Eating disorders are becoming recognized in modern societies worldwide. An increasingly equal opportunity disease, anorexia nervosa is no longer restricted to white upper middle class young women.1 Anorexia nervosa, bulimia, and other eating disorders are found in persons from all socioeconomic strata, starting as young as 5 years of age and ranging through adulthood. Moreover, even given the problems of underdiagnosis in males, boys and men comprise 5% to 10% of all patients. Overall, anorexia nervosa occurs in approximately 1% of child, teen, and adult populations, and bulimia nervosa ranges from 1% to 19% depending on the population studied.2
In this issue, Rayworth and her colleagues3 address physical and sexual abuse in childhood as possible causes of eating disorders in adult women. The authors find associations between physical abuse (especially when combined with sexual abuse) and subsequent disordered-eating attitudes and behaviors. These findings make sense. Those of us who care for persons with eating disorders know that such disorders are often a solution to other problems, albeit a maladaptive one. My patients have ranged from a young lady repeatedly sodomized by a relative, and unable to put food in her mouth without gagging and vomiting, to a member of a wrestling team whose coach weighed-in the boys alone, naked, fondling (or worse) each teammate. My patient got himself off the team by starving himself to the point of hospitalization.
Rayworth's study explores eating disorders in adulthood related to abuse during childhood—a more remote exposure than described previously. If the association in Rayworth's study is causal, it is curious that more severe abuse was not associated with more severe eating disorders. Perhaps factors in addition to the abuse itself (for example, a chaotic childhood home environment) contribute to the expression of an eating disorder. It might also be useful to look at factors such as depression and anxiety that might work along the causal pathway.
The biggest obstacle to understanding these questions is the difficulty of getting valid information, both for the exposure (sexual or physical abuse) and the outcome (eating disorders). Clinicians often feel ill-equipped to handle these issues and could lack training in asking the right questions in a trust-building way. How much more difficult it is for epidemiologists, who have to rely on self-reports in retrospective studies.
Rayworth's study provides justification for exploring this question even more carefully and with attention to the complex of factors that presumably contribute to this disease. Not every eating disorder is a sign of family pathology, and care must be taken not to stigmatize families who struggle with this distressing condition. Still, Rayworth's study suggests that among the possible causes of adult eating disorders, physical and sexual abuse during childhood deserve serious consideration.
ABOUT THE AUTHOR
ELLEN ROME is Head of the Section of Adolescent Medicine at the Children's Hospital at the Cleveland Clinic. She is author of the American Academy of Pediatrics’ position statement on the identification and treatment of eating disorders in children and adolescents.
1. Rome ES, Ammerman S, Rosen DS, et al. Children and adolescents with eating disorders: the state of the art. Pediatrics
2. Rayworth BB, Wise LA, Harlow BL. Childhood abuse and risk of eating disorders in women. Epidemiology
3. Committee on Adolescence, American Academy of Pediatrics. Identifying and treating eating disorders. Pediatrics