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A recent article in People magazine stated that up to 8 million young women suffer from AN, although I believe these numbers are highly inflated. One best-selling book stated that 12 million people in the U.S. suffer from eating disorders. These estimates of prevalence in the population can be misleading and give the impression that just about anyone could be suffering from the disorder (widespread belief that AN is so common may tend to lead to rampant overdiagnosis of the disorder). However, reputable estimates of the statistical incidence of AN in the general population vary from 4 to 10 cases per year per 100,000 (which would extrapolate to between 12,000 to 30,000 new cases per year in the U.S. alone). Prevalence of AN in the general population has been estimated at between 10 and 30 per 100,000 (which would extrapolate to between 30,000 and 90,000 cases in the U.S.). Lifetime prevalence among females has been estimated at between 0.5% and 1%. You can see that it is difficult to accurately determine how many people actually suffer from the disorder. Best selling books would like you to believe that many millions of people have AN, while most scientific surveys show a much smaller number of cases. Any statisticians out there who have a better grasp on this subject, please contact us! Regardless of the estimates, many people currently suffer from the disorder. The focus of this website is not to address every form of dysfunctional eating, but rather to help those individuals who face serious health problems due to an inability to eat.
To understand how Anorexia Nervosa has become so prevalent in today's society, it is helpful to analyze what has changed in our society in the last 30 to 40 years. Has some mysterious neurotoxin been introduced into the drinking water in the last twenty years that is causing a complete personality change in these individuals? Have magazines and television had such an influence on young people that the pursuit of the supermodel body shape causes these young people to pursue thinness at all costs?
I will attempt to show that it certainly is not that simple, but that many factors have combined to unwittingly create this phenomenon. Though the following account is speculative, it is based on common sense, and sound medical and behavioral science. It also fits closely with observation. I encourage you to analyze and criticize this essay, get upset if you wish, but most of all, question your own beliefs about this disorder, and contact us with your thoughts!
Many who are adherents to the conventional wisdom on eating disorders will disagree with this account, but for many, especially parents of an anorexic child, a light will come on where their child's behavior now makes total sense to them. They will find a new compassion for their child and understand just what is going on in their mind and body. Even those who have recovered from a serious eating disorder may vehemently disagree with these views, but I hope that they will still read all the articles in this site, for I am certain some points will strike a chord with them, and maybe they will pause to consider just what was happening with their body and mind during their illness.
Multiple Factors Converge to Create Epidemic
Anorexia Nervosa was almost unheard of before the death of Karen Carpenter in 1983. Of course there were a few documented cases before that time, but Karen's death raised public awareness of this seemingly bizarre disease almost overnight. Some eating disorder researchers have studied autopsy reports from past decades and insist that anorexia nervosa has been prevalent in society for centuries, going mostly undiagnosed. This is wild speculation, since the diagnosis of anorexia nervosa involves analyzing the thoughts and beliefs of the patient (see diagnostic criteria), not simply studying an autopsy report. This of course is impossible in patients that died many years ago of complications of malnutrition. Diagnostic testing equipment was also poor or almost non-existent until recent decades, so it would be speculative at best to assume that no underlying biological disorder existed in these patients. Certainly, since physical illness can cause all the symptoms and behaviors associated with AN, it is impossible to determine if deceased anorexic patients had a mental illness.
The phenomenon that has today come to be called Anorexia Nervosa first appeared among women athletes, especially those involved in sports requiring high strength-to-weight ratio, such as distance running, gymnastics, and ballet dancing. Until the last twenty years, a very small percentage of women participated in serious competitve sports.
In the last twenty years, automation, television, computers and automobiles have had the cumulative effect of making the populace generally much more sedentary than in the past. Added to this, the proliferation of fast-food restaurants, and an explosion in the variety of processed food choices at the supermarket, made consumption of high-calorie, high-fat foods much more convenient.
An increase in crime and in automobile traffic, and the proliferation of sprawling suburbs, made the automobile the best and safest way to transport children to and from their various activities. This further contributed to a sedentary lifestyle for many.
The net result of these factors was that obesity and its associated health problems have become a widespread problem. To stem this tide of obesity and its strain on the healthcare system, public awareness campaigns were launched to inform the public of the dangers of obesity and overeating. As well, since obesity was now so difficult to avoid, status became associated with being fit and thin. Entrepenuers exploited the situation by offering all sorts of products and services to aid in losing weight.School boards encouraged students to participate more in sports, and expanded their physical education programs.
