NL n 2 / 2022
December/2022
The syndemic we are experiencing requires
the search for new methods and new connections.
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Our task is to create and develop a European specialist network for ED with the dual aim of spreading the AED Mission and helping individual, families, providers, countries and their scientific societies on ED to get out of the narrow national arena.
The AED European Chapter board meets every month and plans various initiatives; you can read some of them below.
And follow our monthly webinars!.
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It is time to develop all-age clinical services for eating disorders
Riccardo Dalle Grave, MD
Department of Eating and Weight Disorders, Villa Garda Hospital. Gard (VR), Italy
Almost 50% of eating disorders begin before the age of 18, and many young people require treatments until they reach their mid-twenty and beyond. These data indicate that many patients address transitioning from child and adolescent eating disorders to adult eating disorders clinical services.
The transition from adolescent to adult eating disorders clinical services is often associated with a gap in regular treatment, the interruption of the therapeutic relationship, and the different nature of the treatment offered. Indeed, the nature of the treatment for eating disorders is significantly different in adolescents and adult clinical services. Adolescent services usually deliver family-based treatments, whereas adult services mainly offer individual psychological therapies. The two approaches significantly differ in the conceptualization of eating disorders and the nature of the involvement of parents and patients.
It is understandable why the transition from family therapy to individual treatment, creating a discontinuity in the nature of care, may disorient patients and their parents about the procedures that need to be adopted to overcome their illness, increasing the risk of relapse and negative outcomes.
A solution to the above challenges, ad implemented in some countries, is organizing clinical services that cover the age range from childhood to young adulthood. For this purpose, there are two main strategies:
1. A reach-up model, extending, for example, the family treatments in the transitional age.
2. A reach-down model, adapting, for example, individual psychological treatments to the transitional age.
I think the second strategy is preferable because patients in the transitional age (e.g., 17-19 years) may find an adapted "adult" form of treatment more acceptable than a family-style one.
Enhanced cognitive behavior therapy (CBT-E) is a major candidate among the individual psychological treatments for the transitional age because it has been adapted both for adults and adolescents with promising results.
ONLINE WEBINAR LGBTQI+ - ED (17.11.2022)
by Luca Oppo
On Thursday 17th November, a free webinar “LGBTQI+ and Eating Disorders”, promoted by The European Chapter of AED, took place on Zoom online platform; the purpose of the webinar was to focus on peculiarities and difficulties related to the recognition, reception, taking care and treatment of the specific LGBTQI+ target, with a focus on Eating difficulties and Disorders.
Four speakers were enrolled: Jason Nagata (MD, USA), Kyle Ganson (PhD, Canada), Paolo Meneguzzo (MD, Italy) and Manlio Converti (Psychiatrist, Italy); they employed research projects and scientific literature data to expand these contents and themes by different points of view.
The first speech was “Eating Disorders and Muscularity concerns in LGBTQ+ People” by Nagata and Ganson, that explained gender norms and specifications about sexual and gender minorities, in terms of definition, diagnosis and clinical classification. Nagata analysed feminine and masculine body ideals, regard to specific influence factors (portrayed ideal body by mass media) and gender-related behaviours, acted to reach a thin feminine body or a muscular male body. He put a specific focus on transgender minority population, delving into ED in this target; some studies of the Pride Study were reported. About this, it came to light the importance of identifying a specific growth chart to avoid the current barriers of treatment. Ganson defined the sex and gender background, explaining about sexual orientations, minorities and identities, gender identity and expression. Related to Eating Disorders, he spoke about ED Diagnoses and behaviours, in both LGBTQI men and women, and in sexual minority population. About that, Ganson referred high incidence of ED in this population, and some specific characteristics (contributing factors, barriers to treatment).
The second speech, named “Body weight satisfaction and the role of sexual orientation” was by Meneguzzo. He defined body satisfaction and his factor of influence (self esteem, depression, social comparison), body weight dissatisfaction, Body Image and sexual orientation; he referred two study to explain it. The main conclusion was that Body Image dissatisfaction has an high incidence in these people and it’s influenced by sexual orientation; for this reason was highlighted the necessity of considered sexual orientation like an aspect to assess and considered in the treatment.
