A Silent Problem
By Theodore E. Weltzin, MD
Medical director of Eating Disorder Services at Rogers Memorial Hospital
June 10, 2008
Overview
Eating disorders – including anorexia nervosa, bulimia nervosa and binge eating disorder – effect up to 5 million Americans every year. While eating disorders typically affect females, males make up as much as 10 percent the total population of people with eating disorders.
Because of the destructive nature of the psychological and physical problems often associated with eating disorders, these disorders represent some of the most difficult psychiatric illnesses to treat. Eating disorders can have a major impact on a person's ability to function in the workplace and can be a challenge for employers who have an employee with an eating disorder.
Males and Eating Disorders
The awareness of eating disorders in males is growing.
The behavioral characteristics of anorexia, bulimia and binge eating disorder in men are similar to those of women. Like women, males with anorexia will develop symptoms of weight loss and fear of weight gain. With bulimia and binge eating disorder men and women both develop binge eating symptoms with or without compensatory behavior to purge food. Again, like women, males with eating disorders also are at increased risk for depression, anxiety disorders and alcohol and substance abuse.
However, important differences exist between males and females with eating disorders. Studies show that males are less likely to seek help for emotional problems in general, and this is true among those with an eating disorder. Because eating disorders are typically seen as a "female problems," males are often even more reluctant to seek help. Because of this, males will often struggle with their eating disorder for many years before seeking help. Delaying treatment can reduce treatment effectiveness and increase the risk of medical complications. Delays also increase the risk of depression and problems with school, work and relationships.
Males with eating disorders often do not want to lose weight or attain a lower body weight; they tend to focus on having a more muscular physical shape. Males with eating disorders typically become preoccupied with how muscular they are physically and a male's eating disorder may begin with compulsive exercising in addition to dieting. Historically, males who participate in athletic activities with a high degree of emphasis on weight and shape (including wrestling and gymnastics) have an increased risk of developing eating disorders.
Eating and body image problems in males can occur which do not clearly fit into the category of eating disorders. Compulsive exercisers (in which exercise becomes like an addiction and can have a destructive effect on family, work and physical health) will often become anxious if they cannot exercise. They tend to feel frustrated and believe they have "not exercised enough" rather than a sense of well-being following exercise. This feeling prompts them to exercise rather than spend time with family or friends or have decreased work performance as a result of their need to exercise.
Eating Disorders in the Workplace
Over the last decade, employers have had an increased awareness of the cost of mental illness in the workplace; eating disorders are no exception. Depression and irritability, which often accompany eating disorders, can lead to increased conflict at work. Tardiness, sick days and decreased productivity due to employees engaging in abnormal eating behavior can also be a sign of ongoing eating disorder symptoms or relapse in an eating disorder.
Denial and concealment of eating disorders symptoms occurs almost universally. Since most people are uniquely aware about the eating habits of their coworkers, it is not uncommon for co-workers to make observations about someone's weight or eating habits. Also, in the case of bulimia, employees may be caught by co-workers binge eating or purging while on the job. With improving employee assistance programs, it is not uncommon for employees to seek help from someone in the workplace as a first step in seeking recovery.
Directing an employee to an evaluation by a medical provider should be the first step to assure medical stability. The medical provider, often times in conjunction with a firm's insurance plan, will then refer the patient to a psychotherapist who specializes in eating disorders. This can be particularly difficult with male patients as fewer professionals have experience with male patients with eating disorders.
While the employer may not be included in the employee's treatment, it is important to remember that medical monitoring is needed. This can reduce the chances of medical complications and injury while in the workplace. Psychiatric medications can have side effects need to be taken into account to assure that this also does not impair safety in the workplace.
Modifications in the work place can facilitate recovery. There are several ways employers can improve their workplace for those in recovery from an eating disorder, including:
- Being flexible with additional requests for extra time off. Because of the need for a therapist, dietitian and physician, there can be a number of appointments for which the employee may need time away from work.
- Providing regularly scheduled mealtimes. It is important for an employee in recovery from an eating disorder to have regularly scheduled meal times in order to allow normal eating behaviors to develop.
Eating Disorders, Depression and Anxiety
In addition to abnormal eating and weight, people with eating disorders have an increased risk of having other psychiatric illness. Depression occurs in up to 50 percent of people with eating disorders and appears to be strongly linked to the abnormal eating behavior. Depression is difficult to treat in someone with an eating disorder if his or her eating disorder is not treated at the same time. However, when the eating disorder is treated, about 75 percent of the time, depression symptoms improve as well.
Anxiety disorders also occur frequently in people with eating disorders. Anxiety about food and weight are characteristic of these illnesses, however, studies show that people with eating disorders have increased rates of anxiety disorders including social anxiety and obsessive compulsive disorder. As opposed to depression, anxiety disorders frequently predate the onset of the eating disorder and in that sense may represent a trait for who is at risk for developing an eating disorder.
Medical Problems and Eating Disorders
Because of the serious nutritional symptoms associated with eating disorders, several medical problems are associated with this group of illnesses. Malnutrition is the hallmark of anorexia and is associated with many physical and emotional problems, including weakness and fatigue, low body temperature, hypoglycemia, anemia, easy bruising, low blood pressure and dizziness, and problems with concentration and memory. The medical complications of anorexia often are severe and can be life threatening.
People with bulimia can have several of the physical symptoms of malnutrition. In addition, binge eating and purging can cause electrolyte disturbances, such as low potassium which can result in cardiac failure; gastrointestinal problems, including esophageal tears and bleeding, gastritis and esophageal reflux; severe dental problems, as a result of gastric acids effects on teeth; and a variety of digestive problems, including cramps, bloating, constipation, diarrhea and increased risk of seizures. It is important to emphasize that eating disorders can be medically dangerous and that medical problems can result in death.
Treatment of Eating Disorders
The treatment of eating disorders typically involves a team of professionals, including a therapist, dietitian and medical doctor. Those suspected of having an eating disorder should be evaluated by a medical professional. Some patients will need hospitalization to treat acute malnutrition and dehydration, in addition to other medical problems. A comprehensive assessment will also consider suicide risk and other self-destructive behaviors, including substance abuse. At times, psychiatric hospitalization for depression and suicide may be required.
After a thorough medical evaluation, working with a therapist who specializes in treating eating disorders is essential.
Therapists should focus on examining the causes of the eating disorder, looking at how stress affects these symptoms, and how often the eating disorder becomes a dysfunctional coping mechanism for dealing with stress.
Patients with eating disorders usually need to work long-term with a dietitian. Because medical insurance often does not cover dietary services or more than one dietary consultation, employers can have a positive impact on treatment if they can influence their insurance carrier or managed care company to see this service as integral to an employee's recovery. A dietitian needs to be involved in determining normal body weight, helping the patient develop a health meal plan, monitoring compliance with the meal plan, and helping identify obstacles to recovery.
Summary
An increased awareness of eating disorders and their treatment can help employers to help their employees to receive effective treatment that can lead to recovery from these illnesses for a majority of patients, greatly reduce medical and psychiatric risk for other problems, decrease risk in the work-place, and improve employee productivity.
