You’ll slip into anorexia before you know it!
I have often been confronted with anorexia over the past year — or rather, with the word ‘anorexia’. Sometimes in the form of a concern, sometimes a reproach, sometimes even as a kind of back-handed compliment. The idea that you can accidentally slip into anorexia seems to be very widespread, as if a diet (or lifestyle change, which is what it ultimately boils down to) were a kind of anorexia banana peel, which healthy people can slip on if they’re not careful, and then be sent flying through the air in a wide arc, eventually ending up being fed through a stomach tube.
First of all, a lot of people have a very vague idea of what anorexia is that has nothing at all to do with the medical definition: Anorexia? That’s when you want to get thinner, even though you look totally fine. You get it because you want to be like the skinny models on magazine covers, and you don’t understand that they’re photoshopped …
The medical criteria for anorexia nervosa according to the official International Classification of Diseases (ICD) manual includes that the patient must have an actual body weight at least 15 per cent below the expected weight, or a body mass index of 17.5 or less (for adults). Weight loss is self-induced by avoiding high-calorie food and at least one of the following:
It’s important to realise that the criterion of low actual body weight isn’t there for nothing. Someone who is overweight or of normal weight cannot have anorexia — at most they may have a different eating disorder. Anyone whose weight is healthy, or even too high, should not be diagnosed as anorexic. This isn’t discrimination or ignorance, as I have sometimes heard from the fat acceptance movement. It’s simply logical. Perhaps this is best compared to the following situation.
Imagine a person who is extremely frugal. Rather than buying food, she fishes as much as she can out of rubbish bins and dumpsters. She steals toilet paper from supermarket lavatories, and she never turns on the heating, even in the depths of winter, and sits at home wearing two sweaters and a blanket, still freezing.
If this person is a student, with no financial support from the government or her parents, and who has to support herself as best she can with waitressing jobs, never knowing whether she’ll have enough money for food at the end of each month, we would probably say her situation was sad, but that her behaviour was understandable.
If the person in question was a bank director earning a six-digit salary, our reaction would be quite different. We would classify her behaviour as some kind of delusional disorder, since there is no objective reason for her extreme thriftiness, and she even runs the risk of causing damage to herself — what if one of her customers sees her stealing rolls of paper from a public lavatory, or fishing food out of a dumpster?
A behaviour should never be considered in isolation. It must be viewed in context, otherwise the image of it will be false. Living on 500 kcal a day for six months was a decision that made sense for me when I weighed 150 kg. If I were to do the same thing weighing 56 kg, thereby forcing my body to use up the fat reserves it needs just to survive, it wouldn’t have been a sensible decision, but a harmful one.
It’s also not anorexic for a person in the upper or middle range of a healthy BMI to want to be at the lower end of that range. A desire to lose weight must also be seen in context: for an overweight person, it’s extremely sensible, for a person of normal weight it’s perfectly okay, and for an underweight person it is harmful. There are clear medical criteria here. It doesn’t depend on anybody’s sense of proportion or what they think is normal, too thin, or attractive.
The idea that anorexia is ‘the opposite’ of being overweight, so to speak, and that overweight people can ‘slip’ very quickly into anorexia, is also a myth. For one thing, the statistics tell a very different story: while 60 per cent of people are overweight, only 0.3 per cent are anorexic. When it comes to the consequences, the difference is even more extreme. In the US, anorexia accounts for about 0.00673 per cent of deaths annually (Hewitt et al., 2001), while about 5 to 27 per cent of deaths are because of overeating and overweight (Mokdad et al., 2004; Masters et al., 2013).
While being overweight is already the norm, anorexia is an extremely rare disease. This alone makes it clear that the two phenomena are not based on the same mechanism, and a person is not equally likely to suffer from either condition. Obesity is basically caused by the fact that we follow our instinct to prepare for leaner times too much. Thousands of years of evolution have shaped us to consume as much fatty and sweet food as possible. We experience food as pleasant, rewarding, and positive. Not-eating, on the other hand, runs counter to all our physical instincts, especially when our body weight is at a low.
Although being overweight damages the body and causes illness, our instinct still tells us ‘Come on, we still need that piece of cake’, because evolution has never developed in such a way as to give the body an upper limit, and so the body never reaches the point where it automatically stops us eating, for our own good. But when it’s underweight, our body begins to struggle massively, and the hunger becomes unbearable, even if we might sometimes also experience fasting highs. Still, the body begins to focus exclusively on ‘food’, our thoughts revolve only around food, we get cravings and feel weak, and our body gives us clear signals that there is a problem. Anorexia is a permanent fight against survival instincts, so to speak.
