Alda JA, Farran-Codina A, et al. 

The Mediterranean diet and ADHD in children and adolescents.

3. San Mauro Martín I, Blumenfeld Olivares JA, Garicano Vilar E, et al. 

Nutritional and environmental factors in attention-deficit hyperactivity disorder (ADHD): a cross-sectional study.

A recent study found a negative association between children with ADHD and health eating patterns. 

The Relationship Between Unhealthy Eating and ADHD in Children 

A study identified a key neural mechanism that may directly contribute to binge eating in patients with bulimia nervosa (BN).

In the study, investigators examined brain activation in individuals with eating disorders during these individuals’ efforts to control their eating behavior—making this study the first of its kind.

 They measured activation in 23 women with BN compared to 23 healthy controls using functional near-infrared spectroscopy (fNIRS) during both a standard go/no-go task requiring inhibition of button-pressing responses and a novel go/no-go task requiring inhibition of eating responses. Results showed that the participants with BN made more commission errors during both tasks,

 and that deficient activation of the medial and lateral prefrontal cortices—the brain regions that play a role in the control of behaviors, emotions, and cravings

—was identified in the participants with BN compared with healthy controls. BN subgroups who felt most strongly that they were binge eating during the task (

 = 12) and those with the most severe and most frequent “loss of control” eating (

 = 12) showed an abnormal reduction in bilateral ventromedial prefrontal cortex (vmPFC) and right ventrolateral prefrontal cortex (vIPFC) activation associated with eating response inhibition.

“Our patients describe feeling like they just can’t stop themselves from taking that next bite or sip during binge-eating episodes, but we didn’t understand the neural mechanisms that might underlie that experience,” saidLaura Berner, PhD, assistant professor of psychiatry at Icahn Mount Sinai; principal investigator for the Mount Sinai Center for Computational Psychiatry and the Mount Sinai Center of Excellence in Eating and Weight Disorders; and lead investigator on the study, in a press release. “For the first time, this method has allowed us to measure what is happening in the brains of people with bulimia nervosa when they are trying to inhibit their eating responses, but cannot.”

Fewer than half of adults with BN recover after first-line treatment interventions. The development of more effective treatments has been hindered because the neural bases of the symptoms of BN are still not well understood.

 “Our findings suggest that eating-specific impairments in inhibitory control-related activation may serve as a new target for treatment,” Berner said in a press release. “In fact, we just learned that we received funding from the National Eating Disorders Association to test this idea. We will be using fNIRS-based neurofeedback to train women with bulimia nervosa to increase their own prefrontal cortex activation while eating, and we’ll test how that training impacts symptoms.”

Diminished activation of specific prefrontal brain region may directly contribute to binge eating in bulimia nervosa, new study reveals

. News release. February 28, 2022. Accessed February 28, 2022.

Altered prefrontal activation during the inhibition of eating responses in women with bulimia nervosa

Findings show relationship between binge eating and brain activation.

Study Connects Key Neural Mechanism to Bulimia Nervosa

Researchers found a moderate prevalence of 

 (ICD) and behavioral addiction (BA) comorbidity in individuals with 

 (EDs) in a first-of-its-kind meta-analysis.

Because the prevalence of this comorbidity has never been systematically examined, Daniel J. Devoe, MSc PhD, and colleagues performed a series of random-effects meta-analyses of peer-reviewed literature reporting prevalence of ICDs or BAs in individuals with EDs. The investigators included 35 studies with a total of 9646 individuals who had an ED and analyzed the prevalence of different kinds of behavioral addictions among these individuals. The mean age of participants was 25.5 years (range 16.7 to 43.9), and 97.7% were female.

Results showed that stealing/shoplifting behaviors were the most common form of behavioral addictions in individuals with EDs, with a prevalence of 30%. Devoe et al also noted prevalence of pathological/compulsive buying at 19%, kleptomania at 18%, and pathological internet use at 12%. Intermittent explosive disorder, trichotillomania, and gambling had prevalence rates of 5%, 3%, and 2%, respectively.

