Eating disorders are responsible for more loss of life than any other type of psychological illness.
Millions of people suffer from eating disorders, and while this figure includes individuals who have been diagnosed with an eating disorder, it is also thought to include those who have not received an official diagnosis. Many instances of eating disorders are thought to remain undiagnosed because they are unreported, possibly due to the shame, secrecy and deniability associated with such conditions.
Many eating disorders are atypical, which means that problem-eating behaviours are present, but do not meet the diagnostic criteria for an eating disorder.
Eating disorders are more common among women, but men suffer too. And while eating problems are more prevalent among women of a certain age group, they can affect anyone at any age, from any cultural background.
The study of eating disorders, their prevalence and effects is relatively new. Researchers use different research methods and study different groups of people, which yield different results.
Whilst many have been diagnosed and are receiving treatment, many more remain undiagnosed and at risk. The deniability, secrecy and stigma associated with eating disorders will stop many seeking help, and prevent others taking responsibilty to help a sufferer.
Some useful statistics
1.6 MILLION PEOPLE IN THE UK ARE AFFECTED (1)
20% BECOME SERIOUSLY ILL (1)
14-25 YEAR OLDS ARE MOST AT RISK (1)
1 in 100 women aged between 15 and 30, suffers from anorexia (2)
40% of people with anorexia recover completely (4)
30% of anorexia sufferers continue to experience the illness long-term and suffer physical effects (4)
Up to 18 new cases per 100,000 population per year (1)
5 fold increase in the incidence of Bulimia Nervosa 1988 -1993 (3)
10-15% of mildly obese people enrolled in weight loss programmes have binge-eating disorder. 60% of sufferers are thought to be women, while 40% are thought to be men (7)
EATING DISORDER NOT OTHERWISE SPECIFIED (EDNOS)
This is the description used for an eating disorder that has some characteristics of anorexia or bulimia (or both).
4-6% of the general population develop an EDNOS (5)
50% of individuals who present for treatment of an eating disorder receive the diagnosis of EDNOS (5)
OBESITY (BMI > 30)
46% of men and 32% of women are overweight (BMI 25-30 kg/m2) (6)
17% of men and 21% of women are clinically obese (BMI >30 kg/m2) (6)
Obesity has trebled from 1990 to 2001(6)
1 % of children felt they could talk to their parents about their eating-related concerns
9 % of children felt they might be able to talk to someone at school
17 % of children felt they might be able to talk to a doctor or nurse
92 % of children felt they couldn't tell anyone
(1) Published data from Beat (Eating Disorders Association UK)
(3) Turnball et al 1996
(4) The Royal College of Psychiatrists
(5) National Eating Disorders Association of the US
(6) UK National Statistics
(7) NICE Guidelines: Eating disorders - Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders
Eating disorders are characterised by an abnormal attitude towards food that causes someone to change their eating habits and behaviour.
A person with an eating disorder may focus excessively on their weight and shape, leading them to make unhealthy choices about food with damaging results to their health.
Types of eating disorders
Eating disorders include a range of conditions that can affect someone physically, psychologically (mentally) and socially (their ability to interact with others). The most common eating disorders are:
anorexia nervosa, when someone tries to keep their weight as low as possible, for example by starving themselves or exercising excessively
bulimia, when someone tries to control their weight by binge eating and then deliberately being sick or using laxatives (medication to help empty their bowels)
binge eating, when someone feels compelled to overeat
Eating disorders that do not fit with the above definitions may be described as:
atypical eating disorders
eating disorders not otherwise specified
Causes of eating disorders
Eating disorders are often blamed on the social pressure to be thin, as young people in particular feel they should look a certain way. However, the causes are usually more complex.
There may be some biological or predisposing (influencing) factors, combined with an experience that may provoke the disorder, plus other factors that encourage the condition to continue.
Risk factors that can make someone more likely to have an eating disorder include:
having a family history of eating disorders, depression or substance misuse
being criticised for their eating habits, body shape or weight
being overly concerned with being slim, particularly if combined with pressure to be slim from society or for a job (for example ballet dancers, models or athletes)
certain characteristics, for example, having an obsessive personality, an anxiety disorder, low self-esteem or being a perfectionist
particular experiences, such as sexual or emotional abuse or the death of someone special
difficult relationships with family members or friends
stressful situations, for example problems at work, school or university
How common are eating disorders?
