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Photo: Markus Biehal

In our culture, body-consciousness is a universal phenomenon, especially among young women. For them, the connection between food and body image is distorted. They become obsessed with eating, not eating, or getting rid of what was eaten. Experts don’t really know why. To some extent, the underlying attitudes and behaviors are learned.  Infants and toddlers who have seen adults practicing bulimic behavior have been observed purging as well.  It’s safe to assume that, like most other addictions and compulsions, a combination of hereditary and en-environmental factors predisposes people to eating disorders.

Statistically, compulsive overeating is the most common kind of eating disorder. The problem of obesity in America has been attributed to everything from a sedentary lifestyle to over-sized restaurant portions. The movie Supersize Me has drawn national attention to that issue. Anyone who has used a favorite food (ice cream, chocolate candy, French fries) for emotional comfort when they’re feeling bad has had a taste of compulsive eating.

The next most common problem is bingeing/purging or bulimia. Periods of bingeing and purging alternating with periods of self-starvation are known as bulimiarexia. I am acquainted with people who have used these “weight management” techniques for years. They often escape notice and diagnosis because they look good and their weight is normal.

The most publicized eating disorder is anorexia nervosa. Anorexics starve themselves, some-times to death. Among adolescents, anorexia is the third most common chronic medical problem. While teenage girls and young women comprise the majority of anorexics, the condition is being diagnosed in both genders and a wide range of ages. Athletes and people in professions that emphasize thinness and body build—dancers, gymnasts, runners, wrestlers, and models—are particularly susceptible. As malnutrition creates changes in brain chemistry, they become more and more obsessed with thinness and less and less able to eat normally.

The least-known disorder is orthorexia, which is characterized by obsession with a healthy diet. People who are overly concerned about good nutrition may be at risk for developing food faddism, fetishes, and rituals around food preparation and consumption (washing, weighing, mea-suring, combining, etc). Carl is a classic example. To treat a mysterious disease that he thought he had, he adopted a stringent diet including a measured portion of cooked beans, steel-cut oats, fresh greens washed in bottled water, six nuts, and five olives per meal. Planning what to eat, how much to eat, and how to obtain the purest form of each item occupied most of Carl’s time and energy. When he couldn’t stand the deprivation any longer, he would binge on junk food, experience his “slip” as a fall from grace, and fall into depression.

It is impossible to predict who will develop eating disorders and who will not. Studies show that 20-50% of people treated for eating disorders have a first-hand relative who is chemically dependent. Second only to the presence of an alcoholic parent or grandparent as a precursor to eating disorders is the presence of rigidity and perfectionism in the family. In addition, when there is a closet sex addict in the family, children may become obsessed with body image, particularly if the addict makes verbal innuendos toward them, seems unduly interested in their sexual development, or is physically or emotionally incestuous. Children absorb the subtle  attitudes, beliefs, and behaviors and act them out.

Symptoms to watch for

The symptoms of eating disorders vary. Compulsive overeaters use food for comfort, eat when they’re not hungry, maintain wardrobes in several different sizes, experience enormous shame about their weight and, for that reason, avoid social occasions. Bulimics eat in secret and consume huge amounts of food without gaining weight. They spend long periods of time in the bathroom vomiting. Many use laxatives or compulsive over-exercise as a means of purging.

Anorexia often begins with a drastic attempt to lose weight in adolescence, which the anorexic continues even after reaching his/her goal weight. She becomes obsessed with food, recipes, cooking, nutrition, dieting. She wears baggy clothes to disguise her thinness and avoids mealtime and other social occasions that involve eating. Most anorexics are preoccupied with exercise and working out as well. They complain about being fat even though they are thin.

The consequences of eating disordered behavior can be severe. The medical effects of obesity are well known: high cholesterol levels, high blood pressure, heart disease. Bulimic behavior results in loss of vital minerals leading to heart failure; tooth decay and staining caused by acid in vomit; inflammation and possible rupture of the esophagus; chronic irregularity and constipation, peptic ulcers and pancreatitis. A female anorexic’s menstrual period may stop; breathing, pulse, and blood pressure rates drop; thyroid function slow; nails and hair become brittle; bones become fragile; skin turns dry and yellow; joints swell. Between 5 and 20% of  people struggling with anorexia nervosa die from starvation, cardiac arrest, or suicide. 

The adage “an ounce of prevention is worth a pound of cure” takes on new meaning with eating disorders. Here are some preventative measures: 

(1) Tell yourself the truth about family pain and problems—stop keeping secrets (experts suggest that families stay as sick as the secrets they keep).

(2) Uncover pockets of shame in your personal life and deal therapeutically with self-esteem issues, especially those related to body image.

(3) Abstain from image management (the “what-will-people-think” mentality).

(4) Do not, do not, do not model re-strictive dieting.

(5) Refrain from commenting on other people’s appearance, disdaining Aunt Susie’s obesity, oohing and ahhing over cousin Sally’s slenderness.

(6) Acknowledge and accept your imperfections, don’t demand perfection of others, demonstrate that it’s okay to be human.

(7) Don’t criticize or shame children about weight or less-than-perfect body parts (thick thighs, heavy arms, etc).

(8) Don’t tell them they’ll never get married if they get fat.

(9) Don’t use force or fear to intimidate them into eating/not eating.

Once an eating disorder is entrenched, intervention is difficult because so many anorexics and bulimics are convinced that there’s nothing wrong with them. Before they can get help, they have to be willing to change. They need friends and family to be supportive without trying to control them. Controlling is “helping” that doesn’t help! Appropriate measures include:

(1) Informing yourself about eating disorders.

(2) Examining your own feelings about weight and body image.

(3) Finding a safe place (such as a support group for people affected by someone’s out-of-control behavior) to discharge your frustrations and to focus on your own growth.

(4) Giving unconditional love and acceptance to the sufferer.

(5) Not being over-protective.

(6) Not nagging or making comments (positive or negative) about the person’s weight.

(7) Refusing to try to fix him/her.

(8) Encouraging him/her to get a professional evaluation and seek treatment if indicated.

(9) Allowing him/her to take full responsibility for her/his recovery. 

In my experience, conceptualizing disordered eating as an addiction is the most useful approach to treatment and treatment planning. The essential features of addiction (loss of control over harmful behavior, continued abuse in the face of negative consequences) coincide with the experience of people with eating disorders. Rather than being addicted to a substance, they are addicted to a mood-altering process involving food and image management or, more to the point, to control in general. That’s why most efforts to control their behavior prove futile!

Your response

If you think a loved one has an eating disorder, discuss your observations with an expert. Find out what resources are available so you can offer specific strategies for getting help. When you’re ready to intervene, explain that you care for her and don’t want to lose her. Let her know that you believe in her, that she deserves help, and that you will support her in getting it. 

Treatment should address medical, nutritional, and psychological needs with a team approach that involves a variety of experts (an internist, nutritionist, psychotherapist, psychiatrist, and addictions specialist) and modalities (individual or group therapy, family therapy, and hospital or residential care). This kind of help doesn’t come cheap. But if we think counseling is expensive, we must consider the alternative. The cost of treating late-stage eating disorders is far greater than the cost of providing professional help early on.