Eating Disorders – An NHS self help guide
You may be interested in this guide if…
The written version of this guide was Highly Commended at the British Medical Association Patient Information Awards 2018.
- You feel that your eating might be causing you difficulties but you are not sure if you have an eating disorder
- You think you might have an eating disorder and want to find out more about this
- You are worried about someone who you think may have an eating disorder
- You want to know more about eating disorders
What will this guide do?
- Help you to recognise an eating disorder.
- Help you to understand the things that cause an eating disorder and the things that keep it going once it has got started.
- Describe the effects of an eating disorder.
- Help you think about whether you want to make changes.
- Describe what the next steps could be if you want to change.
What is an eating disorder?
What we eat and how we look seem to have become hugely important. The internet, television, magazines and books are full of information about healthy eating and dieting, particularly as there is growing concern about obesity in society. Yet there are also lots of adverts for fast food, snack foods and chocolate, often next to pictures of very skinny and attractive models. No wonder many people are confused about what it is okay to eat and not eat, and that lots of people feel upset that they can’t live up to these ideal images. Hardly surprising either that most women say they have been on a diet at some point in their lives. Men may also worry about their weight and size, in fact recent studies suggest around a quarter of people with eating disorders are male. On average eating disorders begin around age 16/17, although can be seen in those much younger and older.
So how do we know the difference between having a healthy interest in our weight and shape and having an eating disorder? Put simply, when worries about food, weight and shape get to the point where they are having a really negative effect on our life, this is likely to be an eating disorder. Unfortunately when someone has an eating disorder they are often the last person to see this. This guide can help you to think how you feel about food and your weight, and how this might be causing difficulties in your life. There’s lots of information in this guide, so you might want to listen to it a few times, maybe over a period of time, to help you build up a picture of how you think and feel about your eating, weight and shape.
These are some examples of the things that people with eating disorders often say:
“I know I’m six and a half stone, but if I could just lose another half a stone I’ll be happy”.
“I can’t stop thinking about food, I even dream about it”.
“Some days I’m really good, and I only have an apple all day. But then when I start to eat at night I can’t stop. Sometimes I even make myself sick. Then I promise myself that tomorrow will be different, and I’ll try much harder. But tomorrow is always the same”.
“I’m so ashamed. I’m an ugly fat pig. Eating loads of crisps, cakes and chocolate helps me forget how bad I feel for a while. Food is like my friend, it makes me feel better like nothing else can. But then afterwards I look at myself in the mirror and just cry and cry”.
Types of eating disorder
There are a range of eating disorders and symptoms. More details on these can be found in some of the resources listed in the written version of this guide. The medical names and descriptions for the three main types of eating disorder are:
- Persistent restricted eating leading to significantly low body weight compared to that expected for age, gender and physical health, often with lack of recognition of the seriousness of low body weight,
- An intense fear of becoming fat or gaining weight and/or persistent behaviours that interfere with weight gain (even though significantly low weight). These might include; bingeing, vomiting, taking laxatives and excessive exercising
- Distorted view of own body weight or shape. For example, may see self as fat when others see as thin, and self-worth often linked to this.
- Recurrent episodes of binge eating, where large amounts of food are eaten over a short time, with feelings of being out of control and unable to stop.
- Repeated use of purging behaviours to prevent weight gain from bingeing, such as self-induced vomiting, misuse of laxatives, diuretics, or other behaviours such as fasting or excessive exercise with the same aim, to compensate for the bingeing and prevent weight gain.
- The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for three months.
- Self-worth is unduly influenced by body shape and weight.
Binge Eating Disorder
- Recurrent episodes of binge eating, where large amounts of food are eaten over a short time, with feelings of being out of control and unable to stop.
- Binge eating, usually happens quickly and when not hungry, often eating to the point of feeling uncomfortably full.
- People often feel ashamed and guilty after bingeing, and due to embarrassment often eating is done in secret.
- No active purging such as making yourself sick or taking laxatives is present.
