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1. How do I know if I have an eating disorder?
Lets rephrase this. You have problem eating if your eating behaviour, or your attitudes about food and weight are taking pleasure out of your life. People with eating disorders typically worry a lot about their weight and about the food they are eating (or trying not to eat). You probably have an eating disorder if some of the following is happening:
- Excessive concern and preoccupation about calories or fears of weight gain.
- Eating habits that you know in your heart are abnormal.
- There is a lot of shame and guilt around eating.
- You don’t think you are too thin but other people are worried about you.
- You vomit to avoid gaining weight or use laxatives.
- Your weight is fluctuating a lot.
- There are a lot of foods you strictly avoid to control your weight, and you feel like a terrible person if you eat any of these foods.
- You have unmanageable cravings for certain types of food that you think you should not be eating.
- Exercise is something you are driven to do; you would feel fat or like a bad person if you missed an exercise routine.
- You are depressed and irritable.
- You pretend that you have eaten to get people off your back.
2. What are the eating disorders?
There are 3 types of CLINICAL eating disorder. At their root, all of them are concerned with control of weight and shape. Anorexia Nervosa, Bulimia Nervosa and “all the rest” which we call FEDNEC (Feeding & Eating Disorders Not Elsewhere Classified). This includes Compulsive Eating, and types of anorexia or bulimia which are not severe. There is a less familiar eating disorder called The Night Eating Syndrome and one named Orthorexia, which is thought to be similar to anorexia. People with Orthorexia are obsessed with healthy eating plans such as food allergy plans – but this masks a bad relationship with food. Children may suffer from problems with eating, which are not related to control of weight. There are problems with diagnosis for the following reasons:
- There are degrees of severity for all of these conditions. These days many people especially women are concerned about their eating habits and it is hard to know when someone “tips over” from normal eating, develops problem eating, then falls into a real eating disorder that may have serious medical and emotional consequences. The behaviours associated with real eating disorders include binge eating, starving to the point of emaciation, purging,(vomiting or taking laxatives for weight control), excessive exercising, chewing food and spitting it out, and obsessive dieting
- People don’t come definition-shaped, for example one man’s binge is another man’s good meal. People have different ways of expressing their relationship with food
The bottom line is, if eating “rules your life” you will probably need some kind of help.
Anorexia Nervosa is present when someone has lost a lot of weight through food restriction and often also excessive exercising. Sometimes the decision to lose weight has been purposeful and sometimes it just “happens by accident” as when a person starts restricting certain types of food such as meat or fats or carbohydrate because of health concerns. A young girl or boy who decides to become vegetarian may be on the way toward anorexia. Typically, there is great fear about weight gain, this fear appears to increase the thinner the person becomes.
Anorexics typically consider that weight loss is a good thing, and most consider that they are” fat”, even when they are skeletal. Many will deny that they have a problem, despite the concern of other people, even when they are dangerously thin. A profound fear of weight gain manifests itself as a phobia of eating, which helps keep the illness going. There are other psychological benefits of starvation, which kick in as the illness continues. These benefits, such as feeling special, feeling competent, being different, gaining attention, not having to participate in normal life, not having to “grow up”, not even feeling authentic feelings; all of these help keep the anorexic trapped in his or her illness, and overrides their wish to recover.
Some anorexics “binge eat” although the amounts eaten are small. If they vomit or take laxatives we can say that they have the bulimic subtype of anorexia nervosa. Anorexia is largely a young-female condition although men suffer too and so do children as young as 5, and older or elderly women. These are the “hidden sufferers” who don’t often get the help or attention they may need.
About 1 in 3 anorexics recover (this may take some time) and about 1 in 3 start overeating and may have long term problems with food control. The death rate is unacceptably high with between 1 in 5 dying early as a result mostly of starvation effects or suicide.
