Tomoko Udo of the School of Public Health has examined the connections between eating disorders and mental health. Fewer than 30 percent of people with eating disorders (i.e. anorexia nervosa, bulimia nervosa and binge eating) seek help from a counselor or psychologist. As a result, researchers have found that those suffering from eating disorders are often at higher risk of suicide attempts. According to Udo, health-care providers should carry out routine screenings for eating disorders along with suicide attempt history in order to inform a more comprehensive treatment plan. Udo is an assistant professor in the Department of Health Policy, Management and Behavior. She conducted the study with Sarah Bitley of UAlbany's School of Public Health and Carlos Grilo of the Yale University School of Medicine.
Tomoko Udo of the School of Public Health has examined the connections between eating disorders and mental health.
Fewer than 30 percent of people with eating disorders (i.e. anorexia nervosa, bulimia nervosa and binge eating) seek help from a counselor or psychologist. As a result, researchers have found that those suffering from eating disorders are often at higher risk of suicide attempts.
According to Udo, health-care providers should carry out routine screenings for eating disorders along with suicide attempt history in order to inform a more comprehensive treatment plan.
Udo is an assistant professor in the Department of Health Policy, Management and Behavior. She conducted the study with Sarah Bitley of UAlbany's School of Public Health and Carlos Grilo of the Yale University School of Medicine.
Read more on Udo's latest work.
The UAlbany News Podcast is hosted and produced by Sarah O'Carroll, a Communications Specialist at the University at Albany, State University of New York, with production assistance by Patrick Dodson and Scott Freedman.
Have a comment or question about one of our episodes? You can email us at mediarelations@albany.edu, and you can find us on Twitter @UAlbanyNews.
Sarah O'Carroll:
Welcome to the UAlbany News Podcast. I'm your host Sarah O'Carroll.
Sarah O'Carroll:
I have with me Tomoko Udo, an assistant professor in the School of Public Health. Udo is researching the connection between eating disorders and psychological impairment and chronic medical conditions.
Sarah O'Carroll:
First off, can you help us understand the scope of the problem of eating disorders in the United States; on average, just how many people are affected each year by anorexia, bulimia and binge eating disorders, respectively?
Tomoko Udo:
I've been using national epidemiology data [Source: 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions Third Wave (NESARC-III)] that represents over 36,000 individuals who have not been institutionalized. Based on that data, we found that anorexia nervosa is about...The lifetime prevalence is 0.8 percent, bulimia nervosa is 0.28 percent and binge eating disorder is 0.85 percent. So, that's lifetime. It is much lower than major psychiatric disorders such as depression or substance abuse disorder. Depression could be about 20 percent, maybe over more than 20 percent lifetime prevalence. Substance use disorder, it could be anywhere, depending on what it is, between less than one percent, but alcohol use disorder is 30 percent. So, it is definitely lower than those disorders, but definitely the impact of the disorders is severe, maybe potentially more severe than those [other] disorders.
Sarah O'Carroll:
Okay. So, compared to other types of health issues that we're seeing, perhaps eating disorders are on the lower end of the spectrum, but these still seem significant?
Tomoko Udo:
Mm-hmm (affirmative).
Sarah O'Carroll:
Is that correct?
Tomoko Udo:
Yes. The eating disorders definitely impact everyone. People tend to think that it's a young white female disorder, but what we found, and [what is] consistently reported in our literature, is that's not true. It can happen in males, it can happen at any age and it can happen in any race.
Sarah O'Carroll:
Okay. What kinds of health-related consequences are commonly associated with eating disorders? Because it's not just about trying to lose weight or to have a better body image. What are some other effects?
Tomoko Udo:
All eating disorders are highly associated with other psychiatric disorders, including substance abuse disorder, personality disorder. Based on the same data set, we found that for bulimia and binge eating disorder, over 90% percent of individuals who met the criteria for binge eating disorder and bulimia nervosa diagnoses met other psychiatric disorder diagnoses. For anorexia, it was 80-something percent. If they meet the criteria for an eating disorder, then they tend to also meet at least one other psychiatric disorder diagnosis.
Sarah O'Carroll:
Okay.
Tomoko Udo:
In terms of health effects, binge eating disorder is highly, highly associated with obesity and metabolic disorders. Anorexia has a high risk for osteoporosis, and some others... anemia and so on, bulimia also. Those disorders [occur] because it's about eating, so they tend to have some intestinal problems as well.
Sarah O'Carroll:
It seems like that would just compound the issue; if you're trying to lose weight and that's why you're throwing up in the bathroom or something, and then you gain weight, that would make all of those other mental effects worse, it sounds like.
Tomoko Udo:
Yes. Most importantly, all these disorders associated with functional problems in life. All individuals with any [eating disorder] -- anorexia, it doesn't matter, bulimia, binge eating disorder -- they tend to feel guilty and ashamed that they have these disorders. So, they try to hide it from people. Depending on the severity, for example, if you engage in binge eating behavior a couple of times per day, you may not want to go out eating with people and you might not want to interact with people because they want to hide their disorder. So, that can impact their relationship with others and just functionality. They feel like they're highly impacted by the disorder.