In reality many people may have symptoms that don’t exactly fit the list needed for a diagnosis of anorexia, bulimia or binge eating disorder to be made. If for example someone had all the criteria of anorexia except was not at a ‘significantly low body weight’, they could still have an eating disorder, which may be described medically as an ‘other specified feeding or eating disorder (OSFED)’.
If the symptoms present don’t fit closely enough with any of the specific eating disorders then a diagnosis of ‘unspecified feeding or eating disorder (UFED)’ may be made. OSFED or UFED account for quite a large percentage of eating disorders and can be every bit as serious as anorexia, bulimia, or binge eating disorder.
All eating disorders need to be taken seriously as they can have severe effects on our health.
How do I know if I’ve got an eating disorder?
Having listened to the medical symptoms of the most common eating disorders, you may be beginning to have an idea whether you have a problem with eating.
The following five questions are often used to assess whether someone has an eating disorder. Answer them honestly and if you answer yes to two or more it is very likely you have an eating disorder, and should seek help. If your answer to all of them is no, you may still have an eating disorder. Screening tests like this don’t always pick up every eating disorder.
Question 1 – Do you ever make yourself sick because you feel uncomfortably full?
Question 2 – Do you worry you have lost control over how much you eat?
Question 3 – Have you recently lost more than one stone in a three month period?
Question 4 – Do you believe yourself to be fat when other say you are too thin?
Question 5 – Would you say that food dominates your life?
What causes people to get an eating disorder?
There is no simple answer to this question as there can be lots of different things that make people develop an eating disorder. Eating disorders affect men and women of all ages, races and backgrounds. While eating disorders appear to be about food and weight they actually occur for a complex set of reasons. These are some of the things that, combined together, can trigger eating disorders.
‘Ideal’ images from society and the media
In western society, the ideal woman is often shown as unrealistically young, slim and physically attractive. Men are also encouraged to be muscular and slim. Camera tricks, lighting and the use of body doubles can make us think that the people on the internet, TV and in films and magazines are much more slim and perfect than they are in reality. Fashion magazines and designers often use very slim models suggesting that beauty and glamour is all about looking painfully thin. The reality is different. Few people look like these models without starving themselves but there is still a pressure to try to achieve these looks.
Prejudice about fat people
People can think that if someone is fat they must also be lazy, stupid and ugly. This is, of course, completely untrue. But it can increase people’s fear of becoming fat. Fatness has also become very linked to unhealthiness and while size can affect people’s health, it is a person’s level of fitness that is more important. People who are overweight but exercise can be much fitter and healthier than very slim people who do no exercise. In fact yo-yo dieting is bad for your health.
Low self-esteem and lack of confidence
People with eating disorders often don’t feel very good about themselves generally, and tend to focus on one small area of their life, such as weight and shape, as a way of boosting some sense of self-esteem. For example they might think that losing weight will make them feel more confident and attractive.
Perfectionism and unrealistic expectations
People with eating disorders often set themselves very high standards to achieve. These can include high standards about how much to eat, what weight to be and what shape to be. People can focus on controlling their weight as one way to try to be ‘perfect’. When these goals are not realistic they are bound to fail, and failing only makes them feel worse. Some people also have rigid rules about staying in control of their emotions and not showing how they feel. They can try to use food to deal with difficult emotions rather than talking about them.
Controlling stress, change or difficult feelings
Eating disorders often start in people’s teens and twenties when there are lots of changes in their bodies, their feelings and their sexuality. There may be many other stressors such as: facing exam or work pressure; relationship problems; losses of one sort or another; increased independence or decisions about the future. Some people find these sorts of things very difficult to cope with and an eating disorder may start as a way of managing some of these fears about change. For example, eating disorders can often block out or mask difficult emotions or negative feelings. Often people start to control food and eating because it gives them a sense of controlling something, when many other things in life feel out of control.
Upsetting events like death, divorce, bullying, rape or childhood abuse can produce overwhelming negative feelings, affect your self-esteem and make you feel as if things are out of your control. All of these things can be underlying causes of eating disorders.
