Far Beyond the Surface
You step onto the worn-out scale. A predatory focus grips your being. The all-too-familiar carousel of worries swirls, a small whisper prepares you for the disappointment. You are paralysed - experience has taught you even the slightest movement bumps up the numbers. The world seems to stop and stutter and your senses are drowned as the numbers creep up then trickle down then up then down then up then down then stop. The number is 0.02 less than before. Excuses ricochet in your mind: it must have been because you had just peed or held your breath a bit more or an error of the scale. It cannot possibly be because you did well. Continue continue continue.
Anorexia Nervosa is a disease that is often misunderstood for just ‘the fear of being fat’. In reality, it’s complexities lie deep within the mind, far beyond physicality. Anorexia can affect anyone, regardless of age, gender, sexual orientation, race or ethnicity. It is a psychological and life-threatening eating disorder. Statistics from a 2015 NHS report estimated 1 in 250 women and 1 in 2500 men will experience anorexia in their lifetime. If left untreated, death may result. The disease holds the highest death rates amongst other forms of mental diseases. Death resulting from anorexia for women between the ages of 15 to 24 is 12 times higher than all other causes of death. In order to further comprehend this 20th-century epidemic, a closer look into the causes and complexities of the disease is needed. Disproving the common misconceptions surrounding anorexia will not only remove the stigma and fuel conversations but will unify societies closer together as people understand each other more.
In order to diagnose an individual with anorexia nervosa according to the DSM-5(1), five of the following criteria has to be met:
Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than minimally expected.
Intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight.
Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
Prolonged body weight below the healthy amount can lead to very serious physical consequences for a sufferer. These include having stomach cramps, possibly due to acid reflux and/or constipation, difficulty concentrating and sleeping, deficiencies in certain micronutrients and abnormal hormone levels, feeling cold and fatigue frequently, amenorrhea (irregular periods), fine hair on body and drying or brittle
hair (2). The long-term physical effects of the disease can be very detrimental, including cardiovascular issues such as heart failure, osteopenia which can lead to osteoporosis, indicating a greater risk of bone fractures and breaks, difficulty conceiving and sometimes even infertility. As denial is a recurrent theme amongst many sufferers, many anorexics often seek treatment for these diseases without addressing the underlying cause of their illness.
Besides the seemingly endless list of physical consequences of the illness, the toll anorexia can have on the emotional and mental wellbeing of a sufferer can be as harmful and oftentimes even more damaging. Anorexia often comes along with a range of other mental illnesses such as depression, obsessive-compulsive disorder, general and/or social anxiety, panic disorder and more. Anorexics typically have very low self-esteem and self-worth, causing withdrawal from not only activities they once enjoyed but also from relationships with family and friends. Relationship difficulties may also arise when a loved one expresses concern regarding the anorexic’s food intake or weight, irritating and angering the sufferers. The disease can cause a significant reduction in an individual’s quality of life, school or work performance tends to fall and general contentment in life declines.
Talking to a very close friend of mine, who had suffered from the eating disorder, has changed my perception of the disease greatly. Indeed, it begins with the desire to achieve a lower weight and skinnier body, but as you fall deeper into the abyss of the disease, the obsession no longer falls on physicality, but following your routine exactly and continuing the decline of the numbers on the scale. She refers to that time of her life as a “dark patch” and said that waking up every morning was “tormentful”.
When reading over many personal accounts of the disease, I noticed a lot of variation amongst each case. Some exercised profusely, some did not at all, some also had bulimia and so on. This has led me to believe that an eating disorder is not confined to a list of behaviour, but rather a spectrum of disorders all different for every sufferer. Although losing weight may be the ultimate goal for anorexics, the journey to achieve that goal is so much more than just refusing to eat.
With mental illnesses, it is difficult to identify the root cause of each disease. There is no particular pathogen or genetic mutation that can be blamed, but rather a concoction of factors of varying weights that is different for every individual. The never-ending debate of whether anorexia stems from nature or nurture is partially incorrect as the disease is caused by not just one, but a combination of the two. To a certain extent, our genes determine our physicality and characteristics, however, the environment an individual is in can also have a significant impact on one’s behaviour.
