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What to eat and even whether to eat can be a question for many people. Although some people find the path between a slender silhouette and a tempting torte is an easy one to travel, many others feel that they are being consumed by food instead of being food consumers. For reasons both mysterious yet compelling, patterns of disordered eating can develop. These patterns are known as Anorexia Nervosa, Bulimia Nervosa and Compulsive Overeating. The following discussion will examine these three eating disorders. The causes of eating disorders vary and are not the same for everyone. By gaining greater understanding about how eating disorders develop and by addressing these concerns more directly, people can restore balance to their eating. Likewise, those who wish to be of help may be more effective in their ability to respond.

Anorexia Nervosa is a condition that occurs when a person does not maintain a healthful weight resulting in a weight that is at least 15% below normal. Such persons have an intense fear of gaining weight, regarding most foods as "fattening." They maintain a highly restrictive diet, often an intense exercise regime, and if they do eat, they typically follow that with some form of purging. They often believe themselves to be much bigger and heavier than they in fact are, therefore, they are unlikely to acknowledge that their low weight is a problem. Anorexia occurs in about 2% of the general population, but it is higher among college students, with some evidence that these numbers are rising. It typically occurs in women, although in some men as well, who are often highly educated and from sound economic backgrounds. Usually it begins in adolescence, although some do develop Anorexia in adulthood.

The physical side effects include hormone imbalances, loss of menstruation, decreased body temperature and metabolism, and a decreased heart rate, which poses the risk of mortality. Hospitalization may be necessary to return a person to normal weight. Because they steadfastly deny there is a problem, people with Anorexia usually resist help from others. Inwardly, they may feel conflicted about their eating habits, but often they are too frightened to eat since they tend to regard this as "a loss of control." Friends and family may feel concerned but exasperated since their attempts to help are usually resisted.

Many theorists believe that Anorexia arises in puberty as a response to the anxieties and responsibilities of impending womanhood (or manhood). By keeping their body size small, these adolescents can appear younger than their age and thereby may not be expected to meet adult challenges, such as caring for others or competing in the world of work. They may be seeking the continued support and attention from others at this difficult time of life. Delayed maturation can help to alleviate fears of becoming sexually active or pursuing more intimate emotional relationships. Not eating can also serve as a way to "numb" themselves to many disturbing emotions by narrowing their attention to a more simple and manageable focus on food, hunger and weight, rather than on the more complex concerns that their life may pose for them.

Some adolescents struggle with how to define themselves autonomously and whether to separate from their families. These adolescents may choose eating as the arena in which to wrestle with these questions. Denying themselves food and resisting the impulse to eat may be the only way they feel a sense of will, strength or self-determination. Likewise, not eating can also be a way to resist others. By not "giving in" to those who want them to eat, they can feel a sense of triumph against those with whom they usually comply.

For some, a small body size coincides with their ideal self-image of appearing "perfect" or of "not taking up any space" or of not having any needs or desires that might make them feel vulnerable. Therefore, in adolescence, when identify formation is first developing, a focus on body image may become a prominent way to achieve the ideal self-image they have for themselves. The achievement of their ideal in terms of appearance seems to promise satisfaction in all other domains of their lives. They may believe that due to their appearance, others will regard them as more attractive or treat them better and thereby they would have more confidence in themselves. Even if this does occur, eventually they may feel that these relationships are only "superficial" and want to be liked for "who they are" and not just for "how they look."

Many older women also have begun developing the symptoms of Anorexia. The recent cultural focus on health, exercise and thinness has encouraged many people to control their eating and weight. Some begin diets they are afraid to stop out of fear that they will regain the weight they lost. Not eating at all can seem an easier way to control their weight, without having to make decisions or think much about it. Some gain satisfaction from controlling their weight, especially if they do not feel able to control other areas of their lives. Some feel pressure at least to appear "in control," which being thin has come to imply.