The sexual revolution and changing societal mores also made more provocative clothing socially acceptable, placing more emphasis on body shape than ever before, especially for females. Television and print media reflected the changing values by featuring actors and models that were thinner, more fit, and of course had much lower percentages of body fat than normal. The net effect in evolutionary terms of this increased focus on the body, especially the female form, was to intensify female competition for males (even though most women wouldn't recognize this phenomenon). This increased competition for males manifested itself in women wearing more makeup, more sexually provocative clothing, and of course more attention being paid to body shape and sex appeal. A rapidly rising divorce rate meant that even married women felt threatened with abandonment if they didn't conform to these new standards.
At the same time that all this was happening public awareness of world overpopulation and the development of the birth control pill made it easier for women to avoid pregnancy and to plan smaller families. Simultaneously, the women's movement was encouraging women to participate more in the workforce. The decline in population growth would result in a significant increase in the average age of the population. This older population would require more medical care, increasing the fiscal pressures on the medical system.
As if this increased fiscal pressure on the health care system were not enough, the various labor and professional groups involved in the delivery of health care became more organized, demanding increasing compensation for their services. Increased litigation and malpractice suits also drove up the costs. This again put more fiscal pressure on healthcare systems.To control costs, rationed healthcare became more and more common, especially in countries with universal medicare programs like Canada's. Even in countries with privatized healthcare like the U.S., HMO's (Health Maintenance Organizations) started to proliferate in an effort to control costs. The goal of these measures was to control spiralling costs, and this was done by limiting the services that were given. Limitations were placed on the number and type of diagnostic tests that doctors could request. Many physicians were actually given incentives to do as little testing as possible, with the short-sighted belief that this would provide a net cost saving to the insurer. Besides, due to budgetary restraints, waiting lists for many of these diagnostic tests were getting longer and longer. Since many physicians were convinced that the seemingly bizarre behaviors of Anorexia Nervosa were purely a result of a psychiatric disorder, medical testing was usually limited to blood tests to monitor electrolyte levels and detect serious complications due to malnutrition.
Now add to this mix the increased public awareness of Anorexia Nervosa after 1983. Many documentaries and talk shows focused on this mysterious illness, raising public awareness to the point that the average layperson was now aware of its devastating effects, especially on young women. Many theories were proposed speculating on its cause, and eventually the most universally accepted theory became that of it being a manifestation of an obsessive-compulsive disorder, where the individual is obsessed with losing weight, exercising and dieting even to the point of death from malnutrition. The new ideal of thinness was seen as the triggering factor.
Many books were written on the subject, mostly by psychiatrists and eating disorder counsellors. Many of these books became best-sellers, and further served to entrench in the public's mind that this was purely a psychiatric disorder that could be successfully treated through psychotherapy and nutritional counselling. Some books cited low self-esteem as the underlying cause. Others speculated poor parenting or sexual abuse may be the cause. One author coined a new term, CNC, or Confirmed Negativity Condition as the triggering factor, and insisted that unconditional love was what was missing from the patient's life. Some authors would focus on interpreting the artwork (see Art Therapy)of anorexic patients, claiming this would reveal much about the inner thoughts of the patient. Others would anthropomorphize this urge to avoid food and use terms like " the anorexic voice" or "Mr. Anor" as if this was some sort of demon or person in their subconsious mind. Others would blame the "Negative Mind" conflicting with the "Actual Mind". Interestingly, few, if any of these books would make any mention of physical illness being a common cause of appetite loss. Indeed, a quick look in the index of many of these books would reveal a total absence of any digestive disorder being discussed in the text.
Eating disorder programs began to proliferate around the world, most focusing on treating what was thought to be an obsessive-compulsive disorder. Many privately run programs were able to charge incredible sums for their refeeding and counselling programs, as desperate parents exhausted their savings, or mortgaged their houses in an effort to save their child's life. Some programs acheived moderate success, but most experienced a very high mortality, morbidity, and relapse rate. Some patients that recovered went on to become eating disorder counsellors or psychiatrists themselves, convinced their experience would help them empathize and more effectively counsel other sufferers. In a matter of a few years, a whole new industry was born to deal with this mysterious illness. As this industry grew, it developed a great deal of inertia, and despite its efforts to stem the tide of eating disorders, the epidemic just got worse.
