Special Populations in Eating Disorders_Final

>> Hi, everyone. Last time, we talked a lot about how to recognize an eating disorder. In this lecture, we'll get a little more clarity around that by looking at special populations and then looking at what's healthy versus what is disordered. I'm sure that all of you know that women aren't the only ones who struggle with eating disorders, men get them too. Men actually make up about 10% of this population, although, often, we see only about 1% to 2% in our practices. Their behaviors and concerns around food and exercise are pretty similar if not identical to their female counterparts. In general, we're all pretty familiar with the pressure media puts on women to look a certain way, and we're certainly well aware of what the media does to images of women. Let's look at this for example. We're used to women getting messages that their bodies aren't okay. Kelly Clarkson has an amazing voice, but apparently that wasn't good enough, she also had to be thinner in order to be considered successful. On the left was how Kelly really looked at the same time the cover came out on the right. They airbrushed her and thought it was perfectly acceptable to do so stating, "We're making her look her personal best," except that it actually wasn't even her. Then they went on to say this photo was the "truest" that they've ever put out on the newsstand. Okay then, I will let you form your own conclusions there. The reality is we're subjected to false images every day that set standards that we buy into in terms of how we're supposed to look. Let's look at another example in Vibe magazine's portrayal of Serena Williams. On the left, you see what she really looks like. At the same time, Vibe magazine put out the picture on the right. Her muscles are gone, and she is also apparently not allowed to have knees. It's going to be really interesting playing tennis without knees, don't you think? Anyway, there's increasing awareness of these practices when it comes to women. But what about men? Men are subjected to similar stereotypes. Though we may not hear quite as much about it, they're supposed to be "ripped" or "jacked" with a six pack all the time. They need form-fitting clothes that show their muscles. There's a lot of pressure to be fit, and strong, and healthy. And there's also a lot of pressure to not show emotion. So while it's socially acceptable and normal if you will for a woman to cry, it's not necessarily widely acceptable for men to cry. The reality is we're all humans and we all experience emotion. If we can't express the emotion we feel, that energy has to go somewhere. And eating disorders are actually some of the places that it might go. Eating disorder behaviors are effective or be it dangerous ways of modulating emotion, we'll talk more about that later, but for now, I'm just putting it out there as a way of understanding why people develop eating disorders. Sexual orientation and certain occupations are among factors that apparently increase the risk of eating disorders in men. Statistically, homosexual, bisexual, and asexual men are shown to be higher risk groups. Men with appearance-oriented jobs such as modeling, acting, and those employed in traditionally female occupation like nursing, cosmetology, and food preparation also seem to develop anorexia in particular at a higher rate than the general male population. Most at-risk men are engaged in sports which require them to make weight such as wrestling crew and gymnastics. Swimmers and runners are also at higher risk. However, despite these generalizations, males of all ages, from all backgrounds develop eating disorders. Men and boys develop eating disorders for many of the same reasons that women do, and they experience similar behaviors and feelings. Since eating disorders have been primarily considered to be a women's disorder, men may experience more shame and guilt on top of their already low self-esteem. While societal pressure around thinness allows people to understand a woman's eating disorder, similar compassion for man has been missing, which may be the foremost reason why clinicians have historically seen far less men in treatment. When men do enter treatment in a particular program or group, they're likely to find themselves the only male there. An all-male support group is pretty rare. While eating disorder treatment centers abound, Roger's Memorial is one of the only all-male programs in the United States. And while some men say that they greatly appreciated the sensitivity of their female group members, others only feel even more isolated in their struggle to get well. Also, there's not much information available for and about men with eating disorders. Although, bookshelves abound with books on eating disorders, feminism, mother, father roles, and cultural pressures on women, there are less than a handful of books specifically focused on males and food problems. Furthermore, education and prevention efforts have been primarily targeted at young women when young men are as equally susceptible to cultural stereotypes and often resort to desperate means to change their bodies such as abuse of steroids and growth hormones. Here are a couple of insights from two men. "Anorexia, once you get into the behaviors and the underlying issues is pretty much the same whether you're male or female. I never tried to find an all-male support group or treatment center. I never felt that would be necessary. I found the women I was in treatment with to be very helpful. They always tried to understand me and I think they did." Sometimes, it's harder to get people to understand that you're worried about your weight and that, yes, you're a man. It doesn't seem to be the sort of thing that you can just say to people and expect them to be empathic, where a woman can say to someone, "I'm anorexic," and have people acknowledge the severity of her situation. A guy can say the same thing and people just sort of stare back with this question mark in their eyes. Athletes are another special population whose risks for developing an eating disorder are higher than their non-athletic counterparts. Some of you may have heard of something known at one time as the female athlete triad which referred to eating disorders, amenorrhoea, which is the absence of menses, and osteoporosis. This has been replaced by REDS which stands for Relative Energy Deficiency in Sports. It was changed because scientific evidence proved that underpinning the triad as an energy deficiency relative to the balance between dietary energy intake or AI and the energy expenditure required to support homeostasis, health, and the activities of daily living, growth, and sporting activities. In reality, it was never a triad of three entities but rather a syndrome resulting from relative energy deficiency that affects many aspects of physiological function, including metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular and psychological health, and it also happens to men. That's how the new term or new clinical term REDS came to be. A benefit of REDS education has helped screening disorders. It teaches a continuum that starts with appropriate eating and exercise and then moves to some acceptable dieting to the occasional use of more extreme weight-loss methods like short-term restrictive diets and then ends with clinical eating disorders, abnormal eating behaviors, distorted body image, weight fluctuations, medical complications, and fluctuating athletic performance. Factors specific to sports like dieting to enhance performance result in pressures to lose weight, frequent weight cycling, early start of sport specific training, over-training, recurrent and non-healing injuries, and inappropriate coaching behavior, and regulations in some sports have been suggested as causes of eating disorders in athletes. Gymnastics, wrestling, running, weightlifting, and swimming are sports where athletes are at particular risk. That's not to say that other athletes don't develop eating disorders, I've seen hockey players, basketball players, soccer players, and more. Many decide that they're going to be faster if they lose weight not really realizing that losing muscle mass is not helping their performance. The other interesting fact worth mentioning is that very often the act of dieting itself seems to set off a cascade of biological functions that pull the trigger and activate the eating disorder genes. So keep an eye out for the athletes you work with, keep an eye out for food choices. Really low fat, lots of vegetables, lean proteins, no or hardly any carbs with no variation, these are all cues that you may have an eating disorder on your hands. It's also important to watch out for ethnic and racial stereotypes. In a book written by Becky Thompson some years ago, she very aptly pointed out that certain minorities aren't screened simply due to the stereotypes of their ethnicity. In her book, A Hunger So Wide and So Deep, all of the people in her study met DSM criteria for an eating disorder, yet none of them were diagnosed although they all had regular medical care. She points out that Asians are typically thin, so they don't even get screened. And she also notes that blacks are stereotyped as "larger boned" and "larger body," and therefore, they weren't screened. Just be aware that everyone regardless of weights, ethnicity, sex, age, and socioeconomic class can develop an eating disorder. In summary, you're looking for common threads or patterns like these. How often are they engaged in a pattern that looks abnormal? How severe is it? How long has it been going on? Is it chronic? Is it entrenched? Can they stop? Is it impeding their functioning? Does it cause significant distress or impair the quality of their daily life? Are they fatigued all the time? Is it affecting their relationships? These are all really important cues that tell you that they need a formal assessment. And again, remember, you can work with someone with an eating disorder as long as you're communicating openly with his or her team. Thanks for joining me. Until next time.