Around 1 in 250 women and 1 in 2,000 men will experience anorexia nervosa at some point. The condition usually develops around the age of 16 or 17.
Bulimia is around five times more common than anorexia nervosa and 90% of people with bulimia are female. It usually develops around the age of 18 or 19.
Binge eating usually affects males and females equally and usually appears later in life, between the ages of 30 and 40. Due to the difficulty of precisely defining binge eating, it is not clear how widespread the condition is.
If it is not treated, an eating disorder can have a negative impact on someone’s job or schoolwork, and can disrupt relationships with family members and friends. The physical effects of an eating disorder can sometimes be fatal.
Treatment for eating disorders is available, although recovering from an eating disorder can take a long time. It is important for the person affected to want to get better, and the support of family and friends is invaluable.
Treatment usually involves monitoring a person’s physical health while helping them to deal with the underlying psychological causes. This may involve:
cognitive behavioural therapy (CBT): therapy that focuses on changing how someone thinks about a situation, which in turn will affect how they act
interpersonal psychotherapy: a talking therapy that focuses on relationship-based issues
dietary counselling: a talking therapy to help people maintain a healthy diet
psychodynamic therapy: counselling that focuses on how a person’s personality and life experiences influence their current thoughts, feelings, relationships and behaviour
There is a range of other healthcare services that can help, such as support and self-help groups, and personal and telephone counselling services. See Useful links for more information.
Anorexia nervosa is an eating disorder and a serious mental health condition.
People with anorexia have problems with eating. They are very anxious about their weight and keep it as low as possible by strictly controlling and limiting what they eat. Many people with anorexia will also exercise excessively to lose weight.
It is thought that people with anorexia are so concerned about their weight because they:
think they are fat or overweight
have a strong fear of being fat
want to be thin
Even when a person with anorexia becomes extremely underweight, they still feel compelled to lose more weight.
Though people with anorexia avoid eating food whenever they can, they also develop an obsession with eating and diet. For example, they may obsessively count the calories in different types of foods even though they have no intention of eating it.
Some people with anorexia will also binge eat, i.e. they eat a lot of food in a short space of time. They then try to get rid of the food from their body by vomiting or using laxatives (medication that causes the bowels to empty; normally used for the treatment of constipation.)
The symptoms of anorexia usually begin gradually, such as adopting a restrictive diet. They then often spiral out of control quickly.
How common is anorexia?
Despite being an uncommon condition, anorexia is the leading cause of mental health-related deaths.
Most cases of anorexia develop in girls and women. One in every 200 women is affected. Symptoms of anorexia usually first develop during the teenage years, at the average age of 15 (see Anorexia – symptoms for more information). But the condition can develop at any time, including childhood.
Anorexia also affects 1 in every 2,000 men. Some experts are concerned that the number of men with the condition may be increasing.
The cause of anorexia is unknown, but most experts believe the condition results from a combination of biological, psychological and environmental factors (see Anorexia – causes for more information).
The long-term malnutrition associated with anorexia can cause a range of serious complications, such as:
osteoporosis (weakening of the bones)
One of the biggest challenges in treating anorexia is that it is a condition characterised by self-denial. Many people with anorexia refuse to admit, or are unable to grasp, that there is anything wrong with them or their behaviour.
If the person is persuaded to seek help, it usually takes five to six years of treatment before they make a complete recovery, and relapses are common.
Treatment for anorexia usually involves talking therapies, such as cognitive behavioural therapy, which aim to change the person’s attitudes and behaviour. Nutritional support is also offered to help them gain weight safely.
Around 20-30% of people with anorexia do not respond to treatment, and around 5% will die from complications caused by malnutrition.
The main symptom of anorexia is losing a lot of weight deliberately. For example, by:
eating as little as possible
making yourself vomit
doing too much exercise
A person with anorexia will want their weight to be as low as possible – much less than the average for their age and height. They are so afraid of gaining weight that they cannot eat normally.