Devoe and colleagues identified that ICDs are more closely associated with bulimia nervosa (BN) and binge-purge subtype (AN-BP) than other ED diagnoses and behaviors.This finding supported previous research indicating that individuals with binge-purge subtypes are more likely to struggle with ICDs, partly due to impulse control difficulties and greater emotion regulation. The researchers also noted that certain personality traits (eg, perfectionism, impulsivity), psychiatric comorbidity, age of onset (eg, early age of onset may worsen prognoses), and concurrent substance use disorders may also play a role in deteriorating ED prognoses. They also suggested that future research explore common underlying pathomechanisms.

“Although causal inferences cannot be drawn, the numbers strongly suggest that clinical screening/monitoring of ICDs/BAs should be part of the clinical routine in cohorts with EDs,” Devoe and colleagues concluded.

1. Devoe DJ, Anderson A, Bahji A, et al. 

The prevalence of impulse control disorders and behavioral addictions in eating disorders: a systematic review and meta-analysis

Study also identifies prevalence of specific behavioral addictions in these individuals.

Research Explores Comorbidities in Patients With Eating Disorders

Anorexia nervosa (AN) is a severe psychiatric disorder characterized by restricted eating, significant weight loss, and a profound fear of weight gain. AN and the related disorder, bulimia nervosa, have a lifetime prevalence of 1% to 2% of the population.

 Weight loss in AN results in serious medical consequences and higher levels of care are often necessary to restore weight. AN has the highest risk of mortality of any nonsubstance-use psychiatric disorder and, too often, a poor prognosis.

 Reluctance to recover is sustained by ego-syntonic symptoms that reinforce the illness.

 Only 13% to 50% of patients are considered recovered 1 to 2 years posttreatment, and a sizeable subset (20% to 30%) go on to develop a chronic and unremitting course of AN.

Limited effectiveness of both pharmacological and psychological treatments contributes to this chronicity. Family-based therapy, which works in alliance with parents to maintain eating and restore weight, has had some success in adolescent patients, but not all younger patients achieve adequate benefit. For older patients with AN, evidence-based therapies remain underdeveloped.

Historically, AN has been considered a consequence of psychosocial factors.

 However, considerable recent evidence supports powerful genetic and neurobiological contributions to AN behavior.

 Many affected individuals have an anxious, obsessive, inflexible, and perfectionist temperament that presents in childhood before the onset of AN, becomes exaggerated during illness, and persists in a mild-to-moderate form after recovery. Comorbid depression is common, as is denial of illness and lack of motivation to change.

Recent studies have shed new light on underlying mechanisms driving such AN symptoms.

 For example, when people are hungry, activation of brain circuits normally makes them feel irritable and uncomfortable and makes food more rewarding and motivating. These neural processes appear to be miscoded in AN and sensitized with weight loss.

 Instead, when these individuals become hungry and are presented with food, they experience brain circuit activity associated with considerable anxiety; further, dopamine-related brain mechanisms that motivate and initiate eating fail to activate. Such findings open the door to identifying new targets and new pharmacological approaches in AN.

It is important to note that there are no US Food and Drug Administration (FDA)–approved medications to treat AN. Nonetheless, given the risk of significant physical and psychological consequences of this disorder, off-label prescribing of some agents has become widespread.

For patients with AN who show signs of treatment resistance, the most common medication intervention is atypical antipsychotics. Although promising case reports, open trials, and chart reviews began appearing in the late 1990s, the controlled-trial literature on atypical antipsychotics in AN remains disturbingly limited, which is a testament to the notorious difficulties in recruiting and retaining patients with AN in medication trials. To date, there have been 8 randomized, placebo-controlled trials (RCTs) involving placebo groups. Only 1 of these involved more than 40 patients, and the total number of randomized patients in all trials was less than 350.

Olanzapine is by far the most studied medication for AN, with 5 trials taking place between 2007 and 2019. All but 1 were considered positive, although the degree of benefit typically was small. Two trials involving use of quetiapine had mixed results, and 1 trial with risperidone was negative.

 In the closest thing to a landmark medication study in AN, Attia et al reported results of a relatively large, multisite RCT of olanzapine in adult outpatients in 2019.

