Anorexia—The Beginning

We have been getting it wrong when it comes to anorexia.  Both medicine and psychology have missed the science.  Would you like the real story?  We now have plenty of studies and so much more understanding about the brain and metabolism.  Here’s what the science actually says:

Anorexia is a metabolic disorder.

Anorexia is not caused by controlling mothers.  It is not a disease reserved for rich, entitled, white, skinny girls who want more control over their lives.

Anorexia occurs in all genders, all skin colors, all ages, and all sizes of bodies.

You can’t catch a bad case of anorexia by reading too many fashion magazines.

You can’t cure anorexia by convincing someone to want to eat or by psychoanalyzing the reasons why they are not eating.

The drives to exercise more, weigh less, and restrict food are symptoms of the metabolic disorder.  Not being able to accurately see body size or even notice all of the physical suffering are also symptoms of the metabolic disorder.  They are not the cause of the disorder.

Menstruation is not a marker of whether or not someone has anorexia and does not accurately determine how bad things are.

86% of anorexia is explained by genetics.

The only effective treatment for anorexia is eating.  Food is the medicine.

Okay, let’s catch our breaths.  I wonder which of those statements are the hardest for you to take in.  I wouldn’t be surprised if you flat out disagree with me about some of those statements.  It would make sense if you don’t agree with me.  Doctors and counsellors and everyone have been saying for the longest time that people with anorexia are afraid of getting fat because they have bought the lie that it’s better to be skinny; that it’s their fault they aren’t eating

It’s hard for me to even type that nonsense.  It’s nonsense.

Let’s start with the fact that anorexia is a metabolic disorder that is 86% explained by genetics.  That means that for each person with anorexia, if we make a pie of all the factors that have led to their disorder, genetics would take up about 86% of that pie.  That leaves only 14% left for having a mom who makes comments about needing to lose weight, a dad who goes to the gym to burn off last night’s dinner, an older sister who weighs herself twice a day, the social media scrolls full of dieting tips, friends who skip lunch, being on the gymnastics team, having childhood trauma, and so on.

Most of us have several of those other factors, maybe even all of those factors, and most of us do not have anorexia.  Over 90% of males and females in North America are not happy with their bodies, but only a small percentage of society has anorexia.  Body dissatisfaction might be a risk factor, but by itself, it is unlikely to cause anorexia.  The magic ingredient is genetics.

When the body decides that it’s not getting enough food and that it’s been far too long since it did get enough food, it switches into a starvation metabolic state.  I don’t know how well science really understands just what it is that switches a body into that state.  Literature and treatment for anorexia focus a lot on BMI and how much fat storage does the body has.  For some people, low fat storage might be what causes the body to say, “Woah!  Hold up!  Storage is low, time to switch into a starvation state.”  In the DSM (the diagnostic and statistical manual used for making mental health diagnoses), having a low BMI is a criteria of receiving the diagnosis.  In more recent years, they have added another category of diagnosis called Atypical Anorexia.  You can receive that diagnosis if you are not underweight or are not afraid of gaining weight.  Guess what.  “Atypical Anorexia” is three times more common than anorexia!  Most people with anorexia actually don’t have a low body weight.  That makes it harder for them to get the proper diagnosis and treatment and can really cause them to question if they even have a problem.  This also means that there must be other things that trigger bodies to decide to go into a starvation state, not just low stores of fat.  It seems that some bodies decide to switch into starvation metabolism based on how much or how regularly nutrition is coming in, even if we would think there’s still plenty in storage.

Once a body switches into a starvation metabolic state, there are tons of changes.  Many of the changes relate to body chemistry and decrease the body’s ability to stay warm and repair tissue (including muscles, bones, and organs).  Many systems are put on hold, such as the reproductive system and even the digestive system.  This leads to people in starvation saying that they feel full or constipated.  Insomnia occurs (better stay awake so you can go find more food!) and a compulsion to exercise.  Then there is a whole host of psychological symptoms that occur such as increased anxiety and perfectionism, being more goal oriented, becoming hyper-focused on food and cooking, less aware of emotions, trouble remembering things, lack of interest in sex and more.

The medical and mental health communities have had it backwards for a long time.  We have been trying to treat symptoms of starvation as though this would treat anorexia.  It won’t.  We treat anorexia with food.  And yet we can’t just tell people with anorexia to “just eat!”  They won’t.  But before we get into treatment, let’s say a little more about how people end up with this metabolic disorder.

There are lots of possible roads that can lead to anorexia.  It’s important to remember that there are tons of other people on those same roads who do not end up with anorexia.  We need to be careful about saying that any of these things cause anorexia, because the huge key is genetic vulnerability.  Some possible roads include:

·      Going through a lot of stress and discovering that restricting food brings a feeling of calm or reward for that person.  Restricting food definitely does not bring good feelings for most people!  For most people with the genetic vulnerability, it does.

·      Having a tendency towards OCD that makes restriction, control and rules feel calming.

·      Being an athlete or over-exercising to reduce stress (or for any reason) and not keeping up with food intake.  There’s a term, REDS—Relative Energy Deficiency in Sports, for exactly this phenomenon.

·      Feeling like emotions are super overwhelming, and then discovering that emotions go away with serious food restriction.

·      Dieting.  If food restriction in dieting is severe enough and there’s enough genetic vulnerability, then dieting can lead to anorexia.  This person would find that weight goals just keep getting lower and lower.

·      Illness that leads to weight loss or makes it hard to consume enough nutrition in a day.

·      Restricting eating because of a desire to feel smaller.  For some people, being smaller feels safer.  This can be a normal response to trauma, as a smaller body might feel less threatening to an abuser and an underdeveloped body might feel less likely to catch an abuser’s unwanted attention.

·      Growing up without enough food around.  This can lead to low weight, which can be a risk factor as there is less available fat to lose before the body turns on the starvation metabolism.  It can also lead to internalized beliefs about not deserving to eat.

Notice how in many of these examples, the person may not have any intention to lose weight at all.  Once the starvation metabolism takes over, it is very hard to break out of it alone.  Very often, a person with anorexia isn’t aware of it and cannot recognize all of the symptoms of anorexia as just that.

Treatment for anorexia will vary by the age of the individual, how much support they have from family and friends, and according to that individual’s medical needs.  There needs to be a team of professionals involved in recovery.  In BC, the individual will need to visit their GP who will make a referral to an eating disorder specialist and determine whether hospitalization is required for medical stabilization.  Other team members would be a dietician and a counsellor, both with specialized training in eating disorders.  It is common practice for the members of the professional team to be in communication each other to support recovery.

Doing work with a counsellor includes a few things: noticing which issues are actually symptoms of the eating disorder, learning skills for eating when the whole self is resisting eating, learning skills for regulating emotions, supporting the family members who are assisting with recovery, addressing any other issues that might have allowed the disorder to develop, and supporting ongoing recovery.

Recovering from anorexia is one of the hardest things a person can do.  And it’s possible.  Good support is available.  Everyone deserves a life that is free from an eating disorder.  Let’s do this together.