People with bulimia nervosa typically are normal in weight or even overweight and they regularly use laxatives or they vomit in order to avoid gaining weight usually as a result of overeating or binge eating. As with anorexia, weight gain is greatly feared although the bulimic is not usually afraid of being at a normal body weight, even if they are desperate to lose some weight. It is hard to define a binge because to some people one bar of chocolate can feel like a tragedy and binge events can vary very much from person to person or even for the same person over time.
Bulimics may try hard to restrain their eating, or even starve in between bouts of overeating to try and lose weight, or they try to stave off eating in case one bite brings loss of control. Some, but not all, have chaotic eating patterns, binge eating and purging very frequently. Purging is not an effective way of getting rid of all calories eaten which is why many people with bulimia eventually gain weight.
Bulimia has an addictive feel because it becomes a way of regulating emotions and helping people cope with life. This is why people can be bulimic for many years unless an eating disorder specialist properly treats them, using a form of therapy called CBT. They are often able to conceal their behaviour, even from people who live with them. After all, it feels shameful to confess their problems, even to a doctor. The side effects of bulimia however are very harmful and can lead to illness and even death.
Binge Eating Disorder (BED) is the third main type of eating disorder. Also described as “compulsive eating” it is arguably the most common eating disorder. We believe that almost half of all overweight people who seek help for their weight problem suffer from this disorder to a greater or lesser extent. Weight loss in itself however will not cure the problem.
Compulsive eating can feel like bulimia nervosa except that sufferers do not vomit or take laxatives to control their weight. They have a sense of overeating, which feels out of control. It feels as if they are taken over by someone else. Binge eaters may feel as if they have no willpower where food is concerned and they may eat in secret, guilty and miserable about their behaviour. Because of their eating habits they are always struggling to avoid gaining weight, often without success. They may go from one diet to another in the quest for weight loss and eating control.
People with BED may binge, eat small amounts continuously, or pick at food from time to time. Although the medical profession takes this disorder less seriously than anorexia or bulimia, it can ruin both health and someone’s quality of life. As one person put it: “Food is ruling my life. I wish I could just take it or leave it, but it’s never enough”.
3. Why does someone get an eating disorder?
There is no simple explanation and there has been a lot of research into the causes of eating disorders. We know that we cannot simply blame the culture, fashion magazines, family relationships, early traumatic experiences, or abuse or buried psychological problems like depression or anxiety.
Eating disorders arise from a combination of personal, family, physical or genetic factors as well as life experiences that may cause someone to be both emotionally vulnerable AND sensitive about their weight and shape. DIETING has a role to play in the development of an eating disorder, in fact in most sufferers the eating disorder grew out of dieting behaviour.
It is hard to “tease out” the relative contribution of many of these factors. You may often hear it said that the root of eating disorders is low self esteem and certainly for people with eating disorders, their weight plays a very important role in their opinions about themselves prior to the onset of an eating problem. People who do not develop eating problems may be concerned about their weight but there are other domains in life that influence their self-esteem; these act as a protective buffer. Eating disorders are coping behaviours, which provide the person with an outlet for displacement of feelings, which really relate to other areas of life being out of control.
Looking at people who have eating disorders, we note several things in common:
- Feelings of powerlessness, or worthlessness
- They are terribly sensitive to imagined rejection or abandonment
- Most have poor assertion skills and find it hard to manage relationships healthfully
- They may have perfectionist attitudes, and find it hard to measure up to their own high standards for themselves, but would not necessarily apply those standards to other people
- They are not good emotional problem-solvers, and tend to avoid life’s difficult situations
- Find it hard to say “no” or ask for what they want in life, may be “people pleasers” or go out of their way to be nice, may have moments of aggression when things get on top of them
- They may lack confidence in managing relationships in a way that serves their needs rather than those of other people
4. What's the connection between dieting and eating disorders?
Most people diet at some point in their lives. We believe that weight loss will make us happier and more attractive to others and to ourselves. Dieting success gives us a sense of accomplishment and feeling in control, it attracts compliments and positive feedback from other people.