 Five sites in North America randomized 152 patients to olanzapine or placebo during a 6-year recruitment period. The 16-week trial used a target olanzapine dose of 10 mg/d (mean, 7.77 mg/d), and investigators found a significant increase in weight for the olanzapine group versus placebo. However, the difference in weight gain (ie, 1 lb of body weight/month for a woman of average height) was modest between the groups; patients using olanzapine gained an average of approximately 1.5 lb of body weight/month. Weight restoration is the primary outcome in any AN trial, but use of a medication hopefully also will impact the powerful thought processes and psychiatric symptoms that drive the illness. Importantly, the authors reported that use of olanzapine showed “no significant benefit for psychological symptoms.”

Despite these limitations, expert articles and guidelines most likely recommend olanzapine as the antipsychotic of choice to treat AN, because so few RCTs have involved use of other medications. In our experience, a few types of patients may particularly benefit from olanzapine. For individuals who desire some degree of weight restoration but are struggling due to lack of appetite or drive to eat, olanzapine may provide improvement. In addition, patients with very high anxiety presenting more as fear than cognitive rigidity may benefit from the sedative-like properties of olanzapine.

However, there are substantial roadblocks to successful use of olanzapine for AN. The quality that led to early interest in and dominant study of olanzapine—its well-known propensity to cause weight gain—makes it unacceptable to the vast majority of patients with AN. At best, many of these individuals are ambivalent about weight gain, and even those who have accepted it as a necessary aspect of recovery frequently fear loss of control over the process. It is critical to understand that improvement in body image for AN patients can significantly lag weight restoration. If a medication adds weight but has little impact on thought process, the patient may experience an intolerable emotional state that greatly heightens the risks of nonadherence and resumption of weight loss.

With 14 atypical antipsychotics available for use in the United States, it is astonishing that so few have been studied in RCTs of AN. Given the highly complex and variable receptor-binding properties of this class, leading to clinically relevant heterogeneity—for example, some atypical antipsychotics are known to treat depression better than others—it is premature to conclude that atypical antipsychotics have only minimal benefit for AN based on results reported with use of 3 of the earlier medications. Lack of RCTs with newer, relatively weight-neutral antipsychotics, especially those having a somewhat different mechanism of action (eg, aripiprazole), may be a serious oversight.

Over the past decade, and with the 2019 olanzapine trial notwithstanding, nearly all additions to the literature on the use of atypical antipsychotics in patients with AN have involved aripiprazole. Five peer-reviewed articles from 4 different sites in 3 countries have described very interesting findings from case series and retrospective chart reviews.

 These reports often show benefit for weight gain, but most notably, they have included remarkably similar descriptions of an impact on thought processes related to AN, particularly the loosening of rigid and entrenched rules and distortions. Observations have included reduced eating-specific anxiety and distress; less rigid food choices; diminished obsessional thoughts about food, exercise, weight, and body image; and fewer eating disorder (ED) rituals. Additionally, many patients reported reduced symptoms of depression and non-ED–related anxiety, which will be discussed in the next section. Therefore, regardless of any direct impact on weight, aripiprazole may indirectly enhance weight restoration by improving cognition and thereby promoting a better response to psychological and dietary treatments. RCTs are needed to further investigate these findings.

What may account for this possible difference between olanzapine and aripiprazole in AN? Olanzapine—as well as most other current atypical antipsychotics, including quetiapine and risperidone—is a 5-HT2

 antagonist. Aripiprazole, in contrast, is a D

 partial agonist, meaning it acts differently at dopamine and serotonin receptors. Theoretical arguments have addressed how use of aripiprazole at lower doses (typically, 1-5 mg/d, with occasional titration up to 10 mg/d) may facilitate learning and behavior change in individuals with AN.

For example, basic research has indicated that dopamine receptor stimulation may be beneficial in suppressing previous fears after extinction training. Moreover, neurobiological research suggests that AN is associated with heightened responsiveness in brain reward circuits, which may be due to a hypersensitive dopamine system. Aripiprazole may downregulate D

 receptor activity, which may improve brain function, reduce anxiety, and aid in the psychotherapeutic process.

