By Dina Cohen, MS RD CEDRD
My job sounds like it’s about food, but it’s really about people. I am so fortunate to have a profession in which I can witness people make amazing changes, not just to their eating, but to their lives. This article is dedicated to all my hard-working and inspirational clients, especially those working toward recovery from an eating disorder. It’s tough to change, and I admire you for it.
Following are three key facts about eating disorders. I hope that reading them will give you a greater understanding of what your friend, family member, or neighbor may be experiencing.
1. Eating Disorders Can Be Deadly.
Eating disorders are not about vanity. They are not diets that have gone too far. Eating disorders are psychiatric illnesses that are characterized by severe disturbances to a person’s eating behaviors. Someone with an eating disorder will have an extreme preoccupation with body weight, shape, or size, and she may limit or restrict intake, over-exercise, binge eat, compensate for eating, and engage in numerous other obsessive behaviors around food. Eating disorders cause significant psychological impairment, but they affect more than just the mind; they can affect every major organ in the body. They have the highest risk of death of any psychiatric disorder[1]. Every 62 minutes, at least one person dies as a direct result of an eating disorder[2]. For young people with anorexia, the mortality rate is ten times higher than that of their peers[3].
Eating disorders include anorexia nervosa, bulimia nervosa, binge eating disorder, and OSFED (Other Specified Feeding or Eating Disorder, in which someone meets some but not all of the criteria for another eating disorder).[4] Individuals suffering from each of these will have symptoms specific to their disorders, but what they share is that weight is critically important to their self-worth and that they have unhealthy thought patterns and behaviors around food. Many people will change their behaviors over the course of time so that they no longer fit under one category but will cross over into another, such as from anorexia to bulimia. To me, the particular diagnosis is less important that the fact that the individual is experiencing distress. Anyone suffering from disordered eating should get help, no matter what her problem is labeled. Efficient treatment can prevent years of suffering and can be life-saving.
2. You Can’t Tell if Someone Has an Eating Disorder Just by Looking.
The stereotypical image of a person with an eating disorder is an emaciated teenage girl. In fact, the majority of people with eating disorders are not very thin. Nor are they necessarily young or female. Men, children, and the elderly can all suffer from eating disorders. (I use the pronoun “she” in this article because the majority of people with eating disorders are female, but the information applies to men as well.) Unfortunately, disorders in these populations may go unnoticed for a long time simply because no one thinks to look out for them. You cannot determine the status of someone’s health or relationship with food simply by looking at his or her body.
It’s important to be aware that eating disorders are very good at deception. Anorexia is egosyntonic, which means it becomes part of an individual’s identity. Someone with anorexia often does not see her behavior as a problem (and may in fact see it as a solution), or she sees the problem but denies it and is unlikely to ask for help. She may be very secretive about her behaviors and the problem might not be noticeable until it is already deeply entrenched. Someone with bulimia or binge eating disorder will usually feel deeply ashamed of the disorder and may go to great lengths to hide it. An individual with an eating disorder can come up with an amazing array of excuses for her behaviors in an attempt to reassure others that everything is fine.
It’s important to note that while there’s a very good chance that an emaciated teenage girl does indeed have an eating disorder, she may in fact have some other illness that causes weight loss. You can’t make that assumption just by looking at her. It’s inaccurate to assume that anyone who looks very thin or very large has an eating problem. Likewise, it is wrong to assume that someone who looks “normal” is truly ok. She can have a raging eating disorder and be doing a great job of hiding it. When someone does share with you that she is struggling with her eating, take her seriously, even if you think she looks fine. It has probably taken a lot of courage on her part to communicate this to you.
3. Eating Disorders are Not a Choice
I have never met anyone who consciously chose to have an eating disorder. Ask any sufferer and she will tell you that it is not the way to go. Someone may make the choice to restrict her intake, but she does not make the choice to be enslaved by restriction. In other words, dieting is a “gateway” behavior. People can choose to diet but that does not mean they choose to have an eating disorder. Taking an alcoholic drink increases the risk of alcoholism but it does not mean choosing an addiction.