In an age of material opulence, people who do not "indulge" themselves with food have become models of moral rectitude. A "toned" body, without any "flab" has come to mean that a person is strong, disciplined and not emotionally "soft." Many of these traits seem to be especially desirable among professional women who feel the need to be independent, self-reliant and not emotionally vulnerable in the workplace or in their relationships. Controlling their appearance in this manner can become a primary way to maintain an inward and outward image of perfection. Although these women appear to have these qualities, they may inwardly experience a great deal of anxiety and self-doubt, which they are afraid to let anyone know about.

Some theorists argue that the desire to be "small" but muscular may be serving as a way to satisfy recent social ideals that women express traditional masculine and feminine qualities at once. The more masculine traits of muscular strength and self-reliance may be offset by a smaller, more feminine physique that appears selfless and demure. The physical and emotional strain of maintaining the anorectic behavior lead many to conclude that Anorexia is actually controlling them, but most feel terrified or unsure how to stop it. Consequently, the anorectic girl with her wide eyes and waif-like figure may be serving as the modern woman’s "poster child." Looking out at us from countless magazine covers, she seems to be appealing to us for understanding and relief.

Anorexia can evolve into Bulimia Nervosa, but Bulimia often starts on its own.

Bulimia is described as recurrent episodes of binge eating, consuming large quantities of food in a short period of time, followed by some form of purging either by vomiting, laxatives, vigorous exercise, dieting or fasting. Sometimes "a binge" is only what the person considers to be too much food or the "wrong" kind of food, not necessarily a large quantity of food, which must be purged afterwards. There is often an extreme preoccupation with food, including planning and preparation for binges, which are usually done in secret. Some people do report bingeing and purging with friends, which seems to offer a social sanction for their behavior.

Bulimia is most often found among women, although the number of men with Bulimia is rising. Male and female athletes and dancers are especially prone to Bulimia, due to their concerns about weight and performance. In addition, an increasing number of men are focusing on body building which has led many of them to develop restrictive eating practices, intensive exercise regimes, and in some cases the use of purging for weight control, without recognizing that these are forms of eating disorders. Those who develop Bulimia vary in age, often come from sound economic backgrounds and usually have high concerns for achievement. They are usually dissatisfied with their body size, although they typically are able to maintain a normal weight. Unlike those with Anorexia, they are more likely to acknowledge to themselves that there is a problem, but often are reluctant to admit it to others.

The onset of Bulimia is often preceded by a restrictive diet, which many people find difficult to maintain because of hunger or because they feel frustrated with dieting itself. Although they may initially feel satisfied with being disciplined about their eating, they may also wish to be free of these restraints, especially if the expected rewards in other areas of their lives do not follow. Bingeing can then begin. Viewing suspension of their diet as a personal failure or fearing that resuming normal eating will lead to weight gain, some try purging as a form of weight control. This can lead to further food restrictions and so the cycle continues. The physical side effects of bulimia include dehydration, urinary tract infections, erosion of teeth and the esophagus, loss of normal metabolic and elimination capacities, and diminished electrolytes, which can cause heart trouble.

Bulimic behavior can be the way a person copes with difficult emotions or unsatisfied needs and aspirations. Some people want to let go of the stresses and strains of various responsibilities without causing havoc in their lives. Since bingeing is usually done alone, apart from the other activities of their lives, it can seem a safe way to release stress and to find satisfaction not found in their daily lives. Purging can then be done to regain control, redress any feelings of guilt and avoid any potential weight gain.

Those with Bulimia may use bingeing to alleviate loneliness, anger, boredom, disappointment or exhaustion. The food can act as a surrogate for the affection of a mother, friend or lover, and is often regarded as more reliable than a real person. Some people binge-eat after tending to the needs of others or after addressing any of their other responsibilities, especially if they find these to be exhausting or unfulfilling. So long as the eating is done alone and unselfconsciously, they may feel able to have "something for themselves" or a "reward" without feeling that they are neglecting others or being irresponsible. Therefore, they usually prefer to eat this way in private. Awareness of having eaten in this manner, however, often returns and can stimulate purging afterwards, since they usually regard this way of eating as bad or wrong.