Additionally, almost all patients described in this research on aripiprazole use were being treated concurrently with antidepressants. In contrast, no RCT has formally studied atypical antipsychotic augmentation of antidepressants in AN. Although some RCTs allowed patients already on antidepressants to continue them, use was not systematic or evaluated, and the overall numbers were too small to yield meaningful results. We believe that, particularly for medications such as aripiprazole with known significant effects as augmenters, combination treatment may be 1 key to showing a more robust response in controlled trials. On a practical note, adherence also has improved with use of aripiprazole, because it often is better tolerated. Still, some patients encounter akathisia, which we have been able to minimize by initiating therapy with very low doses (eg, as low as 0.5 mg/d in some patients).

AN is associated with high levels of comorbid conditions. More than 40% of individuals with AN have a lifetime comorbid anxiety or mood disorder, over 30% have an impulse control disorder, and about 27% have a substance use disorder.

 Recent data showed that individuals with AN had a 25% risk of receiving any noneating disorder diagnosis during the first 2 years of longitudinal follow-up and a 55% risk of developing comorbid conditions 2 decades after inclusion.

 Comorbid conditions have been associated with greater illness severity and mortality.

Research on eating disorders traditionally has not focused on comorbidities, but new data highlight the need for treatment of those conditions. Whether eating disorder outcomes will be affected by treatment of comorbid psychiatric illnesses is uncertain, but improving quality of life and reducing suicide rates are similarly important goals.

Few medications specific to AN have been approved by the FDA, yet affected patients frequently receive prescriptions for psychotropics.

 However, studies on pharmacological interventions in AN commonly have not been designed to discern whether individuals taking these medications had more severe illness or higher comorbidity than did others. Because depression and anxiety predict more negative treatment outcome in AN, and comorbid psychiatric disorders are associated with higher mortality among this patient population, use of medication to target these conditions is supported.

 Research may have to adapt and focus more on outcome measures that go beyond weight gain; these may include the study of quality of life, mood, and anxiety measures in relation to use of medical interventions. These measures are crucial in preventing weight loss and relapse after significant resources that involve a high level of care have been used for nutritional rehabilitation.

A recent patient with severe AN in our program also had severe, comorbid obsessive-compulsive disorder (OCD). She had many magical thinking–related obsessions that substantially limited her will to live and contributed to overwhelming major depressive disorder with suicidality. The patient was treated with olanzapine to reduce distress and had been on various antidepressant and antianxiety medications, but she never received an adequately dosed trial of a selective serotonin reuptake inhibitor to treat OCD. During weight restoration, we initiated sertraline, which was titrated to 200 mg/d. After 4 months of treatment, the patient experienced significant relief from symptoms of OCD and could start participating in social activities. AN was still a significant struggle, but the patient experienced improvement in daily life activities and overall functioning.

While olanzapine has shown benefit for AN in RCTs, weight restoration tends to be minor, AN cognitions do not appear to improve significantly, and most patients are unaccepting of a medication known to cause weight gain. RCTs of additional atypical antipsychotics, especially those that have a somewhat different mechanism of action (eg, aripiprazole), used alone and in combination with antidepressants are needed. Research into strategies to better treat psychiatric comorbidities in patients with this disorder may reduce treatment resistance. Finally, early investigations to treat AN and its comorbidities with novel biological treatments (eg, psilocybin, ketamine, cannabinoids, and neuromodulation techniques of repetitive transcranial magnetic stimulation and deep brain stimulation) are ongoing.

 is an associate clinical professor of psychiatry at the University of California, San Diego, and medical director of the UCSD Eating Disorders Treatment and Research Program. 

 is a professor in residence of psychiatry at the University of California, San Diego. 

 is director of medical and clinical services at the USCD Eating Disorders Treatment and Research Program, and clinical professor of psychiatry at the University of California, San Diego. 

 is the founder and executive director of the UCSD Eating Disorders Treatment and Research Program, and professor of psychiatry at the University of California, San Diego.

1. Ward ZJ, Rodriguez P, Wright DR, et al. 

Estimation of eating disorders prevalence by age and associations with mortality in a simulated nationally representative US cohort

2. Arcelus J, Mitchell AJ, Wales J, Nielsen S. 

Mortality rates in patients with anorexia nervosa and other eating disorders

3. Abbate-Daga G, Amianto F, Delsedime N, et al. 

Resistance to treatment and change in anorexia nervosa [corrected]: a clinical overview

4. Wonderlich SA, Bulik CM, Schmidt U, et al. 

Severe and enduring anorexia nervosa: update and observations about the current clinical reality

Presentation of eating disorders in the news media: what are the implications for patient diagnosis and treatment?