Research tells us that in most cases eating disorders follow the onset of dieting behaviours. Restrictive dieting is poor at keeping weight off, with 97% of dieters regaining lost weight plus a little more. Physical changes make it hard to keep weight off. Chemicals released in the brain lead to massive cravings for food and abnormal hungers, which may persist for many months following a diet. The body defends its natural set point vigorously, despite the fact that we may yearn to be slimmer than our normal healthy weight. This fight-back process against our attempts to create a perfect body shape can also show up as abnormal cravings for forbidden foods. Also, with extended periods of dieting, the body may act to protect itself against future famines by setting the set point higher and reducing metabolism.
Emotional changes may make it hard to keep weight off as well. It is only human to feel deprived and irritable when we cannot have foods which have become “taboo”; they become much more desirable than they need to be. Breaking dietary rules leads to feelings that you have “blown it” and you binge on those forbidden foods in the expectation that you will start again tomorrow. Cycles of guilt and remorse usually follow from breaking these arbitrary rules.
People with anorexia have a special capacity to hold out against the abnormal hunger that follows naturally from dieting. This is something that we do not fully understand. But anorexics are hungry and their hunger is so intense that they believe that if they were to start eating at all, they will never ever stop. This is perhaps their greatest irrational fear. But for bulimics and compulsive eaters, their attempts to restrain their eating has become undermined by reactive overeating (which is predictable) and intensified efforts to pay for their sins by more dieting just keeps them trapped in the vicious cycles of their disorder.
But not everyone who diets develops an eating disorder, you might say. This is true. Most people do break their diets and binge to some extent after dieting. But you are most likely to become trapped in a battle with food and weight if your self-confidence is poor, you are not coping well with life in general, and if weight is perhaps the most single important issue on your personal radar.
The treatment of an eating disorder will involve giving up dieting and eating regularly and healthy, a diet rich in nutrients and containing a little of everything. This, together with work on emotional eating, will help to master food cravings. In many cases this will result in a return to a normal healthy weight and a physical body that burns energy and controls weight effectively.
If you are compulsive about dieting, the idea of stopping dieting is terrifying. You fear that you may totally lose control. You may need help to bring your body and your emotional eating brain back to normal.
5. Does an eating disorder mean that someone is depressed?
No. The symptoms of an eating disorder such as starving, purging and binge eating will cause feelings of depression, fear or anxiety, but are not symptoms of another psychological disorder. This is natural because food and weight issues are impacting on someone’s ability to live a full and pleasurable life. These feelings often disappear when a person is properly nourished. Having said this, there is a higher probability of depression and other emotional disorders both in the families of people with eating problems, or in their own personal history.
6. I feel fat and unhappy; I hate myself. What can I do about it?
If you are overweight – and this depends on the relationship between your height, weight and age, then some weight loss may benefit your health and emotional well-being. You may wish to read the section below on treatment for obesity, but please bear in mind that successful therapy for obesity requires in part a healthy relationship with yourself and a level of respect for your body and your health. But many women today feel fat even when they are not fat. Half of all women who are currently on a diet are not overweight. There is enormous pressure for us to conform to a particular body ideal size. In reality, people come in all shapes and sizes. Many things, our genes, our metabolism and our lifestyle determine our personal body weight and shape. This means that some people will be thinner than others just as some are taller. We are at our most healthy when we are at our natural body weight.
How can you determine what this is? It isn’t simple. Giving up restrictive diets and addictive exercise programmes is important, and replace these with treating yourself well and with compassion. Eat in moderation and do not deprive yourself of any foods since this may set you up for a binge. Also be moderately active in a way that you enjoy, not going to a gym to punish yourself or burn off forbidden calories.