The third speech was “Eating and Nutritional Disorders in LGBTI People, from the shadow to the light of epidiological studies”, by Manlio Converti. He started defining the LGBTI Community, with a focus on stress factors that influence mental health and following risky behaviours. Converti reported some advices on meeting and treating LGBTI people, in order to reduce psychic symptoms, including ED. Three specific steps were shared for this purpose: LGBTI inclusive data collection at each first access (a purpose of "sex and Gender orienteering", based on four axes of Sexual Identity), affirmative reception of LGBTI people and affirmative psychotherapy of LGBTI people and their parents. The latest part of the speech concerned some guidelines and indications about LGBTI population target, focusing on the necessity of specific lines useful for taking care and intervention.
This Webinair was full of suggestion, supporting for the European chapter, with the aim of enhancing and encouraging health services professionals about this important themes.
Next is on 14th December 2022, Topic: how to face Christmas holidays if you or loved-one has ED?, European Chapter with FEAST.
News from the EC Conference 2022 in Austria organized by the Austrian scientific society on eating disorders
by Thalia Abatzi
After the first conference of the European chapter in Rome 2018, the idea of a common conference of the European chapter and of the international Austrian conference was conceived at the time of the presidency of the AED Prof. Ursula Bailer. The plans were crossed by the pandemic and more recently by the war in Ukraine. Finally on 21st October 2022 the annual national European chapter conference took place in Alpbach under the chair of Prof Waldherr the president of the Austrian scientific society on eating disorders (ÖGES/ASED) and Prof Umberto Nizzoli the president of the European chapter as part of the 29th Scientific Conference on Eating Disorders co-organized by the Netzwerk Essstörungen. Alpbach is a small, pittoresque mountain village in Tyrol well known for the Tyrolean traditional houses.
The format was hybrid which made it easier to participate from all over the world. The keynote was held by the current president of the AED Prof Dr Jennifer Thomas, USA, on research in avoidant/restrictive Food Intake disorder, a diagnostic entity of the last 10 years. Clinical characteristics and underlying neurobiology were explored, and surprisingly neurobiological features are consistent with patients` subjective experience. Prof Stephen Anderson brought an overview on ethical issues in the treatment of eating disorders. An understanding of these ethical issues is important to be able to judge the best way to deliver evidence-based treatment in a thoughtful, empathic way. Dr Voderholzer from Klinik Roseneck, Germany, spoke on new studies on high calorie refeeding and the risk of refeeding syndrome in severe adolescent and adult anorexia nervosa. Prof. Manzato from Italy spoke over hidden and lesser-known disordered eating behaviors in medical and psychiatric conditions. Finally, Prof Nizzoli spoke on food and addiction closing an interesting afternoon with an exciting discussion on the different topics which lasted through the reception.
A common topic was the concern on the increase in western European countries of eating disorders especially in adolescents during pandemic with closed schools and lockdowns next to depressive disorders which put a huge pressure on the health system services, which were performing already before the pandemic at their limit. The eating disorder hotline esstoerungshotline.at and the network telephone were frequently used.
The 13th Viennese conference on eating disorders 2023 will be held from 16th to 18.3. 2023 at the Medical University of Vienna organized by Prof Karwautz, the current president of ÖGES/ASED. https://essstoerungen2023.medacad.org/
European Chapter of AED
Seventh Conference
Alpach
Some personal thoughts (U. Nizzoli)
In the beautiful alpine setting of Alpbach, where Schrodinger is buried in the small cemetery, the 29th Congress of the Austrian Society on Eating Disorders was held in the new congress hall. The event was in hybrid form and saw the physical participation of a large group of professionals (finally!).
European Conference was a series of presentations that the public definitely appreciated.
Personally I was attracted by the profound report presented by Stephen Anderson who placed the issues currently at the frontier of scientific research and cultural debate: those of the rediscovery of the linguistic religious cultural social traditions of the different population groups, re-evaluating their traditions and opening a new season that it goes beyond the evidence-based medicine that has derived from the collection of data in the Western world, processed according to the criteria of the Western world, by professionals of the Western world, as critically points out APA (august 2022).
We need a cultural revolution to be able to ensure that our clinical sessions (encounters) with our patients are really centred on the person as a whole, physical, psychic, relational and spiritual.
The conference was masterfully chaired by Karin Waldherr with my collaboration.
Thanks to the Austrian colleagues for their hospitality!