After they have eaten, they may try to get rid of food from their body by making themselves sick regularly. Signs of regular vomiting could include:
leaving the table immediately after meals
dental problems such as tooth decay or bad breath, caused by the acid in vomit damaging their teeth and mouth
hard skin on their knuckles, caused by putting their fingers down their throat
The need to obsessively burn calories usually draws people with anorexia to ‘high-impact’ activities, such as running, dancing or aerobics. Some people will use any available opportunity to burn calories, such as preferring to stand rather than sit.
They may try to make food pass through their body as quickly as possible. For example, by taking:
laxatives (medication that helps to empty the bowel) or
diuretics (medication that helps remove fluid from the body)
In reality, laxatives and diuretics have little effect on the calories absorbed from food.
Eating and food
Although anorexia means ‘loss of appetite’, people with anorexia nervosa do not usually lose their appetite; they like food and feel hungry.
However, they do not think about food in the same way as other people. This can show itself in various ways. For example, they may:
tell lies about eating or what they have eaten
give excuses about why they are not eating
pretend they have eaten earlier
tell lies about how much weight they have lost
find it difficult to think about anything other than food
spend lots of time reading cookery books and recipes
Someone with anorexia nervosa strictly controls what they eat. For example, by:
counting the calories in food excessively
avoiding food they think is fattening
eating only low-calorie food
missing meals (fasting)
avoiding eating with other people
cutting food into tiny pieces – to make it less obvious that they have eaten very little, and to make the food easier to swallow
taking appetite suppressants, such as slimming pills or diet pills
They may also drink lots of fluids that contain caffeine, such as coffee, tea and low-calorie fizzy drinks, as these can provide a low-calorie, short-term burst of energy.
Some people with anorexia also begin to use illegal stimulant drugs known to cause weight loss, such as cocaine or amphetamines.
Self-esteem, body image and feelings
People with anorexia often believe that their value as a person is related to their weight and how they look. They think other people will like them more if they are thinner, seeing their weight loss in a positive way.
They often have a distorted view of what they look like (their body image). For example, they think they look fat when they are not. They may try to hide how thin they are by wearing loose or baggy clothes.
Many people will also practise a type of behaviour known as ‘body-checking’, which involves persistently and repeatedly:
measuring themselves, such as their waist size
checking their body in the mirror
Anorexic people usually have low self-esteem or self-confidence. They may withdraw from relationships and become distant from members of their family and friends.
Anorexia can also affect the person’s school work or how well they perform their job.
They may find it difficult to concentrate, and they might lose interest in their usual activities. They may have few interests, even though they seem busier than usual.
Other signs of anorexia
Eating too little for a long time can result in physical symptoms, such as:
fine downy hair (lanugo) growing on their body
more hair on their face
their pubic hair becoming sparse and thin
Their heartbeat may be slow or irregular, which can lead to poor circulation. They may also:
have pain in their abdomen (tummy)
feel bloated or constipated
have swelling in their feet, hands or face (known as oedema)
feel very tired (fatigue), as their sleep patterns may have changed
have low blood pressure (hypotension)
feel cold or have a low body temperature (hypothermia)
feel light-headed or dizzy
In children with anorexia, puberty and the associated growth spurt may be delayed. They may gain less weight than expected (if any) and may be smaller than other people of the same age.
Women and older girls with anorexia may stop having their periods (known as amenorrhoea or absent periods). Anorexia can also lead to infertility.
There is no single cause for anorexia. Most experts have argued that the condition is caused by a combination of psychological, environmental and biological factors, which lead to a destructive cycle of behaviour.
A widely accepted model based on these factors is that some people have distinct personality traits that make them more vulnerable to anorexia.
Environmental factors, such as going through puberty or living in a culture where thinness is an ideal, then causes the person to begin a pattern of long-term dieting and weight loss.
The lack of a normal diet has a biological effect on the brain, which helps reinforce the obsessive thinking and behaviour associated with anorexia.
A cycle then begins. The more the person diets, the greater its effect on the brain and the greater the desire to lose weight. This means that symptoms gradually, and then rapidly, get worse.