For some, the act of purging itself helps them to relieve their stress or to release other disturbing feelings, such as anger, without the consequences of any direct confrontation of those feelings with others. Therefore, some people eat just enough to be able to purge, without actually bingeing. This is still a form of Bulimia. Bulimia can last for years, but it is usually episodic. Periods of regular eating may be punctuated by binge-purge episodes, usually triggered by stressful or disappointing events.

Some people binge without purging, which is known as Compulsive Overeating or Binge Eating Disorder. Similar to those who do purge, they often turn to food to cope with everyday stresses or to gain from food the experiences they find hard to attain in their daily lives. The relative abundance, low cost, and accessibility of most food have led it to become one of the primary ways many in our culture cope with difficulties or seek satisfaction. Advertisements and attractive packaging draw our attention to food as a convenient source of pleasure. At least here, it seems, we can "have it our way." The immediacy of the experience of eating, the directness with which it affects our bodies and minds, lead many people to turn to it for solace and support.

Eating can seem to offer comfort and replenishment, a break from the day when people do not have to think about any other responsibilities or demands from others, or simply an effortless pleasure. Without other such pleasures or ways of relaxing, eating can become a prominent part of the day. Often it can be difficult to stop eating and return to everyday concerns or pressures. The sweetness of a taste, the warmth of a food or the creaminess of a texture may seem so satisfying that a person may want to continue eating in order not to interrupt that experience. Efforts to diet may be thwarted since other forms of satisfaction do not readily replace the pleasure of eating. Eating may be the only source of "full-fillment" people have in their day. Therefore, although those who compulsively overeat may try dieting, they often find it difficult to maintain a weight loss over time, feeling frustrated as they cycle through periods of weight loss and gain.

Those who do attain a weight loss, especially if significant, may find it hard to maintain, due to some difficulties that can arise from a change in their body image. Many people are accustomed to appearing a certain way to themselves and to others. Following a weight loss they may not be sure how to interact with others or may feel frightened by new challenges or expectations that can accompany a new appearance. Some feel threatened by the potential for attracting more attention to themselves. This can be especially true for those who have experienced any kind of physical assault in the past.

Some discover that having a larger body size made them feel more secure or protected. It may have functioned as a way to keep others at a distance either physically or emotionally. Some find that a larger body size made them appear more powerful or that they were "taken more seriously," and therefore regret the loss of the weight.

Therefore, although many people can work hard to achieve a weight loss, they may find themselves gravitating back to their old, more familiar weight. Consequently, it is important to consider the psychological and interpersonal changes that can arise as a result of a weight loss and how one would cope with them. The mind and the body must be coordinate in order to be able to sustain such a change. The physical dangers of being overweight or obese include diabetes, gallstones, hypertension, heart disease and some forms of cancer.

Treatment for those with Anorexia, Bulimia and Compulsive Overeating includes individual or group therapy, nutritional guidance and medical consultation. A history of disordered eating can itself promote physiological changes that need to be addressed both medically and psychologically in order to restore balance to eating. Medical consultation is important to address the many physiological effects of eating disorders. Nutritional guidance can assist people in designing an eating plan that addresses their physical needs and changes and which takes into account their food preferences. Psychotherapy can help a person to identify the reasons for the eating disorder and offer alternative ways to cope. Participation in group therapy can be an opportunity to discuss these issues with others who share similar concerns. Family and friends can benefit from consultation about how to helpfully respond.

SUGGESTIONS FOR FRIENDS AND FAMILY

When approaching a person you think has an eating disorder:

• Consider what behavior or appearance makes you believe they have an eating disorder and bring it to their attention in a supportive manner. Keep in mind that that they may be distressed about something else which is provoking a change in their eating behavior.
  
  e.g., "I've noticed that you don't seem to be eating much lately and I'm concerned about you. I know that often when people are upset about something they lose their appetite," or "I think I've heard you vomiting in the bathroom after you've eaten and I'm concerned about it. Are you feeling okay?"
  