The underlying problems that cause someone to fight against the physical will to live aren’t triggered by a few glamorous photos of skinny models.
Studies have shown, for example, that, unlike bulimia, anorexia is not culture-bound and exists independently of any social standard or ideal (Keel & Klump, 2003). Researchers also found that two-thirds of people with eating disorders reported having experienced sexual abuse in the past and still found it to be the cause of stress in the present (Oppenheimer et al., 1985).
One of my friends worked for several years in a shared-living community for young women with eating disorders and is currently a specialist for eating disorders in a counselling centre. The above findings reflect her practical experience with those women: a high percentage of her clients suffered both from eating disorders and post-traumatic stress disorder after sexual assaults, or they were from highly dysfunctional families.
The idea that anorexia can ‘just happen’, or that you can slip into it if you’re not careful, is a massive trivialisation of a very complex set of problems. As is the belief that phrases like ‘Real women have curves, only dogs like to play with bones’ might save, or even cure, women and girls affected by anorexia nervosa.
In most cases, the symptoms of anorexia do not include a perception of an extremely underweight ideal as attractive. Rather, people affected usually find a normally slender figure quite attractive in others, but their perception is severely disturbed when it comes to their own body. Although they are underweight, they see themselves as ‘fat’. For example, they acknowledge that their slim friends or caregivers have good figures, although they objectively weigh much more than the patients themselves. Treatment of anorexia, therefore, usually focuses on correcting this perceptual disorder. For example, it might include exercises in which patients try on clothes from their normal-weight environment and recognise that they are too big for them.
I recently read in a forum about a man who tricked his anorexic girlfriend into seeing her body differently. He took a photo of her flat stomach, made it anonymous so that she couldn’t recognise herself, and asked her to judge the photo. She said that the stomach in the picture was her ideal because it was so beautifully flat and not fat like her own. When her boyfriend told her that she had been looking at her own stomach, she was shocked — but then it became a wake-up call. Although the experience didn’t immediately cure her perceptual disorder, it was a first step towards being able to see her own body more objectively.
Contrary to many people’s belief, the perceptual disorder behind anorexia nervosa isn’t ‘fishing for compliments’, but rather, the affected person experiences it as enormously traumatic and sees themselves as repulsive. This perception lies outside their conscious control, and well-intentioned comments from people around them — ‘But you’re not fat!’ — are not seen as credible.
The mistaken belief that anorexia is something you choose or pursue like a trendy diet is also often fed by the media. When stars like Meghan Trainor or Jennifer Lawrence talk about how they tried anorexia, but ‘couldn’t keep it up’, the media likes to rip those comments out of context and celebrate them as fat acceptance, even though they’re really about a personal fight against the pressure placed in Hollywood on women’s bodies and their proportions. If an adult really said, ‘I’ve tried anorexia, discovered that it’s stupid, and now I’d rather accept my body as it is!’, the person concerned should have it explained to them that at most he or she took an anorexic person as a role model and deliberately tried to starve themselves down to the same weight — and that some of those ‘role models’ might be unhealthy and thin without actually suffering from anorexia. In a case like that, being convinced that extreme thinness is uncool would actually be enough to cure you of the self-made eating disorder. That doesn’t work with real anorexia.
Anorexia nervosa is not a fashion, triggered by thin models and negative attitudes to being overweight. For anorexics and those at risk from the disease, ‘interventions’ to alter those fashions and attitudes won’t affect them in any way.
Instead, anti-anorexia campaigns result in the patients who are affected actually being further split off from society, because it becomes even easier for them to distance themselves. People with anorexia are by no means incapable of thinking, and they recognise the double standards behind positive portrayals of being overweight. They’re right to say that health is obviously not the prime concern when such an unhealthy ‘ideal’ is promoted, and it makes it all the easier for them to rationalise their condition with statements like, ‘They’re not concerned about my health, they just want me to be as fat as they are.’ When you argue with extremes, an extreme stance can be justified by being better than the opposite extreme — be it overweight people who say they’d ‘rather be fat than a bag of bones’ or anorexic people who say ‘at least I’m not a disgusting fatso’. It’s much more difficult for someone to justify why a healthy middle way is worse than their own extreme path.