Family expectations and attitudes to each other
Sometimes, if a family worries a lot about a son or daughter, and likes to be very protective, a person can grow up with the message that they will be no good at controlling their life themselves. Focusing on controlling their weight can be a way of feeling good at something.
Sometimes if a family has difficulty sorting out arguments a child may feel trapped in the middle, and they may realise that when their family is focused on worrying about the eating disorder they don’t argue as much. This might make them worried about starting to eat again.
If you have a problem with your eating think about all of the factors that have contributed to you developing an eating problem. Make a list of them to help you understand how your eating disorder developed.
What beliefs make people at risk of getting an eating disorder?
All the things described in the last section can affect the way you think about yourself and other people and your beliefs about the world. They can also affect your beliefs about food and weight. These are some examples of the sort of beliefs you might develop from these experiences:
- I need to be in control ….. (and my eating disorder give me control)
- I need to be perfect for people to love me … (and if I lose weight I’ll be perfect)
- If I’m thin I’ll be happy
- People are cruel….(and when I’m upset eating makes the bad feelings go away)
- The world is a scary place that I can’t deal with…. (at least I can control my eating)
- I am disgusting… (and if I can be thin then I’ll feel better about myself)
- I can’t cope on my own…. (and if I’m ill people can’t expect me to cope)
- I deserve to be punished…(and making myself sick is a way of doing this)
Try to think about how your beliefs have been affected by what has happened to you, and complete the next few sentences:
I am …
People are …
The world is …
My body is …
If I am thin then …
If I put on weight then …
It may be helpful to write these down.
What are the effects of eating disorders?
It is helpful to think of an eating disorder as something that both gives and takes. It is important to think about both when it comes to understanding and treating an eating disorder. As you have seen from the previous section, eating disorders don’t just come out of the blue. There are often lots of reasons why a person develops an eating disorder, but all of the reasons share something in common – they cause people to feel distressed and often out of control or unable to cope. When faced with these feelings people look for something to help them manage. Controlling ones eating can feel like it helps people to manage.
To the person with the eating disorder, the things that it can give include:
- Feeling more in control
- Compliments and positive feedback for weight loss
- Constant thoughts about food which block out other distressing thoughts
- A way of asking for help
- What seems like a solution to weight control
- Eating to take your mind off other problems
People do the best they can when things are difficult, and sometimes changing their eating pattern can help in the short term. The trouble is that once an eating disorder has developed other things come into play which create negative consequences and additional problems for the person. Some of these are outlined here.
Starve/binge cycle and changes to your metabolic rate
What does metabolic rate mean? We use up energy no matter what we do. Even when we sleep we are using some energy.
Our metabolic rate is the number of calories or amount of energy you need each day to function. It stays pretty regular (approximately 2500 calories for men, 2000 calories for women), but there are some things that cause changes to this:
- metabolic rates slow down as we get older
- dieting causes metabolic rates to slow down (after dieting for 14 days a persons metabolic rate can have dropped by up to 20%)
- exercise can increase our metabolic rates.
When you starve yourself of food, after a while it gets hard to resist eating. Some people argue that for every diet, there is an equal and opposite binge. In other words, diets or periods of starving yourself do not come for free. The cost is that they simply cause people to rebel, and when they do, they end up usually gaining more weight than they ever lost. Why is this?
Basically it is because of an in-built mechanism left over from prehistoric times, to try to reduce the risk of people dying from starvation when food was scarce. It works like this:
When you starve yourself over a period of time, by not eating at all or by following a really strict diet, your body starts to react like it would if you were stranded in the desert with no way of getting food. It slows down your metabolic rate so that the food you eat can be saved for as long as possible. It also sends messages to your brain to make you think about food a lot with the hope that this will keep food on your mind so you will find food and eat sooner rather than later.
When you do eat, your body wants to get as much food as it can, in case there is another ‘starvation’ period coming, and so your body encourages you to eat lots of food (called a binge). In case of a second period of starvation it keeps your metabolic rate on ‘slow’ so you do not burn up this food as quickly as you would normally. This can last for several months after you have stopped starving or dieting. This is what can cause people to gradually gain more and more weight following a period of dieting.