  If the person acknowledges the behavior but denies that there is anything wrong, suggest that sometimes when people are upset over something they tend to eat "funny" or feel sick and you are wondering whether anything else may be wrong. The point is to acknowledge the behavior and suggest that something else may be provoking it. Often people are more responsive to questions about how they are feeling rather than to judgments about how they are eating.
  
  You can then address the possibility of pursuing some counseling for their concerns; e.g. "If you are stressed about something, you may find it helpful to talk to someone about it." Offer to help them explore counseling resources, if they want. Planting the seed in someone's mind may be enough to encourage them to pursue counseling.
• Avoid taking charge of the person's eating behavior, monitoring their eating or purging, or spying on them. As their monitor, you are likely to be resented eventually, since you will seem to be more in control of them than they are. Avoid making comments or asking questions about how they have eaten that day such as, "Have you been ‘good’ today?" This can make a person feel more ashamed about their behavior and they will likely avoid talking with you about their difficulties any further. Don't search in private places for evidence of an eating disorder. An eating disorder is not "a crime." It is a way a person copes with how they feel. Instead, ask the person if there is anything else you can do to be of help.
• If you are members of the same household, do not change your eating habits to suit their difficulties. Instead let them take responsibility for purchasing whatever special foods they wish and, if necessary, preparing the food for themselves.
• If you live with someone who binges on your food, ask the person to be responsible for replenishing whatever is eaten. Acknowledge that they may not be able to stop bingeing right now, but they are still responsible for the food they eat. Don't supply them with your food.
• If you live with someone who purges and it affects the bathroom, bring it to their attention. Let them know that it is disturbing and that they need to be more careful in cleaning up afterwards.
• If you live with someone who does not eat, don't force them to eat. This only leads to further resistance on their part. Unless medically necessary, the person should be left to choose whether or not they eat bearing in mind that if they want help with their eating difficulties, you can help them pursue options for medical or psychological guidance.
• Do not focus on the person's weight or appearance especially if they bring it up. If it becomes taxing to hear their concerns, address this with them and offer to discuss other issues with them. Say it is more important to you how they think or feel rather than how they look. Avoid making such comments as, "You seem to look much better these days" or "Have you eaten yet today?" Such comments tend to reinforce the person’s sense that you are monitoring them and judging them in terms of their eating behavior and appearance and so they will continue to focus on that around you as well.
• * Avoid giving this person in the house the responsibility for buying or preparing food for others. This is to avoid having the person interact with people primarily in terms of food.
• Remember that it takes time for a person to overcome an eating disorder so be patient. The person cannot "just stop" even if you insist or plead. Focus on their accomplishments in regard to this only if they bring it up. Do not focus on their setbacks. Setbacks are part of the process of getting over the eating disorder.
• Remember that a person with an eating disorder is often moody. This is due to both the psychological and physiological consequences of eating this way. Address with the person how their moods affect you. Let them know you understand they are having a hard time but that it has an impact on others. Being aware of the effect their behavior has on others may encourage them to seek help for themselves.
• Don't interfere with a person's therapy. You may offer to help someone find a therapist or to get to one. However, therapy is a private affair. This is in order for the person to trust the therapeutic relationship. Be aware that a therapist cannot give you information regarding the client unless the client agrees. However, you are free to inform the therapist of information you think may be helpful or important regarding the person. The therapist will guide you on how best to do this.
• Remember that a person with an eating disorder often denies that there is a problem or may be reluctant to discuss it. You may never know if the person is seeking help. However, something you say may strike a person later on and they may follow up on suggestions you make. The important thing is to be patient regarding their progress. Better understanding of eating disorders can make it easier to be patient and supportive towards those you wish to help.

Special thanks to Randi Specterman, PsyD, former psychologist at the University Counseling Center, for writing this material.