Loneliness in Eating Disorders, conference at Villa Margherita
by, Patrizia Todisco, Md
On 2-3 December it took place at Villa Margherita (Vicenza) a meeting focusing on “Conflict and Loneliness in Eating Disorders”. These two topics are currently very important starting from events that are stressing the individuals and the populations both personally, socio-culturally, and politically. Loneliness may arise from the unsatisfaction of the need for belonging to and the distress of attachment systems, and it is a phylogenetically evolved mechanism to prevent isolation from the group of peers. Loneliness is a transdiagnostic construct that can be found in different mental disorders and may represents a predisposing, precipitating and maintaining factor or a consequence of the disorder. The relationship between loneliness and eating disorders (EDs) wasn’t studied well yet and during the first day of the meeting the preliminary data of a multicentric study on this topic were presented together with some explanations of the constructs of loneliness and isolation, and the Hikikomori syndrome.
In the second day of the meeting was addressed the topic of conflict in EDs from different points of view and in its different aspects.
EDs, in fact, may represent a dysfunctional way to improve self-esteem through the preoccupation for and the control of eating/weight/shape, but they can be considered also as a difficulty in the integration of dissonant parts of the individual (e.g. the body and the soul) that are conflicting as the subject is in conflict with the family and the society. Besides, sometimes ED is the only way that the person uses to express the disapproval towards parents, friends, society norms.
The conflict is at the same time necessary to go from childhood to adolescence and from adolescence to adulthood, but often it is so much feared as deadly, harbinger of grief and loss that is avoided at the cost of illness and death, as it happens in some ED patients.
In EDs the overestimation of the body and the appearance leads to a continuous conflict with the own body image that appears as a conflict with the body folded to pathological beliefs. In these disorders, moreover, the conflict apparently happens also against cargivers and therapists because ED is egosyntonic and part of the treatment is to transform it in egodystonic. In the multidisciplinary team specifically established to treat ED patients is also important to avoid conflict through the sharing of vision, mission, language to achieve engagement and commitment in the treatment of such illnesses.
LESSER KNOWN EATING DISORDERS IN MEDICAL CONDITIONS:
COMPLETE ANDROGEN INSENSITIVITY SYNDROME (CAIS) AND EATING DISORDERS
by Emilia Manzato, Md
Androgen Insensitivity Syndrome represents a disorder due to partial (PAIS), mild (MAIS) or complete (CAIS) resistance to androgens caused by X-linked mutations of androgen receptor gene.
CAIS is characterized by a female phenotype and XY karyotype [1].
In fact, subjects with CAIS have a 46 XY karyotype but the complete resistance to androgen action leads to a female phenotype despite testosterone levels -produced by their abdominal undescended testes -are within or above the male normal range [2].
The gender identity and gender role usually show a female pattern in CAIS individuals.
The coexistence of CAIS and Eating Disorders has not been described so far, on the contrary, association with overweight, a risk factor for unhealthy restrictive behaviour, has previously been reported[3].
Overweight adolescents report greater concern about their weight and more Body Dissatisfaction (BD) than their normal weight peers. They are therefore at risk of developing disordered eating behaviour such as severe fasting to lose weight and consequently onset of Binge Eating.
In fact in adolescents and young adults with ED, the prevalence of a history of overweight or obesity ranges from 19.3% to 36.7% [4].
The patients with CAIS and overweight are at high risk to have BD that could promote unhealthy restrictive behavior as well.
Yang et al. reported a case of CAIS with obesity and metabolic syndrome, but weight-related BD was not investigated [5].
Recently, the case of a patient affected by CAIS and Anorexia Nervosa restricting type later shifted to Bulimia Nervosa has been published [6]
In this patient the onset of the Eating Disorder was initially linked to the presence of overweight since childhood.
The BD and the “feeling fat” persisted despite the weight loss leading to the severe restrictive behaviour of Anorexia Nervosa, then shifted to Bulimia Nervosa.
The scientific data highlight the importance of diagnosing and monitoring the overweight and BD in CAIS patients to avoid the onset of an ED.