6. Brandys MK, de Kovel CGF, Kas MJ, et al. 

Overview of genetic research in anorexia nervosa: the past, the present and the future

7. Monteleone AM, Castellini G, Volpe U, et al. 

Neuroendocrinology and brain imaging of reward in eating disorders: a possible key to the treatment of anorexia nervosa and bulimia nervosa

Prog Neuropsychopharmacol Biol Psychiatry

8. Kaye WH, Wierenga CE, Bischoff-Grethe A, et al. 

Neural insensitivity to the effects of hunger in women remitted from anorexia nervosa

9. Frank GKW, Shott ME, Stoddard J, et al. 

Association of brain reward response with body mass index and ventral striatal-hypothalamic circuitry among young women with eating disorders

The role of psychotropic medications in the management of anorexia nervosa: rationale, evidence and future prospects

Cognitive neuroscience of eating disorders

12. Attia E, Steinglass JE, Walsh BT, et al. 

Olanzapine versus placebo in adult outpatients with anorexia nervosa: a randomized clinical trial

13. Frank GKW, Shott ME, Hagman JO, et al. 

The partial dopamine D2 receptor agonist aripiprazole is associated with weight gain in adolescent anorexia nervosa

14. Tahillioğlu A, Özcan T, Yüksel G, et al. 

Is aripiprazole a key to unlock anorexia nervosa?: A case series.

15. Bailer UF, Price JC, Meltzer CC, et al. 

Dopaminergic activity and altered reward modulation in anorexia nervosa—insight from multimodal imaging

16. Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. 

The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication

17. Steinhausen HC, Villumsen MD, Hørder K, et al. 

Comorbid mental disorders during long-term course in a nationwide cohort of patients with anorexia nervosa

18. Kask J, Ekselius L, Brandt L, et al. 

Mortality in women with anorexia nervosa: the role of comorbid psychiatric disorders

Is the severity of the clinical expression of anorexia nervosa influenced by an anxiety, depressive, or obsessive-compulsive comorbidity over a lifetime?

20. Alañón Pardo MDM, Ferrit Martin M, Calleja Hernández MAC, Márquez FM. 

Adherence of psychopharmacological prescriptions to clinical practice guidelines in patients with eating behavior disorders

Psychotropic usage by patients presenting to an academic eating disorders program

Depression, worry, and psychosocial functioning predict eating disorder treatment outcomes in a residential and partial hospitalization setting

23. Spriggs MJ, Douglass HM, Park RJ, et al. 

Study protocol for “Psilocybin as a treatment for anorexia nervosa: a pilot study.”

24. Schwartz T, Trunko ME, Feifel D, et al. 

A longitudinal case series of IM ketamine for patients with severe and enduring eating disorders and comorbid treatment-resistant depression

Treatment studies with cannabinoids in anorexia nervosa: a systematic review

Current therapeutic approaches to anorexia nervosa: state of the art

Only 13% to 50% of AN patients are considered recovered 1 to 2 years posttreatment, and 20% to 30% go on to develop a chronic and unremitting course of AN. How can we improve these outcomes?

Pharmacological Management of Treatment-Resistant Anorexia Nervosa

Representative Jason Ortitay (R-Washington/Allegheny) introduced legislation, 



“Data, especially in recent months, has shown that social media has a negative effect on young people and contributes to 

increased body dissatisfaction and eating disorders

,” Ortitay said. “With the growing use of social media, we need to take steps to bring attention to this issue. Many parents may not recognize the warning signs of an eating disorder. I’m hopeful this legislation will give parents the information they need and also help them recognize negative body image messages in society today.” 

Under 

, which was introduced in December, schools would be required to provide parents and guardians of students in grades 6 through 12 with information regarding eating disorders annually. Additionally, an eating disorder taskforce would be created within the Pennsylvania Department of Education that would develop guidelines for the information provided by the schools.

