‘If I’d gained like half a pound, I’d assume everyone was pointing and laughing at the fat girl. It was so hard to force myself to go to school and face the world those days.’
Many people with anorexia know the calorie content and/or nutritional breakdown of hundreds of foods. It is common for people with anorexia to set themselves a calorie limit for the day and obsessively count exactly how many calories they consume. If they consume more than the allotted amount of calories, they suffer immense feelings of guilt and shame and will often try to burn off calories by exercising. In fact, many students suffering with anorexia will keep themselves constantly moving and may insist on standing instead of sitting as it burns more calories, or may constantly jiggle their arms or legs or walk on the spot. Whilst we’d expect extreme weight loss to lead to lethargy, the opposite is true and people with extreme anorexia will often have the motivation and ability to exercise very hard – perhaps as a result of evolution: when humans lived a hunter-gatherer lifestyle in the past, at times when food was in short supply, we would have needed to expend more energy sourcing food before we succumbed to starvation.
Bulimia nervosa
The defining characteristic of bulimia is the binge–purge cycle (see Figure 1.1). A typical pattern is for a sufferer to consume a large quantity of food in a very short period of time. This is called bingeing. The type of food varies from person to person but is frequently very unhealthy food such as chocolates, crisps and cakes, though it can be just about anything the sufferer can lay their hands on. After the binge, the sufferer will try to remove the calories from their body. This is called purging. Purging can take many different forms: most frequently sufferers will make themselves vomit or will abuse laxatives or diuretics or compulsively exercise. Bulimia usually starts with dieting – and this is almost a ‘default’ setting, but when there is a slip in the diet, or a stressful situation arises and food is sought for comfort, this will often trigger a binge which in turn triggers a purge. Bulimia is typically quite cyclical, though the frequency of the cycle can vary from several times a day to every few weeks.
Figure 1.1: The binge–purge cycle
As only about 50 per cent of calories are generally expelled via purging, it does not tend to work as an effective weight-loss tool, but may prevent the weight gain which would otherwise result from bingeing. The result of this is that many people with bulimia maintain a roughly average weight, making the illness incredibly hard to detect. However, some bulimics will experience fluctuations in their weight, as they may gain weight during difficult periods when they are binging and purging heavily, and lose a little weight when they are binging and purging less or restricting their food intake heavily.
‘I was on a diet ever since I could remember. It never worked because I wasn’t very good at sticking to it. When I started taking laxatives I thought I’d found a magic bullet, but it didn’t work out that way as I started bingeing more and more often and on larger and larger quantities of food. It was like, now I had a way to get rid of the food, it was okay to eat it. But it wasn’t. I was miserable when I was bingeing. I was miserable when I was purging and I was miserable in between times too. It was an awful time.’
Like people with anorexia, people with bulimia tend to suffer from very low self-esteem and attach a huge importance to their shape and weight. They too tend to consider themselves too fat regardless of how fat or thin they are and they use purging in order to try and control their weight.
Binge eating disorder
Binge eating disorder, sometimes referred to as compulsive eating or emotional overeating, is a disorder typically characterized by a pattern of eating large quantities of, often unhealthy, food over a short period of time, usually within about two hours. It is very similar to bulimia, the key difference being that sufferers do not purge after binging. This is the reason why compulsive eaters tend to be overweight whereas bulimics tend to be closer to a normal weight.
Binges tend to involve consuming unhealthy food very rapidly and are associated with a feeling of loss of control. Bingeing usually happens in secret and many people suffering with binge eating will make efforts to control their diet outside of binges – so a young person who is apparently eating healthily but whose weight is increasing constantly may be secretly bingeing.
Binge eating is often dismissed simply as greed. This is not the case. Binge eating is an eating disorder and its sufferers need just as much help and support as people suffering from bulimia or anorexia.
‘I felt like I’d succumbed to the wrong eating disorder. If I’d have had the strength to starve myself then people would have cared. With every pound you lose, they care about you more. But when you’re gaining weight no one stops to think “Hey, I wonder if she’s okay,” they just think “fat cow” and walk on.’
As binge eaters consume large volumes of food but do not purge, they tend to be overweight. In some cases they will be very overweight or obese and their weight is likely to continually increase until the underlying issues are addressed. This weight gain will usually be far in excess of the usual weight gain you’d expect to see in a growing child.
When talking about their binges, binge eaters will often refer to a lack of control and a complete inability to stop themselves eating, almost as if their body is working on remote control during a binge and they can’t press the stop button. Binges tend to happen in secret with the sufferer often making attempts at a healthy diet outside of their binges in order to control their weight. A student whose weight is increasing despite apparently healthy eating habits could be secretly bingeing.
As with anorexia and bulimia, binge eaters tend to suffer from very low self-esteem, which is frequently exacerbated by the teasing, bullying and social stigma that is commonly experienced by people who are overweight. This can be a vicious cycle as sufferers’ low self-esteem will drive them to eat compulsively and the resulting weight gain will lower their self-esteem further. In most cases, they are aware there is a problem and are often desperate to address it but are completely unable to do so without help and support to address their underlying issues.
Other eating disorders
In addition to the three major eating disorders, individuals can be diagnosed with Other Specified Feeding or Eating Disorder (OSFED – formerly known as Eating Disorder Not Otherwise Specified or ‘EDNOS’). OSFED is a diagnosis that is applied to patients who do not meet the diagnostic criteria for one of the three major eating disorders, though this diagnosis is not an indication of a less severe eating disorder, but rather a different combination of symptoms. This is a relatively frequent occurrence as people with eating disorders do not always neatly fit into diagnostic categories and may suffer from symptoms or behaviours typical of more than one of the disorders without reaching the diagnostic criteria for any single disorder.
Whilst it’s important to understand the different forms eating disorders can take, I would suggest you forget about the labels and aim to support anyone who is suffering from an eating disorder or eating disorder-like tendencies – early support for someone with a subclinical eating disorder can often prevent them from developing a full-blown eating disorder.
Eating problems specific to under-11s
Children under 11 can develop a wide range of food difficulties