Each of these factors is explained in more detail below.
Research has found that most people who develop anorexia share certain psychological factors that help to define their personality and, to some extent, their behaviour. These include:
a tendency towards depression and anxiety
poor reaction to stress
excessive worrying and feeling scared or doubtful about the future
perfectionism – setting strict, demanding goals or standards
inhibition – where a person restrains or controls their behaviour and expression
feelings of obsession and compulsion (though not necessary ‘full-blown’ obsessive compulsive disorder) – an obsession is an unwanted thought, image or urge that repeatedly enters a person’s mind. A compulsion is a repetitive behaviour or mental act that a person feels compelled to perform.
The fact that most cases of anorexia develop during puberty suggests that puberty itself is an important environmental factor contributing to anorexia.
It may be that the combination of the hormonal changes during puberty and feelings of stress, anxiety and low self-esteem that many teenagers have during puberty could trigger anorexia.
Another important environmental factor is Western culture and society. Girls (and, to a lesser extent, boys) are exposed to a wide range of different media which constantly reinforce the message that being thin is the only way to be beautiful, and that thinness should be pursued at all costs.
At the same time, magazines and newspapers focus on celebrities' minor physical imperfections, such as gaining a few pounds or having cellulite.
Other environmental factors that may contribute towards anorexia include:
a stressful life event, such as losing a job or a relationship
pressures and stress at school, such as exams or bullying
difficult family relationships
physical or sexual abuse
Your brain requires a healthy, nutritious diet to function normally. It uses a fifth of all the calories you eat. So the extreme dieting associated with anorexia can disrupt the normal functions of the brain, possibly making anorexia symptoms worse.
Malnutrition can also change the balance of hormones in the body, which can disrupt the normal functioning of the brain.
There are a number of theories on how the brain may be affected by anorexia. One theory is that the changes mentioned above cause the brain to become very sensitive to the effects of an amino acid called tryptophan, found in almost all types of food.
This sensitivity may then cause feelings of anxiety in people with anorexia when they eat. At the same time, starving themselves and excessive exercise is known to lower levels of tryptophan, which may make the person feel calmer and more relaxed.
Another theory is that the system controlling a person’s sense of appetite becomes disrupted.
Appetite is controlled by a part of the brain called the hypothalamus. When your body needs more food, your hypothalamus releases chemicals, known as neurotransmitters and neuropeptides, which stimulate your appetite.
Once you have eaten enough food, your body will release a hormone called leptin, which signals to your hypothalamus that you have eaten enough food. Your hypothalamus will release a different set of chemicals that essentially reward you for eating, and make you feel satisfied.
It is thought that due to changes in the brain, the ‘appetite-reward pathway’ becomes scrambled in people with anorexia. The feeling of fullness after a meal does not produce a sense of reward, but a sense of anxiety, guilt or self-loathing. In turn, feeling hungry may help to reduce these negative feelings.
Anorexia in men
It is a common belief that eating disorders only affect women, but around 1 in 10 people with eating disorders are male.
The causes of these illnesses in men can be different to those in women: in many cases, anorexia results from bodybuilding or exercise, or specific occupations, such as athletics, dance or horse racing. However, like many women, younger men are becoming increasingly vulnerable to disliking their bodies, and are being bullied or teased as children for being overweight.
Bulimia nervosa is an eating disorder and mental health condition.
People who have bulimia try to control their weight by binge eating and then purging the food from their body by being sick or using laxatives.
As with other eating disorders, bulimia has a number of different causes, including depression, low self-esteem andstress.
Bingeing and purging
Eating disorders are characterised by an abnormal attitude towards food that causes someone to change their eating habits and behaviour. It can be difficult to understand how an eating disorder develops.
Everyone has their own eating habits. For example, people with a food intolerance need to avoid eating certain foods to stay healthy. However, the habits of people with eating disorders are motivated by an overwhelming fear of getting fat.
People with bulimia tend to alternate between eating excessive amounts of food (bingeing), and then making themselves sick or using laxatives (purging) to maintain a chosen weight. This is usually done in secret.
