What causes eating disorders?

There are many theories and no one simple answer that covers everyone. For any particular person, some or all of the following factors will be woven together to produce starving, stuffing, and purging.

  • Biological factors

Temperament seems to be, at least in part, genetically determined. Some personality types (obsessive-compulsive and sensitive-avoidant, for example) are more vulnerable to eating disorders than others. New research suggests that genetic factors predispose some people to anxiety, perfectionism, and obsessive-compulsive thoughts and behaviors. These people seem to have more than their share of eating disorders. In fact, people with a mother or sister who has had anorexia nervosa are 12 times more likely than others with no family history of that disorder to develop it themselves. They are four times more likely to develop bulimia. (Eating Disorders Review. Nov/Dec 2002)

Studies reported in the New England Journal of Medicine (3/03) indicate that for some, but not all, people heredity is an important factor in the development of obesity and binge eating.

Also, once a person begins to starve, stuff, or purge, those behaviors in and of themselves can alter brain chemistry and prolong the disorder. For example, both undereating and overeating can activate brain chemicals that produce feelings of peace and euphoria, thus temporarily dispelling anxiety and depression. In fact some researchers believe that eating disordered folks may be using food to self-medicate painful feelings and distressing moods.

A note about stress and overeating: New research suggests that there is a biological link between stress and the drive to eat. Comfort foods — high in sugar, fat, and calories — seem to calm the body’s response to chronic stress. In addition, hormones produced when one is under stress encourage the formation of fat cells. In Westernized countries life tends to be competitive, fast paced, demanding, and stressful. There may be a link between so-called modern life and increasing rates of overeating, overweight, and obesity. (Study to be published in Proceedings of the National Academy of Sciences. Author is Mary Dallman, professor of physiology, University of California at San Francisco [2003].)

  • Psychological factors

People with eating disorders tend to be perfectionistic. They have unrealistic expectations of themselves and others. In spite of their many achievements, they feel inadequate, defective, and worthless. In addition, they see the world as black and white, no shades of gray. Everything is either good or bad, a success or a failure, fat or thin. If fat is bad and thin is good, then thinner is better, and thinnest is best — even if thinnest is sixty-eight pounds in a hospital bed on life support.

Some people with eating disorders use the behaviors to avoid sexuality. Others use them to try to take control of themselves and their lives. They are strong, usually winning the power struggles they find themselves in, but inside they feel weak, powerless, victimized, defeated, and resentful.

People with eating disorders often lack a sense of identity. They try to define themselves by manufacturing a socially approved and admired exterior. They have answered the existential question, “Who am I?” by symbolically saying “I am, or I am trying to be, thin. Therefore, I matter.”

People with eating disorders often are legitimately angry, but because they seek approval and fear criticism, they do not know how to express their anger in healthy ways. They turn it against themselves by starving or stuffing.

  • Family factors

Some people with eating disorders say they feel smothered in overprotective families. Others feel abandoned, misunderstood, and alone. Parents who overvalue physical appearance can unwittingly contribute to an eating disorder. So can those who make critical comments, even in jest, about their children’s bodies.

These families tend to be overprotective, rigid, and ineffective at resolving conflict. Sometimes mothers are emotionally cool while fathers are physically or emotionally absent. At the same time, there are high expectations of achievement and success. Children learn not to disclose doubts, fears, anxieties, and imperfections. Instead they try to solve their problems by manipulating weight and food.

In addition, research suggests that daughters of mothers with histories of eating disorders may be at higher risk of eating disorders themselves than are children of mothers with few food and weight issues.

According to a report published in the April 1999 issue of the International Journal of Eating Disorders, mothers who have anorexia, bulimia, or binge eating disorder handle food issues and weight concerns differently than mothers who have never had eating disorders.

Patterns are observable even in infancy. They include odd feeding schedules, using food for rewards, punishments, comfort, or other non-nutritive purposes, and concerns about their daughters’ weight.

Still to be determined is whether or not daughters of mothers with eating disorders will themselves become eating disordered when they reach adolescence.

Also, if mothers and fathers preach and nag about junk food and try to limit their children’s access to treats, the children will desire and overeat these very items. A recent study (Am J Clin Nutr 2003;78:215) indicates that when parents restrict eating, children are more likely to eat when they are not hungry. The more severe the restriction, the stronger the desire to eat prohibited foods. These behaviors may set the stage for a full blown eating disorder in the future.

  • Social factors

Sometimes appearance-obsessed friends or romantic partners create pressure that encourages eating disorders. Ditto for sorority houses, theatre troupes, dance companies, school cliques, and other situations where peers influence one another in unhealthy ways.

