Most of us at some time or another have been on a diet, or had concerns about our body image. In this western society, where a great deal of emphasis is placed on appearance, this is far more common than not. Dieting can become problematic, however, if it is taken too far. If you find yourself stuck in a cycle of dieting, and or out of control eating and a persistent feeling of dissatisfaction with your body, then you might have an eating disorder.
An eating disorder is characterised by obsessive thoughts about food and body weight. This includes people who limit the amount of food they eat (Anorexia nervosa), eat lots of food in a very small time and then purge (Bulimia) or overeat often (Compulsive overeating).
The SCOFF questionnaire, below, asks some important questions that might help to clarify if this is a concern for you. If you answer yes to two or more of these questions, then it is worth exploring the possibility that you have an eating disorder:
S — Do you make yourself Sick because you feel uncomfortably full?
C – Do you worry you have lost Control over how much you eat?
O – Have you recently lost more than One stone (6.35 kg) in a three-month period?
F – Do you believe yourself to be Fat when others say you are too thin?
F – Would you say Food dominates your life?
Eating disorders tend to be under-reported. That is, people who engage in disordered eating may not realise that there is a problem until someone else points out their concern, or until their quality of life begins to be affected. People also tend to keep their eating disorder secret, especially in the early days of the problem emerging, because the eating disorder might initially seem like a good solution for other problems. However if left untreated, an eating disorder can itself become a serious problem.
Some of the following signs may indicate that your eating disorder has become a problem:
- You find yourself increasingly making excuses not to go out with friends because it involves eating;
- You find yourself avoiding activities that might involve revealing your body – eg going swimming or out to dressy events;
- You feel too tired to engage in usual activities;
- You have trouble concentrating;
- You find yourself thinking constantly about food. This might include calorie counting and meal plans;
- You can only feel OK about yourself after doing exercise;
- You exercise when injured or unwell;
- You are using laxatives or diet pills;
- You have felt dizzy or faint;
- Others are saying you have lost too much weight;
- You have trouble getting out of the house in the morning because of needing to complete eating disorder behaviours;
- You find yourself constantly checking your body in the mirror, measuring and pinching it;
- You weigh yourself very frequently (eg every day or more);
- You are very self-critical and feel that you will only be OK when you have achieved a certain weight.
Eating disorders are real, complex, and devastating conditions that can have serious consequences for health, productivity, and relationships. They are not a fad, phase or lifestyle choice. Eating disorders are serious, potentially life-threatening conditions that affect a person’s emotional and physical health. People struggling with an eating disorder need to seek professional help. The earlier a person with an eating disorder seeks treatment, the greater the likelihood of physical and emotional recovery.
An eating disorder is a serious mental health problem. Eating disorders are estimated to affect approximately 9% of Australians – both males and females. A person with an eating disorder may experience long term impairment to social and functional roles and the impact may include psychiatric and behavioural effects, medical complications, social isolation, disability and an increased risk of death.
The impact of an eating disorder is not only felt by the individual, but often by that person’s entire family or circle of support. For families, the impact may include caregiver stress, loss of family income, disruption to family relationships and a high suicide risk.
While estimates of the incidence of eating disorders vary between countries and studies, there is agreement that eating disorders, disordered eating and body image issues have increased worldwide over the last 30 years. These estimates do not take into consideration the frequent under-reporting and under-treatment of eating disorders.
Health Consequences of Anorexia Nervosa
In anorexia nervosa’s cycle of self-starvation, the body is denied the essential nutrients it needs to function normally. Thus, the body is forced to slow down all of its processes to conserve energy, resulting in:
- Abnormally slow heart rate and low blood pressure, which mean that the heart muscle is changing. The risk for heart failure rises as the heart rate and blood pressure levels sink lower and lower.
- Reduction of bone density (osteoporosis), which results in dry, brittle bones.
- Muscle loss and weakness.
- Severe dehydration, which can result in kidney failure.
- Fainting, fatigue, and overall weakness.
- Dry hair and skin; hair loss is common.
- Growth of a downy layer of hair – called lanugo – all over the body, including the face, in an effort to keep the body warm.
Health Consequences of Bulimia Nervosa
The recurrent binge-and-purge cycles of bulimia can affect the entire digestive system and can lead to electrolyte and chemical imbalances in the body that affect the heart and other major organ functions. Health consequences include:
- Electrolyte imbalances that can lead to irregular heartbeats and possibly heart failure and death.
- Electrolyte imbalance is caused by dehydration and loss of potassium, sodium and chloride from the body as a result of purging behaviors.
- Potential for gastric rupture during periods of bingeing.
- Inflammation and possible rupture of the oesophagus from frequent vomiting.
- Tooth decay and staining from stomach acids released during frequent vomiting.
- Chronic irregular bowel movements and constipation as a result of laxative abuse.
- Peptic ulcers and pancreatitis.
Binge eating disorder often results in many of the same health risks associated with clinical obesity, including:
- High blood pressure.
- High cholesterol levels.
- Heart disease as a result of elevated triglyceride levels.
- Type II diabetes mellitus.
- Gallbladder disease.
What causes an eating disorder?
The factors that contribute to the onset of an eating disorder are complex. No single cause of eating disorders has been identified; however, known contributing risk factors include:
- Genetic vulnerability
- Psychological factors
- Socio-cultural influences
There is some evidence that eating disorders have a genetic basis. The genes that are most implicated in passing on eating disorders are within biological systems that relate to food intake, appetite, metabolism, mood, and reward-pleasure responses. It has been shown that this genetic influence is not simply due to the inheritance of any one gene, but results from a much more complicated interaction between many genes and quite possibly on inherited genetic factors as well.