People with bulimia purge themselves because they feel guilty about the binge eating, but the bingeing is a compulsive act that they feel they cannot control.
Who is affected by bulimia?
Bulimia can affect men and women, but women are 10 times more likely to develop bulimia than men. However, bulimia is becoming more common in boys and men.
Recent studies suggest that as many as 8% of women have bulimia at some stage in their life. The condition can occur at any age, but mainly affects women aged between 16 and 40 (on average, it starts around the age of 18 or 19). Bulimia can affect children, but this is extremely rare.
The main symptoms of bulimia are binge eating and purging (ridding your body of food by making yourself sick or taking laxatives).
Binge eating is repeatedly eating vast quantities of high-calorie food, without necessarily feeling hungry or needing to eat. The urge to eat can begin as an attempt to deal with emotional problems, but can quickly become obsessive and out of control.
Binge eating is usually a very quick process and you may feel physically uncomfortable afterwards. When binge eating is a symptom of bulimia, it happens regularly, not just once or twice.
Sometimes, the binges are spontaneous, where you eat anything you can find at that moment. Binge eating episodes can also be planned, where you make a shopping trip to buy foods specifically to binge on.
For more information, see the Health A-Z topic on Binge eating.
Purging is a response to bingeing. After you have eaten lots of food in a short space of time, you may feel physically bloated and unattractive. You may also feel guilty, regretful and full of self-hatred.
However, the main impulse to purge is a powerful, overriding fear of putting on weight.
The most common methods of purging involve making yourself sick or using laxatives to encourage your body to pass the food quickly.
Less common methods of purging include taking diet pills, over-exercising, extreme dieting, periods of starvation or taking illegal drugs, such as amphetamines.
Cycle of guilt
Bulimia is often a vicious circle. If you have the condition, it is likely that you have very low self-esteem. You may also think you are overweight, even though you maybe at or near a normal weight for your height and build.
This may encourage you to set yourself strict rules about dieting, eating or exercising, which are very hard to maintain. If you fail to keep to these strict rules, you binge on the things that you have denied yourself. After feeling guilty about bingeing, you purge to get rid of the calories.
Other signs of bulimia
Other signs of bulimia can include:
regular changes in weight
an obsessive attitude towards food and eating
large amounts of money being spent on food
disappearing soon after eating (usually visiting the toilet to vomit)
episodes of over-eating
periods of starvation
scarred knuckles (from forcing fingers down the throat to bring on vomiting)
depression and anxiety
unrealistic opinions about body weight and shape
Causes of bulimia
There is no simple answer to the question of what causes bulimia. Although the condition is linked to a fear of getting fat, more complex emotions usually contribute to the problem. The act of bingeing and purging is often a way of dealing with these intense emotions.
Some common factors that may lead to bulimia are outlined below.
If you have an eating disorder, you may have a low opinion of yourself and see losing weight as a way of gaining self-worth.
You may use bingeing as a way of coping with unhappiness. People with bulimia often feel depressed, so they binge regularly. However, purging does not relieve this depression and the cycle continues. For more information, see the Health A-Z topic aboutDepression.
Bulimia can sometimes occur following stressful situations or life events. For example, you may develop the condition after dealing with a traumatic experience, such as a death or divorce, or during the course of important life-changing events, such as getting married or leaving home.
Bulimia can also occur in people who have experienced physical illness, and in people who have been sexually abused. Some people with bulimia have experienced a difficult childhood, with family problems, arguments and criticism.
Other mental health problems
Bulimia is often linked with other psychological problems. Research shows that bulimia is more common in people who have anxiety disorders, obsessive compulsive disorder(OCD), post-traumatic stress disorder (PTSD) and personality disorders.
Cultural and social pressure
Some people believe that the media and fashion industry create pressure for people to aspire to low body weights.
Many young people become affected by eating disorders around the time of puberty, when hormonal changes can make them more aware of their body.
If teenagers feel they have no say in their lives, bulimia can seem like the only way they can take control.
There may be a genetic factor related to developing bulimia. Research suggests that people who have a close relative who has or has had bulimia are four times more likely to develop it than those who do not have a relative with the condition.