Research tells us that women with poor body image misinterpret negative emotions such as anger and sadness and feeling unlovable as “feeling fat” – so next time you have a fat moment and experience those familiar self loathing thoughts, ask yourself “what else is it I might be feeling?” Then calm down and say “I approve of myself”. Give yourself a hug or find something nice to do for yourself. If you keep practising this, your feelings will change and your eating habits will start to get better. There is simply no point in responding to those fat thoughts by starving, bingeing or punishing yourself with promises to eat as little as possible or lose weight as soon as you can. This will just set up an endless cycle of yo-yoing up and down, and getting more and more frustrated with yourself.
You may wish that your natural weight was lower. Most women do, some more intensely than others. You may have to make a choice between trying to fit your body into a size smaller box, or having more energy for life, better skin and less depression and irritability. When you understand that “I feel fat” is a code for other reasons for not liking yourself, you can become free to develop the parts of yourself that will give you greater self confidence. Ask yourself “Is my weight the real problem or the way I FEEL about my weight?” Please learn to treasure your body- because it is yours.
7. I suspect that someone I know has an eating disorder; what can I do to help?
It is troubling to recognise that someone you care about may be suffering from an eating disorder. The decision to approach the individual can provoke much anxiety since it is difficult to know what to say and what to expect from the situation. Perhaps you have broached the subject and got an angry response.
It is important to understand that they might not welcome your expression of concern, either because they are ashamed to admit their behaviour, or they feel “in control” and don’t want anyone to “make them fat again.” It will, therefore, be important for you to be as well educated as possible about eating disorders.
Part of this knowledge is understanding the many reasons why people are reluctant to get help:
- Perhaps they feel they “should” be able to do it by themselves
- Perhaps they don’t really trust anyone to be able to help them
- They may not want their problem to be out in the open for other people to track
An eating disorder is often a way of coping with deeper problems that it may take a long time to tease out. Thus you cannot expect a person to be able to give it up unless they are strengthened in other ways. We get calls from many concerned people. Someone who is worried about a colleague at work who is getting thinner and sicker and avoids interacting with others. Students who know that their housemate is making herself sick and food is disappearing. Parents or husbands who are anxious and worried about someone who doesn’t want to talk.
Each case is different. Personal factors in your social relationships make each situation unique. It is thus really hard to give advice that is proper for each individual case. There is no rule which can apply in every case. There are words which can be helpful and words which can drive someone into greater denial and secrecy. Timing is important too.
Friends must be helped to show concern, but not to get over-involved or take responsibility for the health of the sufferer. We have sometimes advised a student living with a sufferer to move house, in order to protect their own mental health. Parents or partners need specialist advice from an expert, both in finding the best way to approach the sufferer, and also in managing the illness step by step once it is out in the open.
So, in summary, there is no quick fix advice. We advise any concerned person who really wants to take action to have a counselling session with an expert to fine-tune a proper response. Sometimes a concerned carer, friend or colleague may need continued professional help and support in order to handle their own emotional responses to the individual with an eating problem, for the sake of all concerned.
8. What help is available?
Help for eating disorders is patchy at best. GPs are not formally trained to understand or treat eating disorders, although their help in managing physical risk is invaluable. Most NHS trusts provide a service only with serious cases of anorexia or bulimia and, due to demand, there may be long waiting lists or only help in non-specialist mental health units.
Help is available in many forms. The NICE 2004 Guidance on eating disorders advised self-help for less severe cases of binge eating disorder and bulimia nervosa. Other forms of self-help are to be found in books and manuals or CDs, please check that they are based on CBT and not any system that is unproven by research and proper evidence.
A form of therapy called CBT adapted for eating distress is recommended for bulimia and compulsive eating. Many counsellors and psychotherapists claim to treat eating problems and may do so with success, however, we urge you to check the credentials of any therapist who advertises eating disorder treatment skills. The NCFED is the only organisation that ensures core skills in CBT for the treatment of the overeating disorders.
The treatment of anorexia poses more problems. Family therapy is regarded as helpful for younger patients although few receive this in practice, and the therapist ideally is trained in the management of family interactions specific to the range of anorexic behaviours, as well as general family behaviours.
Some people are more comfortable with groups, either as therapy groups or support groups, which help people to come together, find friendship and normalise their feelings around food and weight.