It’s no surprise that in our weight-obsessed environment, some individuals develop an unhealthy relationship with food and their bodies in order to cope with emotional difficulties or other life stresses. These are often people who are prone to conditions such as perfectionism, anxiety, impulsivity, and emotional dysregulation. Their biochemistry and personalities make them more vulnerable to adopting unhealthy coping mechanisms, and in certain circumstances or settings, they may develop disordered eating. In other words, genes load the gun and environment pulls the trigger. Dieting is one trigger. Trauma is another. Sometimes someone can avoid a trigger, and sometimes that’s impossible. But what is certainly true is that no one chooses to be a loaded gun.
What an individual with an eating disorder can do is choose to do the things that help her recover. Recovery is excruciatingly difficult, and this is something that can seem incomprehensible to someone without an eating disorder. Why can’t someone with anorexia just eat? Why can’t someone with binge eating disorder just stop bingeing?
Eating disorders expert Dr. Anita Johnston provides the following allegory to help explain why letting go of an eating disorder is so very challenging:
Imagine yourself standing in the rain on the bank of a raging river. Suddenly, the water-swollen bank gives way. You fall in and find yourself being tossed around in the rapids. Your efforts to keep afloat are futile and you are drowning. By chance, along comes a huge log and you grab it and hold on tight. The log keeps your head above water and saves your life. Clinging to the log you are swept downstream and eventually come to a place where the water is calm. There, in the distance, you see the riverbank and attempt to swim to shore. You are unable to do so, however, because you are still clinging to the huge log with one arm as you stroke with the other. How ironic. The very thing that saved your life is now getting in the way of you getting where you want to go[5].
To an outsider, an eating disorder looks like a problem. But to a sufferer, the eating disorder is the solution to other problems in her life. In the words of a client, “My eating disorder is a coping mechanism that I latched onto as a means of self- preservation. My eating disorder is what keeps me sane when I feel like I’m losing it - it is not a prank that I'm pulling in order to get your attention.” Undereating, overeating, food and exercise rituals, and the amount of headspace devoted to weight and shape actually serve to numb or distract an individual from painful thoughts and feelings.
With the right help, people with eating disorders can and do recover. It is difficult road and it may be a long one, but it is possible – and also very worthwhile. We know that there are many causes for eating disorders, and because not everyone with an eating disorder has the same underlying problem, treatment must be individualized for each person. There are many levels of treatment for eating disorders and the level of care will depend on the severity of the condition, but even on an outpatient level, several team members are generally required to facilitate recovery. This is because an eating disorder affects someone’s physical and psychological wellbeing on many levels. Team members may include a physician, psychotherapist, registered dietitian, and psychiatrist. If you are a family member or friend of someone struggling with an eating disorder, you are a critical part of her recovery as well. Part 2 of this article will focus on what you can do to help support an individual in recovery as well as steps you can take to help prevent eating disorders in the people you care about. (This includes you!)
[1] Arcelus J, Mitchell, AJ, Wales J, Nielsen S. Mortality rates in patients with Anorexia Nervosa and other eating disorders. Archives of General Psychiatry. 2011: 68(7), 724-731.
[2] The Eating Disorders Coalition for Research, Policy & Action. September 25, 2014
[3] Smink, FE, van Hoeken D, Hoek, HW. Epidemiology of eating disorders: Incidence, prevalence and mortality rates. Current Psychiatry Reports. 2012: 14(4), 406-414.
[4] *Orthorexia and ARFID (Avoidant/Restrictive Food Intake Disorder) are disorders in which restrictive eating does not stem from body image concerns and is not the topic of this article
[5] Johnston, Anita. Eating in the Light of the Moon. Carlsabad. Gurze Books. 2000