Vomiting does not get rid of all the calories eaten. After a binge many people feel guilty or disgusted with themselves, and so they make themselves sick (called purging). They think that being sick will get rid of all the food they have eaten.
Unfortunately this is not the case. Studies have shown that vomiting after a binge only gets rid of approximately 30 to 50% of all the calories eaten. So often people find they are also beginning to gain weight, despite making themselves sick. Any sense of relief is quickly replaced by feelings of loss of control, or failure. You may then promise yourself that you are going to try even harder not to eat from now on, and develop more rigid rules about what it is okay to eat and what it is not okay to eat. But the more you vomit the more your body craves food. This just brings you back to the start of the cycle, and you find yourself stuck going round and round it over and over again.
Taking laxatives and diuretics
Laxatives and diuretics don’t help people lose real weight. They work by getting rid of fluid and waste. Neither has any effect on the way calories are absorbed by the body and so they do not lead to weight reduction. While in the short term you may weigh less or have a flatter stomach, the changes are only temporary as our bodies immediately start to react against this, leading to water retention, which takes you right back to where you were. Unfortunately laxative and diuretic abuse can also cause increased bloating, constipation and potassium and sodium deficiencies which affect how well our muscles work.
Avoiding going out or doing things
When people feel low and worried about how they look, they sometimes avoid seeing their friends or doing the things they used to enjoy. This not only makes them feel worse, and keeps them from getting support, but also means that their self-esteem may get even worse as they have nothing else to feel good about except losing weight.
People with an eating disorder can spend a lot of time weighing themselves and examining their bodies. Sometimes this makes them feel better, but often it just sets them off thinking about their bodies even more, and feeling even worse. Weighing yourself more than once a week is a bad idea because it won’t give you an accurate picture of what your weight actually is. Our weight changes all the time depending on the time of the day, the time of the month, when you last ate etc.
Changes to your health
As you may have started to realise, there are lots of different ways in which an eating disorder can affect people. Changes to our eating can also, unfortunately, have some medical consequences to our bodies and health. Some of these are discussed in the next section. This list is not intended to frighten you or make you feel bad, and for that reason we have not listed all of the consequences of having an eating disorder. It is here to help you to begin to see how and what your eating disorder might be taking from you. Remember too that most of these difficulties will go away when you recover from your eating problems. However, most of these symptoms can become worse with time, so they shouldn’t be ignored.
We have listed the problems that people tell us bother them the most. Obviously not all of these things will affect you. Different eating disorders affect different people in different ways. If you are concerned or interested in learning about other problems, you will find more information in the self-help books listed at the back of the guide. Or you can speak to your GP, or a recognised eating disorder helpline (see end of guide for further information).
How eating disorders affect your body
- Dry skin, loss of skin colour, thinning or brittle hair and nails – due to nutrition deficiency.
- Tooth decay – if you make yourself sick the acid from your stomach begins to damage your teeth, increasing your chances of tooth decay. Brushing your teeth after being sick can rub the acid into your teeth even more. Instead it is better to rinse your mouth with mouthwash or water.
- Face and body are bloated or swollen – this can be due to bingeing, vomiting, laxative and/or diuretic use. Repeated vomiting can also cause the glands around your face and throat to swell, making you look fatter in the face when this is not really the case.
- Irregular or loss of periods for females, and in some cases problems getting pregnant.
How eating disorders affect the way you feel
- Depression, mood swings, anxiety and irritability
- Low self-esteem and poor body image – often people become more withdrawn
- Increased tiredness and sleep problems
- Poor concentration and memory
- Loss of sex drive
These problems can be the result of nutrition deficiency and reduced metabolic rate and will improve once your eating improves. Our electrolyte balance (these are the chemicals that are needed to make nerves and muscles work properly) is affected by repeated vomiting, and this causes many of the feelings described earlier. Once people stop vomiting this imbalance will right itself.
When someone develops an eating disorder it is because at the time it felt like it a solution to the problems or feelings that they had. It gave the person something helpful in difficult times. Unfortunately after a while eating disorders can also begin taking things from the person too.