Considerable amounts of research have established the link between genetics and eating disorders, however, the genetic component cannot be fully liable for the development of the disease. For example, individuals with a family member who has an eating disorder are 11-times more likely to develop an eating disorder themselves and twin studies reveal genetics account for 40%-60% of the development of anorexia nervosa, bulimia nervosa and binge-eating disorder (3). However, not all who have a genetic predisposition to anorexia develop the eating disorder. Similarly, some who do not have the alleles linked to anorexia develop anorexia. This is an indication of environmental influence in the development of the disease.
Nonetheless, it is important to realise that genetics also contribute to determining the environment an individual is exposed to. For example, a genetically-influenced trait e.g. personality can influence the lifestyle of individuals. Those who are more meticulous and artistic may choose more body-focused sports such as ballet instead of less appearance-based sports such as basketball. The onset of eating disorders can also be caused by a stressful or traumatic event in one’s life, and the response an individual has to this event is also influenced by genetics. For example, the impact of a sudden death of a loved one may be more detrimental on a person who is genetically predisposed to anorexia and is more likely to lead to a fixation on controlling weight, than someone else who does not have the genetic components of anorexia.
Nurture, the way an individual is raised and lives can significantly contribute to the development of an eating disorder. Many do not realise the effect childhood has on adult lives. Childhood bullying can be a large toll on an individual’s insecurities and self-esteem. According to the National Eating Disorder Association, as many as 65% of individuals suffering from an eating disorder say that bullying contributed to the development of their illness. Bullying has been made easier through the use of social media; writing a negative comment about someone on the internet is easier than saying that same comment to their face. Social media not only encourages cyberbullying, but the pressure to fit into the literally thin set of societal expectations has become more immense. As people are constantly exposed to the picture-perfect and carefully-curated lives of those online, comparison is inevitable. The constant comparing can have drastic effects on self-esteem, leading to the obsession over perfecting one’s appearance - the ultimate recipe for anorexia.
Parents have a considerable impact on their children’s eating patterns and behaviours. It is not unusual for individuals suffering from an eating disorder to have parents with personality traits associated with eating disorders such as perfectionism and obsessive behaviour on their appearance. The extent of parental influence on children’s eating was examined Suzanne E. Mazzeo and Cynthia M. Bulik and it was found that a mother’s comment regarding their appearance and weight affected the self-esteem of fourth and fifth-grade sons and daughters. Studies concluded that a mother’s dieting and restrictive eating patterns were reflected in their daughter’s eating behaviour as early as the age of 10 (4). Thus, the parental role in anorexia development is significant - especially in those who are genetically vulnerable.
Fundamentally, it is the interaction between an individual’s genetics and environmental exposure that lead to the development of anorexia. As Dr Bulik, a leading researcher on anorexia nervosa initiative (ANGI) would say “Genes load the gun, environment pulls the trigger”. Therefore, during treatment, it is important to acknowledge the contribution of both nature and nurture factors and that each factor influences each and every individual differently.
Over 70 million people worldwide suffer from an eating disorder, anorexia being one. It is a quiet illness that slowly strips an individual of their freedom and happiness beyond their control. In order to prevent this debilitating illness from becoming more prevalent, we all need to remember that it is the difference in our shapes, sizes and colours that makes us all truly unique and beautiful. Remind yourself of all the fascinating functions your body is capable of. Remind yourself that there are people who love and care for you and that you are not alone.
By Melanie Utharntharm, Grad 20 Shrewbury Student
1- Opal Food and Body. DSM-5: Feeding and Eating Disorders [Online] [accessed Dec 2019]
2- National Eating Disorders, 2018. Anorexia Nervosa. [Online] [accessed Dec 2019]
3- Trace SE, Baker JH, Penas-Lledo E, Bulik CM. The genetics of eating disorders. Annual Review of Clinical Psychology. 2013;9:589-620.
4- Suzanne E. Mazzeo and Cynthia M. Bulik, 2010. Environmental and genetic risk factors for eating disorders: What the clinician needs to know [Online] [accessed Dec 2019] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719561/#R33