REFERENCES
1 Oakes MB, Eyvazzadeh AD, Quint E, Smith YR (2008) Complete androgen insensitivity syndrome – a review. J Pediatr Adolesc Gynecol 21(6):305-10
2.Lanciotti L et al. (2019) Different Clinical Presentations and Management in Complete Androgen Insensitivity Syndrome (CAIS). Int J Environ Res Public Health 16: 1268. doi:10.3390/ijerph16071268
3 E. Manzato, M.Cuzzolaro, LM Donini (eds.), Hidden and Lesser-known Disordered Eating Behaviors in Medical and Psychiatric Conditions, Springer Nature Switzerland AG 2022 261https://doi.org/10.1007/978-3-030-81174-7_26
4 Rastogi R, Rome ES. (2020) Restrictive eating disorders in previously overweight adolescents and young adults. Clev Clin J Med 87 (3): 165-171
5 Yang P, Liu X, Gao J, Qu S, Zhang M (2018) Complete androgen insensitivity syndrome in a young woman with metabolic disorder and diabetes: A case report. Medicine 97(33): e11353. doi: 10.1097/MD.0000000000011353
6 Manzato E, Gualandi M, Roncarati E. Complete androgen insensitivity syndrome (CAIS) and eating disorders: a case report. Eat Weight Disord. 2020;
Food and Addictions
by Umberto Nizzoli, PhD
Key-words: Addiction, Substance Use Disorders, Eating Disorders, Food Addiction, Human development, Autonomy, Craving
Everything that is loved grows, Father Vincenzo Sorce used to repeat (1), which is equivalent to observing that those who are not loved, that is the unwelcome child, suffer damage to the development of the brain architectures that expose them to developmental disorders, like ADHD, during childhood and can further develop into behaviour disorders and drug use disorders during adolescence as evidenced by research conducted at Harvard Child Development Institute (2).
Our biological structures are predisposed to welcome. When we born we are in a state of absolute dependence and we are biologically built to live the condition of dependence. The quality of the mother-child interaction is the tool that lays the foundation for later emotional regulation and cognition (3).
A text by Ogden (4) talks about unlived lives; the hypothetical lives that the individual could have developed and followed if in certain circumstances, such as suffering an accident or met someone other, he would have had other occurrences. Inside the individual there remains a memory of unlived lives, memories of sketched hypotheses and for some reason that did not happen. Those memories give rise to an emotional background of melancholy for the renunciations that are inherent in them.
Growth is the mixture between opportunities, accidents and choices.
The arrow of growth is sustained with a series of renunciations.
The strength of resilience to frustration is a buildable quality, which helps to face the defeats and losses in life by keeping hope high and knowing how to resist frustrations. (5)
As human beings we have to face an existential enigma: it can happen that the individual becomes so continuously fixated on his need to own a certain object or to assume a behaviour so that that evolutionary trajectory, made up of achievements flanked by multiple frustrations, seems to be interrupted.
On the perspective of the WHO (1948) health is a positive condition not limited to the absence of disease that measures the level of psychic, physical, relational and, according to some authors, spiritual well-being, addiction is what is on the opposite end.
Although it is not accepted within the DSM-5 (5) because it is considered not sufficiently supported by research evidence, it is too polluted by its media use, the practical use of the term Addiction is found more and more frequently in thesis, publications, titles and reports, including this article.
The National Institute od Draug Abuse, NIDA (6) uses the term Addiction to describe compulsive drug seeking despite the negative behaviours and negative consequences of which the subject is aware. Addiction is a chronic disorder with relapses characterized by compulsive and continuous research, despite the negative consequences and with effects of modification of the brain architectures.
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There are an enourmos quantity of human behaviours that can be considered as addictive. |
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The DSM-5 declares them to be equivalent in terms of the neuronal process.
Addiction is a disease of a brain that structures itself following its experiences. According to this model, the concept of addiction as a disease has emerged (7) for the maintenance of which craving is fundamental (8), that is the basic syndromic condition of all addictions, characterized by appetitive urge to seek pleasure and an irrepressible implementation, even to the disadvantage of the very will of the subject. A visceral and overwhelming "hunger" that underestimates the damage. (9).
The relationship between eating disorders and substance use disorders is one of the many possible comorbidities, although many times underestimated and insufficiently investigated in clinical practice
ED and SUD have various similarities: neuro-biological, emotional and behavioural mechanisms seem to bring them together.
There are high rates of comorbidity between ED and SUD (10)
In individuals with ED, the prevalence of SUD is roughly 50%, against 7-9% in the general population, while in people with SUD about 35% have ED against about 3-7% of the general population.. The literature highlights the concomitance of ED subtypes with SUD types (10, 11, 12, 13, 14))
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In DSM5 alongside the disorders related to the use of substances, a new category is introduced, Addictive behaviours. The DSM-5 declares them to be equivalent in terms of the neuronal process.