People vulnerable to eating disorders also, in most cases, are experiencing relationship problems, loneliness in particular. Some may be withdrawn with only superficial or conflicted connections to other people. Others may seem to be living exciting lives filled with friends and social activities, but later they will confess that they did not feel they really fit in, that no one seemed to really understand them, and that they had no true friends or confidants with whom they could share thoughts, feelings, doubts, insecurities, fears, hopes, ambitions, and so forth. Often they desperately want healthy connections to others but fear criticism and rejection if their perceived flaws and shortcomings become known.

  • Cultural pressures

In Westernized countries characterized by various forms of competition, and in pockets of affluence in developing countries, women often experience unrealistic cultural demands for thinness. They respond by linking their self-exteem, or self-disgust, to their weight.

Cultural expectations can be cruel and unrelenting. “In order for a woman to consider herself happy, she has to be in a good relationship, be happy with her kids, her friends have to like her, her job has to be going well, her house has to look really good — and she has to be thin.” (Professor Alice Domar, Harvard Medical School. Parade Magazine, October 11, 2003)

  • Media factors

Quote: Advertising has done more to cause the social unrest of the 20th century than any other single factor. –Clare Boothe Luce, American author and diplomat (1903-1987)

People in western countries are flooded by media words and images. An average U.S. child, for example, sees more than 30,000 TV commercial each year (TV-Turnoff Network, 2005). That child watches more than 21 hours of TV each week plus dozens of magazines and many movies every year. In those media, happy and successful people are almost always portrayed by actors and models who are young, toned, and thin. The vast majority are stylishly dressed and have spent much time on hair styles and makeup.

Factoid: According to Health magazine, April 2002, 32% of female TV network characters are underweight, while only 5% of females in the U.S. audience are underweight.

In contrast, evil, stupid, or buffoonish people are portrayed by actors who are older, frumpier, unkempt, perhaps physically challenged. Many are fat.

Factoid: Again according to Health magazine, only 3% of female TV network characters are obese, while 25% of U.S. women fall into that category.

Most people want to be happy and successful, states that require thought, personal development, and usually hard work. The media, especially ads and commercials for appearance-related items, suggest that we can avoid the hard character work by making our bodies into copies of the icons of success.

Reading between the lines of many ads reveals a not-so-subtle message — “You are not acceptable the way you are. The only way you can become acceptable is to buy our product and try to look like our model (who is six feet tall and wears size four jeans — and is probably anorexic). If you can’t quite manage it, better keep buying our product. It’s your only hope.”

The differences between media images of happy, successful men and women are interesting. The women, with few exceptions, are young and thin. Thin is desirable. The men are young or older, but the heroes and good guys are strong and powerful in all the areas that matter — physically, in the business world, and socially. For men in the media, thin is not desirable; power is desirable. Thin men are seen as skinny, and skinny men are often depicted as sick, weak, frail, or deviant.

These differences are reflected in male and female approaches to self-help. When a man wants to improve himself, he often begins by lifting weights to become bigger, stronger, and more powerful. When a woman want to improve herself, she usually begins with a diet, which will leave her smaller, weaker, and less powerful. Yet females have just as strong needs for power and control as do males.

Many people believe this media stereotyping helps explain why about ninety percent of people with eating disorders are women and only ten percent are men.

In recent years it has become politically correct for the media to make some effort to combat eating disorders. We have seen magazine articles and TV shows featuring the perils and heartbreak of anorexia and bulimia, but these efforts seem weak and ineffective when they are presented in the usual context. For example, how can one believe that a fashion magazine is truly motivated to combat anorexia when their articles about that subject are surrounded by advertisements featuring anorexic-looking models? How can one believe that the talk show hostess is truly in favor of strong, healthy female bodies when she frequently prods her stick-like thighs and talks about how much she wants to lose weight from her already scrawny body?

In May 1999, research was published that demonstrated the media’s unhealthy affect on women’s self-esteem and body awareness. In 1995, before television came to their island, the people of Fiji thought the ideal body was round, plump, and soft. Then, after 38 months of Melrose Place, Beverly Hills 90210, and similar western shows, Fijian teenage girls showed serious signs of eating disorders.

In another study, females who regularly watch TV three or more nights per week are fifty percent more likely than non-watchers to feel “too big” or “too fat.” About two-thirds of the TV-watching female teens dieted in the month preceding the survey. Fifteen percent admitted vomiting to control their weight. TV shows like the two mentioned above are fantasies, but all over the world young women, and some not so young, accept them as instructions on how to look and act. That’s really a shame.