Sarah O'Carroll:
Okay. I was also hearing when you were sharing an answer to the first question that this is sort of a root cause that then spawns other issues. At the beginning, you were sharing numbers on how [these types of] eating disorders results in slightly lower numbers than other types of common health issues. So, is it possible that some people don't want to share about the eating disorders but will say that they're suffering from depression, or something, and that can result in different numbers?
Tomoko Udo:
That could be possible, but this number is lower than some estimates that we have done in the past, but it's not significantly lower. Again, if you go back to the number of people who actually meet the criteria for eating disorders, it is definitely lower than those, but we don't know. I don't know. I personally don't know what disorder happened first and so on. Binge eating disorder for example is a later onset compared to other two disorders; and anorexia definitely is [more common for] teenagers [who are] 16, 17 years old; bulimia, maybe a few years later; binge eating disorder is 25. That was the average [age] that we found at the onset. So, depending on what other disorder you're looking at in terms of co-morbidity, it could be earlier or it could be later. Yeah.
Sarah O'Carroll:
Okay. How likely are people suffering from eating disorders to seek help?
Tomoko Udo:
What we found was that the treatment seeking behavior is very low. This particular data set also asks, "Have you ever seen any help?" So, we're not just talking about a psychiatric, psychologist or counselor, we talked about even support groups and so on, but including that, on average for anorexia, about one third [sought help]. A little over one third of people reported seeking any help in their lifetime. Bulimia is a little over 60 percent and binge eating disorder is about 50 percent, I believe. Many people don't seek any kind of help, even including self help and support. When you look at the counselor, psychologist that we consider as specialized treatment, that number is less than one third. Very, very low.
Sarah O'Carroll:
Mm-hmm (affirmative).
Tomoko Udo:
Part of the problem, I think, is that there are not many specialized treatment centers for eating disorders, even within New York. For practices that are specialized in eating disorders, there are only three across the state. So, that's part of the problem. In terms of who are less likely to seek help, men tend to be less likely to seek treatment compared to women, and racial and ethnic minorities are less likely to seek treatment compared to Caucasians.
Sarah O'Carroll:
Okay. Can you perhaps speak to why that might be?
Tomoko Udo:
We are just hypothesizing why it could be, but again it comes back to this notion that eating disorders are primarily for young females, Caucasian females. So, maybe even when they're experiencing eating disorder symptoms, they might not think that that is a problem and know what it is -- or feel ashamed, especially with men. They tend to report some shame that they're developing an eating disorder, having a body image problemm, and so they don't seek treatment because they're ashamed. Those are the populations that tend not to seek specialized treatment. They tend to go to primary care. So, it might be that again, when they go to the primary care, doctors probably don't think to ask whether they have an eating problem because they don't... fit into this category of young Caucasian females. That might lead to miss detection of the problem when they're experiencing eating disorder symptoms.
Sarah O'Carroll:
Now, it also looked like from your study that you were looking at the connection between eating disorders and suicide attempts.
Tomoko Udo:
Yes.
Sarah O'Carroll:
Can you share a little bit about what that research entailed?
Tomoko Udo:
We found that the lifetime history of an eating disorder is strongly associated was reporting of suicide attempts in their lifetime. To go into detail, an interesting part that we found was that [people with] anorexia actually have different subtypes. So, one of them is restriction [where] people kind of focus on restricting their calorie intake and so on. Another type would be binge eating and purging. They may also have other body image problems. Those binge eating and purging subtypes had the highest percentage of reported suicide attempts across all the binge eating disorder diagnoses that we looked at.
Tomoko Udo:
We don't know why. We weren't able to explore the part of why, but that was something that we found very interesting and something interesting to pursue I guess.
Sarah O'Carroll:
Okay. For this study, you also were looking at diagnostic criteria for eating disorders. Why does the language matter in terms of diagnosis and treatment, and what kinds of changes did you observe that were interesting or that perhaps made you look at the problem differently?
Tomoko Udo:
We decided to use this data set and focused on an approved list of eating disorders. This was the first epidemiologic survey in the U.S. after the diagnostic criteria changed in 2013. So, in terms of eating disorders, there were some major changes that happened. Anorexia, it used to require the absence of a menstrual cycle, they removed [requirement]. They're no longer so restrictive about BMI requirements. They kind of loosened up the criteria in that way. With binge eating disorder, bulimia, they also kind of loosened up the criteria for the frequency. Another important thing is that binge eating disorder never had a formal diagnostic criteria prior to DSM-5 [Diagnostic and Statistical Manual of Mental Disorders]. It was part of other eating disorder criteria. So, they also made it into individual diagnostic criteria.