Pennsylvania legislators worked with eating disorder survivors to develop House Bill 2158, individuals like Emily Rosenberg.

“I have been passionately working with Pennsylvania legislators on this bill over the years to raise awareness of the serious nature of eating disorders. My hope is for parents and guardians to become educated on eating disorders to help with early identification and prevent long-term suffering,” said Rosenberg. “As a survivor, I use my voice and lived experience to educate and bring hope to those struggling by sharing the message that recovery is possible. Eating disorders are not a choice and nobody deserves a life with one. I did not give up on my recovery and I will not give up the fight to pass this needed legislation.”

Senator Steve Santarsiero (D-Bucks) is sponsoring a similar bill in the Senate.

 “Eating disorders exist across the broad spectrum of age, race, ethnicity, gender, and socioeconomics affecting more than 30 million Americans. As we see younger children expressing dissatisfaction with their bodies and 

, it’s important to equip parents early with up-to-date information and local resources on this condition,” said Santarsiero.

Martha Watson, a Pennsylvania resident and advocate, lost her daughter to an eating disorder. “She was diagnosed at the age of 11, but sadly the eating disorder was already entrenched and though we fought a valiant 10-year battle, we lost her. I don’t want other families to have the same outcome, so I have become a passionate advocate for raising awareness and understanding about eating disorders,” said Watson. “By providing parents and schools with tools to identify an eating disorder early and resources to help intervene, this bill will definitely save lives.” 

The founder and CEO of the National Alliance for Eating Disorders, Johanna Kandel, also supports both bills. “Eating disorders wreak havoc on Pennsylvania families, the local economy, and the already-overburdened medical system. With this legislation, parents and school leadership will be better equipped to recognize when eating disorders present themselves and to refer youth for appropriate care. Not one more life should be stolen by this insidious disease. The National Alliance for Eating Disorders strongly urges the Pennsylvania Legislature to swiftly pass House Bill 2158 and Senate Bill 988 because students deserve better.” 

House Bill 2158 has been referred to the House Education Committee for review. 

1. Ortitay proposal to require schools to raise awareness about eating disorders. News release. December 14, 2021. Accessed January 6, 2022. 

http://www.reportitay.com/News/22981/Latest-News/Ortitay-Proposal-to-Require-Schools-to-Raise-Awareness-about-Eating-Disorders-

3. Senator Santarsiero introduces legislation to help young Pennsylvanians and their families combat eating disorders. News release. December 15, 2021. Accessed January 6, 2022. 

https://www.senatorstevesantarsiero.com/senator-santarsiero-introduces-legislation-to-help-young-pennsylvanians-and-their-families-combat-eating-disorders/

Representative Jason Ortitay and Senator Steve Santarsiero have introduced legislation to help increase awareness of eating disorders in children. 

Pennsylvania Legislators Push to Increase Awareness of Eating Disorders in Children

“In the United States, there are roughly 28.8 million people with an eating disorder, which is about 9% of our population. Globally, that jumps up to 70 million,” said Rebecca Owens, DNP, MBA, MSN, RN-BC, to the audience of the 

American Psychiatric Nurses Association (APNA) 35th Annual Conference

Owens explained that up to 80% of eating disorders go undetected or never receive treatment. She felt it was important to start with a review of the 4 big ED classifications: anorexia nervosa, bulimia nervosa, avoidant/restrictive food intake disorder, and binge eating disorder.

With 92% of frontline clinicians admitting in hindsight to potentially missing an eating disorder (ED) diagnosis, Owens suggested 2 screening tools for consideration that might help clinicians catch more patients that need care: the SCOFF Questionnaire and the EDA-5.

The SCOFF Questionnaire is a UK-developed, straightforward, 5 question screener for EDs that can be used in almost any setting. Studies show it is highly effective for potential or actual ED identification, particularly high mortality disorders (anorexia or bulimia), with good psychometric properties.

S- Do you make yourself SICK because you feel uncomfortably full?

C- Do you worry you have lost CONTROL over how much you eat?
O- Have you recently lost more than ONE stone (a couple pounds) in a 3-month period?

F- Do you believe yourself to be FAT when others say you are too thin?

