Be on Lookout for Unhealthy Eating Practices Beyond Recognized Eating Disorders, Says Expert

Over the past several decades, it’s been a popular trend to define scandals by affixing them with the suffix “-gate” (Russiagate, gamergate, etc.). A similar type of branding is being seen in the field of eating disorders, as both popular media and research articles have coined terms such as “bigorexia” or “drunkorexia.”

At a session yesterday, leading expert Evelyn Attia, M.D., director of the Columbia Center for Eating Disorders at Columbia University Medical Center, discussed some of these unusual eating practices that have received recent attention. She noted she was not a big fan of some of these labels, but they have served to highlight the complexity of disordered eating beyond the well-known disorders of anorexia nervosa and bulimia nervosa.

Briefly, four eating problems that clinicians have reported seeing more often include the following:

• Bigorexia: Using food restriction and other behaviors (weightlifting, performance enhancers) to try and develop a certain type of muscular body pattern; mostly practiced by males.


• Diabulimia: Purposefully restricting use of insulin by diabetics in an effort to lose weight.


• Drunkorexia: Reducing calorie intake to compensate for planned future drinking of alcohol, which is very common in college-aged young adults.


• Orthorexia: Having an unhealthy focus on eating foods that are considered healthy or pure.

Each of these four can clearly be dangerous, Attia noted. For example, the potential risks of binge drinking with an empty stomach are well known, as are the dangers of not maintaining insulin treatment.

But while psychiatrists should be aware of these growing issues, they should also remember they are just labels, not diagnoses. “Make sure to do a thorough history and workup of these patients to see what formal eating disorders, and other disorders, are layered on top of these presentations,” she said.

Attia noted that psychiatrists have many options to choose from, for while the “-exias” are not codified, DSM-5 did increase the number of recognized eating disorders. This included some conditions previously codified as childhood disorders, like avoidant-restrictive food intake disorder (avoiding food for reasons other than weight or body image) but also new conditions like atypical anorexia, in which a patient meets all the criteria for anorexia except that they are not underweight.

Attia said the introduction of atypical anorexia was welcomed by many psychiatrists and patients, “since there is no weight cutoff before someone can get into trouble.” She cited work showing how some people who have received bariatric surgery develop intense anxiety over becoming obese again and develop hallmark anorexia symptoms, despite having BMIs that are still above average.

Attia said the eating disorders field is still learning a lot following the addition of these new conditions in DSM-5. With regard to atypical anorexia, should a patient with a higher BMI be encouraged to restore lost weight to prevent problems if the patient relapses? Also, she said it is critical to have more validated assessment tools, as current ones are geared toward women worried about weight and are less suited for other motivations or genders. ■

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