- A sensitive temperament
- A tendency to be afraid of one’s emotional experience
- Low self-esteem
There is a developing body of research suggesting that people who are prone to having an eating disorder are more likely to have suffered physical, emotional or sexual abuse or neglect during childhood.
Specific additional personality traits may be associated with each type of eating disorder. It is also important to include that prolonged starvation induces change in cognition, behaviour, and interpersonal characteristics. It can therefore be difficult to discern the psychological causes from the psychological effects of eating disorders.
Evidence shows that socio-cultural influences play a role in the development of eating disorders, particularly among people who internalise the western beauty ideal of thinness. Images communicated through mass media such as television, magazines and advertising are unrealistic, airbrushed and altered to achieve a culturally perceived image of ‘perfection’ that does not actually exist.
The most predominant images in our culture today suggest that beauty is equated with thinness for females and a lean, muscular body for males People who internalise this ‘thin ideal’ have a greater risk of developing body dissatisfaction which can lead to eating disorder behaviours.
Low self-esteem has been identified by many research studies as a general risk factor for the development of eating disorders. Strong self-esteem, or a sense of self compassion has been described as essential for psychological well-being and for strengthening the ability to resist cultural pressures.
Body dissatisfaction or negative body image
Poor body image can contribute to impaired mental and physical health, lower social functionality and poor lifestyle choices. Body dissatisfaction, the experience of feelings of shame, sadness or anger associated with the body, can lead to extreme weight control behaviours and is a leading risk factor for the development of eating disorders.
Body dissatisfaction is also linked to depression and low self-esteem and has been found to be widespread in adolescent girls in Australia.
Treatment of Eating Disorders
An eating disorder is a psychological problem, with physical consequences. For this reason, effective treatment requires attention to both the physical and psychological aspects of the disorder. The severity of your illness will determine the level of treatment you may require at any particular time. If you are finding the physical aspects of your disorder are overwhelming you and you need 24 hour support, inpatient treatment may be indicated. If your symptoms are severe, and you need intensive support, a day program might be the best option. If you can manage your eating disorder symptoms on your own with the support of family and loved ones, outpatient treatment is appropriate.
If you need extra help to manage the physical aspects of your eating disorder, inpatient treatment can prevent further deterioration of your eating disorder, and help to give your treatment a boost. There are several private hospital based eating disorder units in Sydney, including the Northside Clinic, Northside West Clinic and Wesley Private Hospital. There are very few publicly funded eating disorder hospital beds in NSW, and a long waiting list for beds. It is a good idea to ensure that you have private health insurance to cover the cost of an inpatient admission, which can range from 3 to 8 weeks in length. It is important to note that most private health insurance companies have an 8 week waiting period before the insurance can be used.
Day Program Treatment
If you require intensive support to resolve eating disorder symtpoms, a day program might be the best option. These are offered at the private hospitals listed above and there is also a publicly funded day program in Sydney and some in other parts of NSW. Day programs run for up to 5 days per week. They provide supported meals and intensive psychological and dietetic support. In contrast to inpatient treatment, going home at the end of the day and on the weekend enables the generalisation of new skills learned into the home environment.
A team approach is essential for treating eating disorders in an outpatient setting. Your treatment team should be comprised of professionals you trust, who are experienced in working with people with eating disorders and have an understanding of how your eating disorder affects you. Ideally, there should be communication between the professionals on your treatment team to ensure that you are getting the same message from everyone on your team.
Selecting a Treatment Team
Your GP will be involved in your treatment in an ongoing capacity, and you may need to see your GP as often as weekly, depending on the severity of your eating disorder. A GP with eating disorder experience will understand the need to monitor your weight, heart functioning and blood electrolyte levels and will advise on how often this is needed. She may recommend that you have an ECG and a bone density scan, depending on your symptoms.
If you have had an eating disorder for a long time, you may not really know how to eat ‘normally’, or what life without following eating disorder rules might look like. A compassionate and understanding dietitian will help you move away from the extremes and dietary rules imposed by an eating disorder, and help you move towards healthy, sustainable eating. Your dietitian should be experienced in treating eating disorders and help you move towards a non-dieting approach.
Psychological therapy will help you understand how you came to have an eating disorder. An understanding and compassionate therapist will help you determine whether you are ready to let go of your eating disorder, and how to cope without it. Developing an understanding of how you came to have an eating disorder, and building skills to enable you to manage life challenges may take some time. If there is trauma underlying your eating disorder, it will be important to begin a process of healing from these experiences.
The Course of Treatment
Treatment can be a little bit like the coast of South America. That is, there are ups and downs. Just when you thought you were doing really well, you can have a lapse, or a relapse, and feel like you are back at square one. It is easy to forget how far you have really come. It is important to stay engaged with your treatment team, and be honest about how you feel. Eating disorders can take some time to treat. You team will understand your feelings of ambivalence. Even if you feel like you want to give up, it is of vital importance to be open and upfront about this, and stay engaged. You deserve treatment, even though your eating disorder might be telling you that you don’t. A supportive therapist will know that this is a normal part of having an eating disorder, and help you come to terms with wherever you are on your recovery journey.
Brewerton, T.D (2007) “Eating Disorders, Trauma and Comorbidity: Focus on PTSD” Eating Disorders: The Journal of Treatment and Prevention 15(4): 285-304
National Eating Disorders Collaboration www.nedc.com.au