F- Would you say that FOOD dominates your life?

EDA-5 is an electronic, semi structured, interview-based, diagnostic tool that is available online at: 

. It facilitates ED diagnoses in general medicine and psychiatric settings and reduces patient-clinician burden in ED determination. Owens shared a few sample screens and told the APNA audience she finds it to be a “very practical, very easy tool to use.”

“The more of us that are understanding the complexities of eating disorders, the better it will be for our patients and communities,” said Owens.

Owens also emphasized the urgent need for improved ED treatment outcomes, and more availability of specialized ED services. “We want to be prepared to capture and help these patients get into timely treatment. It quite literally could be a life and death measure, as we’ve heard through the statistics.”

In a psychiatric setting, step 1 may be an identification of the ED itself, as patients may be coming in for other psychiatric comorbidities, such as an anxiety disorder, a mood disorder, or substance use disorder.

“There’s a lot to learn,” Owens said. “Early screening, diagnosis, and treatment are crucial to prevent long term, life threatening EDs.”

Nearly 80% of eating disorders go undetected. What screening tools can help identify them? 

A Life and Death Measure: Eating Disorder Treatment 

Psychiatrists are called on to help patients with an array of stubborn mental health illnesses. Some of the most challenging to treat are also the deadliest: eating disorders. Characterized by a persistent disturbance of eating that impairs health and psychosocial functioning, these disorders include anorexia nervosa, avoidant/restrictive food intake disorder, binge eating disorder, bulimia nervosa, pica, and rumination disorder. Too often, their outcomes are tragic. Anorexia nervosa is associated with the highest mortality rate of all psychiatric disorders, with fatal outcomes observed in approximately 10% of cases, primarily from 

Recently I watched the 2017 Netflix film 

, a semi-autobiographical story about a 20-year-old named Ellen and her journey to recovery from anorexia nervosa. It is based on the experiences of Marti Noxon, the film’s director, and Lily Collins, the actress who plays Ellen. The film starts with a written warning of triggers, a warning that should be taken seriously by anyone likely to be upset or encouraged by the behavior.

In the film, Ellen is a cynical, artistic young woman whose anorexia has made her life unmanageable. Forced to see a new doctor by her nervous stepmother, she ends up in an inpatient rehab unlike any other she has been in before: A house with 7 young individuals supervised by a blunt house manager and an unconventional clinician—Dr Beckman, played by Keanu Reeves. The young patients are diverse, both demographically and in terms of their eating disorders. The housemates include a Black female with binge eating disorder, a White female with bulimia nervosa, a British white male with anorexia, and a pregnant White female with anorexia (who has a miscarriage). The movie’s diverse cast reflects the epidemiology of eating disorders, which affect individuals of various ages, sizes, socioeconomic statuses, gender identities, races, and cultural and ethnic backgrounds.

When we meet Ellen, her weight has fallen dangerously low; she exercises excessively, shows obsessive attention to counting calories, and hints at a preoccupation with thoughts of food, consistent with the diagnosis of anorexia nervosa. Another character with anorexia nervosa also feels distressed when she learns the number of calories that she has received through a feeding tube. Ellen wears loose clothing, which is a warning sign for anorexia, since loose outfits hide weight loss and can help the wearer 

 She reassures her sister and herself that she has it all under control, a common belief among patients with eating disorders.

Another character, Anna, has bulimia nervosa. She engages in the purging behavior of vomiting, uses laxatives, and exercises secretly. Anna’s experience of binge eating is not shown, despite binging being a core component of bulimia. Often, individuals with binge eating disorder are not given significant attention, even though this is the most common eating disorder in the 

The movie also shows the exasperation of the patients’ families. Ellen’s stepmother and stepsister exemplify the fallacies that so many individuals have about eating disorders. “Why don’t you just eat?” Ellen’s sister asks in exasperation, while her stepmom gibes: “Do you think this is beautiful?” The pathogenesis of eating disorders is complex and attributable to a combination of genetic, environmental, and biological factors, including dysregulation of homeostatic drive and the 

 Like most mental illnesses, childhood adversity plays an important role. Ellen’s mother came out as gay when Ellen was 13 years old and now lives in Phoenix, running a horse therapy farm with her partner. We do not see the father; he seems to be physically and emotionally absent. The child with the eating disorder is often expressing dysfunction within the family system through her behaviors and symptoms, as Ellen exemplifies.