The term “food addiction” (FA) was originally coined in 1956 by Randolph (15), who associated it with addictive drinking.
Food addiction, especially activated by refined and manipulated, palatable foods, would override the cortical inhibitory processes that signal satiety to cause the compulsive consumption of food in large quantities. The loss of control and compulsive behavioural patterns of food consumption replicate the patterns of drug use observed in the SUD (16, 37). The salience of food incentives is a key factor, in particular for the one rich in sugars and fats that triggers the desire and pleasure of its use ("wanting" and "liking") as components of the reward (35) causing a real and own dependence (17, 18, 19).
References
1 Stornello S, Oltre le pieghe dell’anima, Ordine Psicologi Sicilia 2020
https://www.oprs.it/psicologi-e-psicologia-in-sicilia/oltre-le-pieghe-dellanima-la-mia-storia-come-psicologo-di-comunita-al-tempo-del-coronavirus/ 2020
2 The Science of Neglect: The Persistent Absence of Responsive Care Disrupts the Developing Brain: Working Paper No. 12
National Scientific Council on the Developing Child (2012). The Science of Neglect: The Persistent Absence of Responsive Care Disrupts the Developing Brain: Working Paper No. 12. Retrieved from www.developingchild.harvard.edu.
3 The functional architecture of mother-infant communication, and the development of infant social expressiveness in the frst two months Lynne Murray1,2,3, Leonardo De Pascalis1,4, Laura Bozicevic1, Laura Hawkins1, Valentina Sclafani1 & Pier Francesco Ferrari, 2016 Scientific RepoRts | 6:39019 | DOI: 10.1038/srep39019
4, Ogden T H., (2016) Vite non vissute. Esperienze in psicoanalisi (Traduttore: S. Boffito), Cortina Raffaello, Psicologia clinica e psicoterapia
5, DSM-5 Diagnostic and statistical manual of mental disorders, Fifth edition,Arlington, VA, APA 2013
6, NIDA, The Science of Drug Use and Addiction, Guide, 2018
7, O’Brien, C. P. & McLellan, A. T. (1996) Myths about the treatment of addiction. Lancet, 347, 237–240
8, Isbell, H: Craving for alcohol. QJ Study of Alcoholism 1955;16:38-42.
9, Nizzoli U, Margaron H, Caretti V, Croce M, Lorenzi P, Zerbetto R (2011) Craving. Alla base di tutte le dipendenze, Mucchi
10 Brownell K.D., Gold M.S. (2014), Food and Addiction, A Comprehensive Handbook, Oxford Univ Press USA
11, Calero-Elvira A, Krug I, Davis K, López C, Fernández-Aranda F, Treasure J. (2009) Meta-analysis on drugs in people with eating disorders.Eur Eat Disord Rev. Jul;17(4):243-59. doi: 10.1002/erv.936.
12, Conason AH, Brunstein-Klomek A, Sher L. Recognizing alcohol and drug abuse in patients with eating disorders. QJM: An International Journal of Medicine. 2006;99:335–339.
13, Courbasson CM, Smith PD, Cleland PA. Substance use disorders anorexia, bulimia, and cocurrent disorders. Can J Public Health. 2005;96(2):102-6
33, Fouladi F, Mitchell JE, Crosby RD, Engel SG, Crow S, Hill L, et al. Prevalence of
alcohol and other substance use in patients with eating disorders. Eur Eat Disord
Rev. 2015;23(6):531–6.
14, Tinghino, B., Lugoboni, F., Amatulli, A. et al. The FODRAT study (FOod addiction, DRugs, Alcohol and Tobacco): first data on food addiction prevalence among patients with addiction to drugs, tobacco and alcohol. Eat Weight Disord 26, 449–455 (2021). https://doi.org/10.1007/s40519-020-00865-z
15 Randolph, T. G. (1956). The descriptive features of food addiction; addictive eating and drinking. Q J Stud Alcohol, 17(2), 198-224.