Tomoko Udo:
There are many reasons to look at the prevalence in the U.S. because the last time that happened was 2007, which is more than 10 years ago. It was important to update the data. This is not necessarily just for this particular dataset, but there is always a challenge in terms of doing epidemiologic surveys on psychiatric disorders. There are many, and all studies tried to look at the older disorders. It takes a lot of time, so we have to limit how long the survey should take because people get burdened, people may not want to answer a question.
Tomoko Udo:
When that happened, you can only really limit what kinds of questions that people can ask. This particular survey done by NIAAA [The National Institute on Alcohol Abuse and Alcoholism], this is the third time that they did it. Prior to surveys, they actually didn't include eating disorders. Part of it, because again, it has a lower prevalence compared to other major psychiatric disorders, so they may not be able to get a sufficient number of people to meet that criteria. That could be one of the reasons, but either way they added it and so that's another new aspect that our study highlighted. There was some criticism in terms of how the questions were asked for the eating disorder for that.
Sarah O'Carroll:
Criticism from...?
Tomoko Udo:
From other... Yes, peers.
Sarah O'Carroll:
Okay.
Tomoko Udo:
... our peers and they felt like it wasn't asking enough questions, I guess. So, that was the limitation of this data set and a limitation in our study overall because we were using this dataset, but we also wanted to highlight that...Also, highlight the need to do more research and data collection, have more population level understanding of eating disorders and then also, highlight how little epidemiological research has been done at least in the U.S. around eating disorders. There definitely are ways to make these questions better to capture eating disorder symptoms and people who might have an eating disorder. Our hope really has been to push this ahead based on this data set and then kind of push the field so that people will be motivated to study more at the population level.
Sarah O'Carroll:
What I'm hearing is, when the questions are limited then that will inherently exclude some people from being in that category, and then getting diagnosed and getting treatment.
Tomoko Udo:
Right.
Sarah O'Carroll:
Is that right?
Tomoko Udo:
Right, because sometimes you have to just not ask. If someone says, "No," a lot of times... We built the survey so that if someone says, "No," to a certain question, they just skip the whole thing. That kind of limits what other... because eating disorders -- anorexia, bulimia, binge eating disorder -- they are the major ones, but there are also other types of eating disorders that we looked at, but we couldn't do that just because it just was not asked. None of the rest of the questions are not asked. Those are the limitations, but it's just not specific to this in particular. It just happened with a psychiatric epidemiology survey studies just because of the consideration of burdening --
Sarah O'Carroll:
Okay.
Tomoko Udo:
... the participants. You have to kind of do cost/benefit analysis in the sense of what you include in a survey and what can we do and what you want to study, like what you want to get at the most.
Sarah O'Carroll:
Because if it's a comprehensive questionnaire that takes a really long time, then people might get discouraged or say, "I'm not going to handle this."
Tomoko Udo:
Right.
Sarah O'Carroll:
Okay.
Tomoko Udo:
There are a lot of ways to make surveys better and especially with an eating disorder, definitely we see that there are better ways to structure a question and to ask a question. Again, we're hoping that this is going to stimulate interest in doing so in the future.
Sarah O'Carroll:
Okay.
Tomoko Udo:
Yeah.
Sarah O'Carroll:
So, more research on this, what sounds like, is still an emerging area of research --
Tomoko Udo:
Mm-hmm (affirmative).
Sarah O'Carroll:
... but what other takeaways are there here for public health officials seeking to address this issue? It sounds like from earlier, seeing more specialized treatment centers would be good, more reporting.
Tomoko Udo:
Mm-hmm (affirmative).
Sarah O'Carroll:
What else is there that could really help this?
Tomoko Udo:
If you think about going to primary care... You mentioned a little bit, but your own interest and my own experience, that they ask about whether you eat or not and your weight. If you go to a doctor appointment, they talk about that, but they really don't ask how you eat. So are you skipping meals -- it could even be that if they do it on a regular basis, that is actually... Especially to control their weight, that is considered as disordered eating behavior, but I don't think people, doctors, really don't ask that kind of question. They just want to know if you're eating and what you're eating, but not how. So encouraging that kind of training so that more detection can happen would be good.
Tomoko Udo:
Also, like any other psychiatric disorder, including substance abuse disorder and depression and other mental health issues, I think is really important to remove the stigma around eating disorders so that people feel more comfortable about sharing their story or seeking help when they feel like they can't... They shouldn't feel ashamed that they have a disorder.
Sarah O'Carroll:
That seems to go beyond just public health officials, but you and I as daily citizens and being friends to others and trying to be caring and not saying, "Oh, you're a man and you have an eating disorder? How weird," but trying to normalize that.
Tomoko Udo:
Right. Yes.
Sarah O'Carroll:
Okay. Tomoko, thanks so much for being here.
Tomoko Udo:
Thank you.
Sarah O'Carroll:
Thank you for listening to the Ualbany News Podcast. I'm your host, Sarah O'Carroll and that was Tomoko Udo from the School of Public Health. You can let us know what you thought of the episode by emailing us at mediarelations@albany.edu, or you can find us on Twitter @UAlbanyNews.