Ellen and her peers are shown in a residential group home in which they have a lot of say in their treatment. This may not be a realistic portrayal. Treatment of eating disorders generally involves an interdisciplinary team; this team includes a mental health clinician, dietitian, and a general medical clinician. Although Beckham conducts individual and family sessions, the treatment approach overall does not match with commonly used, well-established therapy plans like cognitive behavioral therapy, psychodynamic psychotherapy, or the Maudsley model of 

Beckham has a tough tone: He calls Ellen’s attitude “childish and cowardly” and tells her, “You know how [to recover].” He makes statements such as, “Stop waiting for life to be easy. Stop hoping for somebody to save you....Face some hard facts and you could have an incredible life.” These ideas suggest that Ellen needs to simply use her willpower and decide to get better, which is not a realistic vision for recovery. For Ellen, it was not about eating, it was about deciding to choose life. To achieve long-term recovery, the focus needs to be redirected to the underlying emotional, cultural, psychological, and spiritual issues.

Several noteworthy scenes have stayed with me: The emotional scene when Ellen asks her mother to feed her like a baby; the thousands of emotions that trace across her face every time she steps on the scale to be weighed; and the way she constantly circles her upper arm with her middle finger and thumb (a practice known as body checking). At the end of her family therapy, Ellen states, “I’m sorry that I’m not a person anymore; that I’m a problem.” This is touching, because medical professionals and family can lose sight of the fact that their patients are individuals with feelings, not just diagnoses.

Noxon’s film does an incredible job of portraying the nuances of this complicated character living with an even more convoluted illness while also developing the world around her. 

 finds the humor in its material, the absurdity of real-life mixed in with real dangers. Collins, who has been honest about her own experiences with eating disorders, channels that struggle into a fine performance.

In 1983, when Karen Carpenter died of anorexia, the general public expressed shock that someone could starve themselves to death. In the 1990s, unfortunately, skinny was the overwhelming female beauty standard. Now some websites glamorize anorexia, advising readers on how to avoid eating, and some show so-called 

 pictures on Instagram. The more we talk about eating disorders as a serious mental illness, the more we can break down the walls of stigma that keep individuals from seeking the early intervention that improves prognosis.

is chief resident physician of psychiatry at the University of Missouri–Columbia.

1. Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. 

. National Eating Disorders Association. Accessed April 21, 2021. 

. National Eating Disorders Association. Accessed April 21, 2021. 

4. Treasure J, Claudino AM, Zucker N. Eating disorders. 

5. Zipfel S, Giel KE, Bulik CM, et al. Anorexia nervosa: aetiology, assessment, and treatment. 

A television drama looks at eating disorders from the patient, physician, and family perspectives. What does it get right—and wrong?

Breaking the Skinny Standard: Anorexia on Screen 

Obsessive-compulsive disorder and related conditions like 

, hording disorder, and trichotillomania are all common mental health issues. They all impair psychosocial functioning and quality of life, sometimes to a dangerous degree. Fortunately, well-known, first-line treatments are often effective. But for tough cases, clinicians may need other options.

In this Mental Health Minute, Katharine Phillips, MD, previews an upcoming panel at the American Psychiatric Association’s annual meeting: “

Treatment of Severe Obsessive-Compulsive and Related Disorders: What Do You Do If First-Line Treatments Don’t Work

?” Phillips and the panelists will discuss the latest research and treatment developments.

is currently professor of psychiatry, DeWitt Wallace Senior Scholar, and Residency Research Director for the Department of Psychiatry at Weill Cornell Medicine. She is also an attending psychiatrist at New York-Presbyterian Hospital and adjunct professor of Psychiatry and Human Behavior at the Alpert Medical School of Brown University.

Have your patients had unrealistic ideas about their bodies or appearances? 

Share comments with your colleagues by emailing 

Obsessive-compulsive disorder and related conditions do not always respond to first-line treatments. Fortunately, new options are on the horizon. 

Eating Disorders