16 Blum K, Oscar-Berman M, Barh D et al. (2013) Dopamine genetic and function in food and substance abuse. J Genet Syndr Gene Ther; 4: 100 - 121
17 The National Center on Addiction and Substance Abuse at Columbia University
(2003) Food for Thought : Substance Abuse and Eating Disorders. Nancy Reagan
Linda Johnson Rice Georg Rupp. 12:73
18, Melchionda N, (2014) Food Addiction. Sviluppo dei Disturbi Alimentari e delle Obesità, Mucchi, Modena
19, Kenny PJ (2011) Common cellular and molecular mechanisms in obesity and drug addiction. Nat Rev Neurosci; 12(11): 638-51.
Italian Congress on ED, SISDCA
by Daniela Beltrami
The XV SISDCA national Congress took place at the Auxological Institute located at Villa Caramora in Verbania, beautiful location on the wonderful Lake Maggiore from the 6th to the 8th October 2022. It was a precious chance to meet each other’s, after the pandemic and in the middle of the Russia-Ukraine conflict (as said Giovanni Spera). A hybrid modality was chosen to support a larger participation.
In the current era of health, social, climate multiple crisis, where an extraordinary chaos rules, the Congress attention deeply focused on the concept of Diversity, intended as singularity but especially as complexity.
An interesting speech about Eating and Nutrition Disorders during the Global Syndemic age (by Umberto Nizzoli) introduced the opening day. Contrary to the quick and connected world necessities, a careful and deep analysis of diversities, contradictions and
backgrounds is needed, to better understand the problems and to create a brand new sort of order. Instead of being a disturbing barrier, from this point of view the crisis becomes a great opportunity.
The first day hosted an exciting report about the possible impact of traumatic events on the etiopathogenesis of Eating and Nutrition Disorders and on the complexity of psychopathological cases (by Patrizia Todisco) . Recent stressful events like pandemic and war have contributed to reveal hidden symptoms and exacerbate existing clinical profiles which can be described and treated with different paradigms. An integrative approach that involves selecting the best solution for a single individual living in a specific background from different therapeutic orientations, is strongly recommended (by Giovanni Abbate-Daga Leonardo Mendolicchio, Armando Cotugno, Emilia Manzato). After a great talk about Obesity during the Global Syndemic (L. Donini, R. Schumann), the second day focused on the concept of complexity and diversity between populations, cultures and pathologies.
The copious joint sessions with SIRIDAP, SIE, SIPA, SIO, the Eating & Weight Disorder annual report and the round table discussion with patients associations made the atmosphere even more cooperative and multidisciplinary.
Eating disorders in Bulgaria
by, Detelina Stamenova
Clear numbers of ED patients in Bulgaria are not available. According to statistical data, in the period 1951-1960 and in 1988-2000, the incidence increased from 0.45/100,000 to 20.1/100,000 for anorexia nervosa and 35.8/100,000 for bulimia nervosa. Lifetime morbidity is as high as 18.6%: 1% for anorexia nervosa, 3.6-5% for BN and 14% for other eating disorders. These values are significantly higher in risk groups (athletes, dancers, actors, models) and in studies in the general population (5% for AN and 7% for BN), with half of the patients not reaching the health system at all (Milanova, 2013 ). According to National Statistic Institute (2018), eating disorders are among the four causes of recognized permanently reduced working capacity/type and degree of competence 7.3%, being included in one group with diseases of the endocrine system, eating and metabolic disorders.
In their latest data, eating disorders are included in the same column as another type of illness, namely grouped as "Eating, Sleep and Sexual Disorders” and it indicates 151 hospitalized patients, which is slightly more than in 2017, when the number was 130 (NSI, 2019).
The average age of onset of eating disorders is low, and in recent decades the age of onset of anorexia has been decreasing worldwide from 14-17 years to 9-12 years. In bulimia, nervousness begins around 15-30 years, psychogenic rebirth - 20-40 years, but it is noticeable, apart from the withdrawal at an earlier age and the onset of the disease, and after 40 years in women, which was not observed until recently (Milanova, 2013).
Determining the exact number in Bulgaria is very difficult for several main reasons:
- Much restraint of the person is not performed psychiatric and psychological help
- Many affected individuals do not share with doctors that they have an eating disorder when they go for treatment for some of the side effects (for secondary amenorrhea, heart problems, gastro-enterological, dental, etc.)
- Many general practitioners lack of knowledge and can not diagnose eating disorders in their earlier stages.
The health system is not prepared to meet ED patients and to offer holistic treatment as well and support to their families.
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