On the home front,due to the extensive media coverage of eating disorders, parents began to immediately suspect that their child may have AN when they saw their child not eating much at mealtimes and losing weight to the point of being malnourished. In many families, mealtimes would become a time of tension and arguing as worried parents did their best to encourage their child to eat. Often their child would play strange games with their food, eating one pea at a time or pushing the food around their plate in a desperate attempt to make it look like they were actually eating. Some parents would find that their child had not been eating their school lunches, and in fact had lied about it and hid the leftovers. At this point some parents would find they could no longer trust their child to tell the truth. For many parents, this would be a devastating experience, as they never thought that their previously well-behaved child could ever tell a lie. If the child did eat their breakfast or supper, they would often disappear into the bathroom or their bedroom right after eating. If the parents found out that their child had been vomiting up meals, or secretly using laxatives, they were finally convinced their child had a full blown eating disorder. It was time to go to the doctor.
By the time mom takes her daughter or son to see the doctor, she has made an effort to educate herself as much as possible about eating disorders. If she has surfed the web, or read some of the best-selling books on the subject, she will be fully convinced that her child has either Anorexia Nervosa or Bulimia Nervosa, or both. If she hasn't had the opportunity to read up on eating disorders, she'll be amazed at how the doctor seems to uncannily know about the strange eating habits, the hiding of food and vomiting or laxative abuse, and all the exercising. Normally the doctor will weigh the child, do a quick physical examination, issue a lab requisition for bloodwork and/or urinalysis, and arrange for the patient to see a psychologist and enroll in an eating disorder program. Subsequent apointments with the doctor will be scheduled, to monitor weight and nutritional status. Unless the parents insist, little or no diagnostic testing will be performed to look for an underlying cause of anorexia, since this was obviously a conscious decision to lose weight on the child's part (over 80% of girls try some form of diet by their teen years; most are intensely aware of their weight and figure).
A crucial factor to consider here is that a small percentage of the general population will have some chronic digestive disorder that they may not realize they have. Chronic disorders usually develop gradually, so they often allow the sufferer to adapt to the condition without them knowing something might be wrong. Moodiness, irritability, mild epigastric pain, constipation, bloating, stomach aches, or food fussiness might be the only observable symptoms. Many parents often dismiss these symptoms simply as whining, attention-seeking, or manipulation by the child. I believe it is these individuals with chronic disorders who end up unable to develop an appetite suitable to their energy expenditures.
To understand how all these factors combined to create the explosion in the number of anorexia nervosa cases, it is vital to realize that AN has come to be universally accepted as a psychiatric disorder, both by psychiatrists and by most, if not all physicians. It is also crucial to be aware that young people, especially women, are dieting and exercising in numbers perhaps never before seen in the history of mankind. This dieting and exercising may be the evolutionary equivalent of a selection pressure, and we can see natural selection at work as many young people are unable to pass on their DNA to the next generation. Particularly at risk is the high-achieving young person with a digestive tract disorder, as their single-mindedness and perseverence may end up being their undoing. If their digestive tract were healthy, they probably would develop a suitable appetite for their energy expenditures and naturally acheive and maintain a healthy body mass. However, due to a poor appetite they eventually reach a stage of malnutrition where a hyperactivity starvation response develops, making their weight loss difficult to control without hospitalization and force feeding.
Because the eating disorder specialist and attending physician have made the assumption that the patient's digestive tract is in perfect working order, the behaviors and symptoms are mostly misinterpreted and misunderstood. The patient really doesn't understand what's going on in their body and mind, but the eating disorder counsellor seems to have all the answers, so eventually the patient accepts these explanations as reality. If the digestive tract disorder is causing only a mild dysfunction, cognitive behavioral therapy may be enough to tip the scales in favor of weight gain. However, if the medical condition is severe enough to cause a total inability to eat, the patient will be in extremely serious trouble, because no attempt will be made to address the medical issues, except those associated with malnutrition. Indeed, if the patient is seriously malnourished, many physicians will shy away from extensive diagnostic tests or surgical interventions until sufficient body mass is regained.
You can see that the main contributing factor in this epidemic is the belief held by the medical and psychiatric communities and by the general public that anorexia in a weight-conscious society will always have psychological origins. This belief has precipitated a "psychotherapist's free-for-all" regarding the interpretation and treatment of eating disorders. It is time to return to a sane, methodical, scientific approach to this problem, before more lives are ruined. It will not be easy. The conventional wisdom has gained so much inertia that it will likely take many years before the epidemic of anorexia nervosa is brought to an end.
New opinions are always suspected,
And usually opposed, without any
other reason but because they are
not already common.
John Locke
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