Under certain conditions, where an individual’s eating problems have led to physical or emotional crisis, a more intensive approach may be needed such as being in hospital or in a more structured treatment programme. You can access these services through a GP or directly through a Private Hospital /Treatment Service. The fees for Private in-patient or day care treatment are likely to be very heavy and may be funded in some cases by private health insurance.
You can research where these services are on the Internet. Lifeworks Community at + 44(0) 1483 757 572 may be able to give you further guidance.
9. I can't get to a treatment service. What can I do?
People with eating problems are everywhere. First concentrate on self-help which includes learning as much as you can about your problem from books or the internet. Be curious and realise that an eating problem is not a sign of weak will or character flaws. People from all walks of life and all ages, students, teachers, bankers, lawyers, can develop problems with control of eating.
The NCFED offers TELEPHONE COUNSELLING for people who cannot get to a therapist due to geography or lifestyle demands.
If you can muster the courage to talk to your GP, do so from a position of strength, having learned some facts first of all. The GP may be able to recommend you to someone local. It is still up to you to ask the right questions to be sure that your counsellor has a formal training in eating disorders work.
These are the questions we recommend:
- Do you understand the physiological/biological aspects of eating disorders and appetite?
- What is the extent of your knowledge of nutrition?
- Are you trained in CBT for eating disorders?
- What other formal training have you done for eating disorders?
- A good competent therapist will be willing and able to answer your questions.
10. I am a student interested in doing a project on eating disorders; can you give me some help with statistics, written material and opinions?
Statistics can be misleading since different questions throw up different results, which is why we at the NCFED do not publish statistics. Also, there are many hidden cases of eating problem. Eating disorders exist on a continuum, from mild to severe cases, and many “normal” people have issues with food and weight – so it isn’t really possible to identify how many “real” sufferers there are in the community at any point in time.
Some information is available on the information page of our website which you can download and use. We do not have posters or teaching materials.
Regarding providing research references or opinions on aspects of eating disorders for your individual project: our Press Office can speak to journalists as and when needed. However, experts at the NCFED require a subscription to our tutorial service for personal help with individual projects.
Call 0845 838 2040 to discuss.
11. I just need help with weight loss; can you help? Do I need to stay in a clinic?
If you have a real struggle with weight loss, the chances are that you are experiencing problems with compulsive eating. Perhaps you binge from time to time, or nibble constantly. Are you a yo-yo dieter, losing weight only to put it right back on?
Many “clinics” for overweight tend to be based on philosophies to which the NCFED does not subscribe – viewing compulsive eating as an addiction or subscribing intensive dieting and detoxing. Weight loss is not the cure for overeating, as many of you have already found out for yourselves. The cure for weight problems associated with compulsive eating cannot be found in a clinic. Sooner or later you will need to learn how to cope with people and situations in the real world in which food is ever-present. The NCFED is happy to help you to lose weight. We can do this by firstly dealing with the emotional reasons why you overeat, strengthen your motivation, then find a weight loss strategy that suits your social and emotional makeup. Finally, we will teach you lifelong practical and psychological skills to commit you to permanent change.
There is no quick fix, which is why we strongly advise against you going into a clinic for weight loss. Be aware that there are many programmes which claim to treat obesity or compulsive eating, earning big profits by making false promises and capitalising on the distress of desperate individuals.
Dealing properly with a weight problem can take many months, sometimes more. If your weight problem is severe, and affecting your health, we can explore the options available to you which might include medication, or even surgery, and we are qualified to give you a full assessment of the right way forward for you, personally.
12. What about men and boys?
Men and boys get eating disorders (and stubborn weight problems) too, at about one-tenth the rate of women. Most books talk about typical sufferers as “she”. This makes it very hard for men to seek help for what they think is regarded as a women’s problem.