Although it can be hard to think about these things, some of them can have serious consequences. By trying to think about these things openly and honestly it can help people to think about how to regain control over their eating again or at the very least how to minimise the potential damage that eating problems can cause.
Do I want to change this?
Thinking about change can be a difficult thing, especially if it feels like you don’t know how else to cope. It is very helpful to take some time to think about the pros and cons of change so that you can weigh up what you need to change to recover. Making a list might help you to look differently at your current situation.
In one column write all of the reasons why you might be tempted to keep your eating disorder. Then use all the information you can to list all the reasons you might want to change in the second column. Then you can use the information in the two columns to help you decide what to do next.
I don’t want to change
For some people, at some points in their life, the positives of using an eating disorder to cope with life outweigh the negatives, and they decide that they are not ready to change. If this is how you feel, remember that if you do change your mind in the future, help is available. You don’t need to keep coping in this way forever. If, at some point in the future the costs of living with an eating disorder start to outweigh the benefits, maybe you can return to this guide and work through it again. However if your weight is very low or you are vomiting frequently, it is very important that you see a doctor. Studies suggest that the sooner someone seeks help for an eating disorder the better.
I’m still not sure, I think it could be difficult
If you have worked through this guide and have started to recognise you have a problem, you might be feeling quite scared, or even trapped. On one hand you might feel that you know what the consequences of your eating disorder are, and you are worried about this. On the other hand you might feel that at least the eating disorder is familiar. You know where you stand with it. The idea of changing things may seem like a huge mountain to climb, and you might feel hopeless that things can ever be different. You might also be worrying about what people will think when you tell them about your problem, and what therapy will involve. If control has been important to you, or if you feel a lot of guilt and shame, the idea of telling someone else about your life may feel difficult. It is important to try to be understanding and kind to yourself in order to begin to work towards managing your eating problem.
Therapists working with people with eating disorders understand that the process of change can be difficult, and will work with you to put together a treatment plan that balances what suits you best and what keeps you safe, with what you can manage at that time.
Taking the step of seeking help can be hard. If the thought of going for help fills you with dread, remember that you don’t have to go back a second time unless you want to. Use the first session as a chance to find out what is on offer. You will be able to ask questions and decide whether or not you want to accept any help.
If you don’t want to seek help right now, there are also a number of very good self-help books and online packages that can offer lots of practical advice and strategies for making changes to your eating. Evidence suggests that self- help books can really help, so it is worth giving it a go. Some of these resources are listed at the back of this guide. But once again, if your eating disorder is severe, or your weight is very low, it is vitally important that you seek medical advice as soon as possible.
I want to change, what do I do next?
Taking the step of seeking help can be hard, and sometimes it takes more than one attempt to get the help you need.
A good place to start is to talk to your GP. If your problems are still in the early stages, they may be able to give you some more self-help information like this to work through. There are also the resources listed in this guide which may be a good place to start if your physical health is not too bad and you are not losing weight too quickly.
Your GP may also suggest a referral for some more specialist help. This may involve individual, family or group therapy depending on what you need. A therapist will help you to develop your understanding of your eating disorder and help you to recover.
There are also voluntary organisations specifically set up for people with eating disorders. Often these have telephone information or help lines that you can call.
Remember that wherever you go for help it’s up to you to decide whether you think the help on offer is for you. Don’t be afraid to ask questions if you are offered an ‘assessment’ appointment. This appointment is for you to assess the help on offer as much as for the person you see to understand your problems.
It is particularly urgent to seek help if your weight is very low (a BMI of 17 or lower) as there is urgent risk to your health and risk of permanent harm. If you have any thoughts of suicide please consult your GP urgently.
A list of useful contacts, books and references are available in the written version of this guide.
- Dr Lesley Maunder and Lorna Cameron, Consultant Clinical Psychologists.
- Dr Jen Murphy, Clinical Psychologist, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Many thanks to the NIWE Eating Distress Service.
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust has developed this resource with the support of NHS healthcare staff, service users and local voluntary sector groups.