An important question for people who watch TV, read magazines, and go to movies — do these media present images that open a window on the real world, or do they hold up a fun house mirror in which the reflections of real people are distorted into impossibly tall, thin sticks (or impossibly muscular, steroid-dependent male action figures)? Media consumers need to be wise consumers of visual images.

And wise consumers of verbal images too. The impact on vulnerable, insecure people cannot be calculated when they hear celebrities say things like “Whenever I watch TV and see those poor starving kids all over the world, I can’t help but cry. I mean I’d love to be skinny like that, but not with all those flies and death and stuff.” –Mariah Carey

For more information on this topic, we recommend “Remote Control Childhood? Combatting the Hazards of Media Culture,” a book by Diane Levin. In addition, parents can help their children learn to think critically by teaching them to ask the following questions about material presented through the media:

    • Who created the message?
    • For what purpose? (It’s often to sell something. Sit-coms, for example, are considered “bait” by the TV industry to attract viewers who can then be shown commercials.)
    • Does the message make me want something? Who benefits if I do want this thing and pay to get it?
    • Is the message accurate or true?
    • What lifestyles and values are presented? Which ones are omitted?
    • Who are the so-called experts? Paid actors or real people?
    • If research is cited, is it real science or just surveys and annecdotes?

For an online interactive exercise in media analysis, visit the children’s section of the Public Broadcast System’s website. The exercise is aimed at younger children, but everyone can learn from it, and parents are encouraged to work through it too.

  • Triggers

If people are vulnerable to eating disorders, sometimes all it takes to put the ball in motion is a trigger event that they do not know how to handle. A trigger could be something as seemingly innocuous as teasing or as devastating as rape or incest.

Triggers often happen at times of transition, shock, or loss where increased demands are made on people who already are unsure of their ability to meet expectations. Such triggers might include puberty starting a new school, beginning a new job, death, divorce, marriage, family problems, breakup of an important relationship, critical comments from someone important, graduation into a chaotic, competitive world, and so forth.

There is some evidence to suggest that girls who achieve sexual maturity ahead of peers, with the associated development of breasts, hips, and other physical signs of womanhood, are at increased risk of becoming eating disordered. They may wrongly interpret their new curves as “being fat” and feel uncomfortable because they no longer look like peers who still have childish bodies.

Wanting to take control and fix things, but not really knowing how, and under the influence of a culture that equates success and happiness with thinness, the person tackles her/his body instead of the problem at hand. Dieting, bingeing, purging, exercising, and other strange behaviors are not random craziness. They are heroic, but misguided and ineffective, attempts to take charge in a world that seems overwhelming.

Sometimes people such as diabetics who must pay meticulous attention to what they eat become vulnerable to eating disorders. A certain amount of obsessiveness is necessary for health, but when the fine line is crossed, healthy obsessiveness can quickly become pathological.

Perhaps the most common trigger of disordered eating is dieting. It is a bit simplistic, but nonetheless true, to say that if there were no dieting, there would be no anorexia nervosa. Neither would there be the bulimia that people create when they diet, make themselves chronically hungry, overeat in response to that hunger, and then, panicky about weight gain, vomit or otherwise purge to get rid of the calories.

Feeling guilty and perhaps horrified at what they have done, they swear to “be good.” That usually means more dieting, which leads to more hunger, and so the cycle repeats again and again. It is axiomatic in eating disorders treatment programs that the best way to avoid a binge is to never, never allow oneself to become ravenously hungry. It is far wiser to be aware of internal signals and respond to hunger cues early on by eating appropriate amounts of nourishing, healthy food.

For an excellent and detailed discussion of the dangers and disappointments of dieting, visit NEDA, our sister organization.

  • Multidimensional risk factors

A panel at the 2004 International Conference on Eating Disorders in Orlando, Florida, suggested the following spectrum of risk factors. The more any one person has, the greater the probability of developing an eating disorder.

    • High weight concerns before age 14
    • High level of perceived stress
    • Behavior problems before age 14
    • History of dieting
    • Mother diets and is concerned about appearance
    • Siblings diet and are concerned about appearance
    • Peers diet and are concerned about appearance
    • Negative self-evaluation
    • Perfectionism
    • No male friends
    • Parental control
    • Rivalry with one or more siblings
    • Competitive with siblings’ shape and/or appearance
    • Shy and/or anxious
    • Distressed by parental arguments
    • Distressed by life events occurring in the year before the illness develops
    • Critical comments from family members about weight, shape and eating
    • Teasing about weight, shape and appearance