Male athletes (ANY sport), gay men, male models, men who have suffered from teasing because of weight problems, can also develop serious concerns about their body shape and eating disorders. Since dieting is a common trigger for the development of an eating problem, men who diet for any reason can be vulnerable. An unusual form of body image problem known as “The Adonis Complex” can exist among men who feel that their body shape is too puny. They may attempt to beef up their structure by doing strange things to the diet, exercising addictively and taking supplements and even steroids in pursuit of a muscled and toned body shape.
Once an eating disorder develops, it is exactly the same illness whether the sufferer is male or female. Thus, men benefit from the same treatment as women. However male reluctance to seek help is compounded by many believing that their particular issues about being male will not be addressed. The NCFED has an essay about male eating problems on the information page of the website.
Men and boys (as fathers, brothers and partners) have a hugely important role to play in the PREVENTION of eating problems among their women. Teasing, making comments about weight or negative appearance or food intake, is important. We ask men and boys to examine their attitudes toward food and weight and to think about whether comments they make to women are supportive or detrimental. Do you laugh at fat jokes or say bad things about fat people, tell your daughter that she could do with losing a few pounds or make the wrong response when your girlfriend says “do I look fat in this?”
Try communicating that you don’t want to support any conversation which links self-worth to her feelings about her weight, and ask her if there is any other distress she is experiencing which is underneath her questions about her weight.
If you have a daughter, take care to avoid making comments about her weight or indeed negative comments about the weight of other women. When fathers show that they have “emotional” feelings about the shape or weight of any woman, this is known to be a risk factor for bulimia in their daughters.
13. How can I prevent my child from developing an eating disorder?
Home can be a ripe breeding ground for body insecurity, especially among female children. Mothers who have eating disorders themselves are especially worried that they might infect their daughters with their problems. There is a good basis for some of these fears since children look to their parents to model (or rebel against) their own behaviour in many respects. There is also strong evidence that dieting behaviour in mothers is a risk factor for dieting in adolescent girls, which may trigger future eating problems.
Here is a list of guidelines for parents:
- Say nice things about your body or say nothing at all – whatever you feel about it. Avoid saying “Does this make me look fat?” Or making comments about needing to lose weight.
- Model good behaviour around food. Please don’t diet in front of the children! Make sure you are taking care of yourself with food – not over-controlling yourself. This means eating a wide range of foods and not teaching them that women shouldn’t eat.
- Learn which behaviours show that you are able to take care of yourself properly and practice these in front of children – they learn by example.
- If you do have an eating disorder – get some help to minimise the risk of transmission.
- Make weight teasing totally forbidden in the family. Don’t make comments about the body parts of a child.
- Give lots of unconditional love. Don’t “reward” a child for being slim or castigate them for being “too fat”. Not even veiled comments like “You would look better in that if you lost a couple of pounds”.
- Don’t praise other people for having lost weight in front of your child.
- Learn how to respond to comments from the child if they complain about being too fat – a good response is ” I wonder….is there something else on your mind”.
- Learn about the symptoms of eating disorders but recognise that many teenagers have habits that look like eating disorders.
- If a child suddenly decides to go vegetarian, keep an eye on them, it is often a way of dealing with a bad body image.
- Please don’t encourage your child to go to a slimming club with you to support YOU in losing weight!
The answer, in summary, is that you can’t control everything that might happen to your child because there are many influences that might place them at risk of having an eating disorder. This includes the behaviour of their friends, their own personality development, teasing experiences, and anything at all that can affect their self-confidence and their belief in themselves to cope with life. At the same time, there is much that you can do to help minimise the influence of potentially harmful experiences.
14. Is the media responsible for eating disorders?
For a full answer to this consider reading the essay on the media on our information page. The media is not the cause of eating problems but is a significant socio-cultural determinant of why so many people express their personal distress through the language of food and weight. One of the most important aspects of prevention of eating disorders is teaching children media literacy so that they do not fully “internalise” thin ideal images. In other words, they question the importance or possibility of looking the same as models and pop stars. Some of this literacy starts in the home.