sBMJ | Eating disorders

Eating disorders

Medical students with "disordered eating"need to be supported not judged

It is the run up to the exams, and you have just munched your way through a whole packet of chocolate biscuits while revising pharmacology. Does this mean you have an eating disorder? Well, a lot depends on what you do next. If you realise that you are nervous and bored and eating for comfort but do not worry too much about the excess calories you have just eaten, you are "normal." If you vow to get yourself into a training regimen after the exams and live only on mineral water, salads, and cottage cheese for the next month, you might be borderline normal. However, if you rush to the toilet and stick your fingers down your throat, feeling guilty and panic stricken, then you may be at risk of developing an eating disorder.

Eating disorders - anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified (EDNOS) - are bad news. They cause much mental as well as physical damage1 2 and tend to become chronic.^{3 4} Anorexia nervosa causes more deaths than any other psychiatric illness, mostly through suicide and cardiac arrhythmias,⁵ and eating disorders in general are the third most common chronic illness in young adults after asthma and obesity.⁶

Distinguishing between "normal" dieting and an eating disorder¹⁰

Denial of dieting - Dieters typically want to talk about their diet all the time
Denial of hunger and craving - Dieters usually admit when they are hungry
Covering up weight loss - Dieters want to show off their weight loss
Increased interest in food - Dieters want to stay away from preparing food, thus avoiding temptation
Needing to eat less than others - Dieters are not usually so competitive about eating less
Eating slowly - Dieters normally eat quickly
Becoming more obsessional - This is typical in people who are deliberately starving themselves. It includes food hoarding, night time eating, and aversion to eating in public

They are also difficult to diagnose and treat. People with eating disorders rarely admit that they have one, as they often feel ashamed. This means that their lives become entrenched in secrecy and deception, which makes them feel even more guilty. If this sounds vaguely familiar (such as with alcoholics and drug addicts) it is because the driving force behind these behaviours is often the same. In most cases eating disorders are not really about diet fads at all, though they might begin that way.⁷ They are often not disorders in their own right but a symptom of underlying problems.

It is usually fairly easy to spot a severely anorexic person who is seriously underweight, but what about a normal weight person with bulimia? Is it normal to consume eight days' worth of food in about two hours and then try to vomit it all up again or purge it away with laxatives? Up to 5% of the population may be bulimic,8 and many of them have had the disorder for at least four years.⁹ And then there is EDNOS. This category includes a varied group of people who clearly have disordered patterns of eating or perceptions about their size and weight but who may not meet the strict diagnostic criteria for anorexia or bulimia nervosa. It might include someone who is on a permanent diet but who occasionally snaps and binges on chocolate or someone who starves all day after a big meal the night before or who exercises excessively to burn off the extra calories. Such examples sound very familiar don't they?

Steps involved in self help guides for bulimia and binge eating^{11 12}

Monitoring - Keep a systematic record of your eating so you know precisely what has been happening
Establishing a meal plan - Decide on what pattern of eating is sensible and try to stick to it
Learning to intervene - Learn what set of circumstances cause you to binge and what you can do to prevent this from happening
Problem solving - Learn to define problems which cause you difficulty with your eating and learn to deal with them
Stop dieting - Systematically widen the range of foods you eat
Change your mind - Identify the beliefs which underlie your difficulties with eating and attempt to modify them

My point is that sometimes a strict diagnosis is only academic. Does it matter that people don't meet all the criteria for an eating disorder when they definitely have a problem with food or with their body size and shape? I therefore prefer to use the term "people who have disordered eating" rather than "people who have eating disorders."

Unfortunately many people with disordered eating are often unfairly judged. Eating disorders are wrongly thought to be the self inflicted whims of silly and selfish people, thus trivialising the serious coping mechanisms that they really are. People with an eating disorder often use it as a way of ignoring all the other problems in their lives that they don't want to deal with. Most of the time, the issue is purely about control. Because they can't control many of the things going on in their lives - studying, exams, relationships, etc - they control the only thing that they can - food. In reality, the problem is often not really about food at all (see Clare Lindsay's article, p 239).

Principles for helping people with eating disorders¹³

Treatment must address psycological factors associated with eating disorders, such as low self esteem and anxiety
Eating disorders need to be recognised as early as possible before habits are firmly established
Services should be accessible and confidential to encourage people to ask for help
Effective treatment requires active commitment. All approaches to treatment should promote autonomy, be flexible, and promote trust
In both assessment and treatment the therapist's knowledge and understanding is more important than their specific profession
Support over many years may be needed
Family and friends need support for themselves to help cope with the impact on their own lives as well as helping the person with the eating disorder

People with disordered eating are often sensitive, perfectionists, and high achievers. Is it any wonder then that medical schools seem to be full of them? In many cases the stresses of studying medicine contribute to the development of disordered eating Yet medical students with disordered eating are often told that they "should know better," thus making them feel even more guilty and ashamed. What they need is support and help.

Some general practitioners are more sympathetic than others, but student health staff are usually well clued up about eating disorders and will readily refer you to a counsellor if you are brave enough to admit that you have a problem. You might have to wait for a while, and so you might want to try a self help guide while you are waiting.

Screening questions for eating disorders¹³

If you answer yes to any of the following questions you may have an eating problem:

Do you always have to eat less than other people?
Do you have an intense interest in food and want to cook for others?
Are you always counting calories?
Are you worried about the shape of your body or your weight?
Do you like to eat alone?
Do you like to do a lot of exercise, more than your friends?
Do you like to disguise your weight by wearing bulky clothes?

More specific questions:

Do you ever make yourself sick, use laxatives or diuretics?
Do you ever binge?
Have you noticed any weaknesses in your muscles, especially when climbing the stairs?
Have you fainted or had dizzy spells?

If you are worried about your own or a fellow student's situation then don't despair. There are many organisations, individuals, and self help groups and books that can help. Such help is often not from the medical profession itself, but perhaps this is just as well. Doctors would medicalise the conditions, which are usually deeply psychological and need counselling and support rather than investigations and drugs.However, a bit more understanding and empathy wouldn't go amiss.

Rhona MacDonald, editor, studentBMJ

I did a masters degree in Public Health project on the management of eating disorders in primary care and have professionally counselled many people of all ages with disordered eating.

Help available:
The Eating Disorders Association provides telephone counselling, educational and self help material, a 10 week programme for people with bulimia, and a list of local self help groups. Its address is 103 Prince of Wales Road, Norwich NR1 1DW. Helpline: 01 613 621 414 (open 9 am to 6 30 pm weekdays). www.edauk.com

studentBMJ 2001;09:217-260 July ISSN 0966-6494

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