Anorexia Nervosa | Bulimia Nervosa | Binge Eating

Dieting | Exercise | Dental Care | Health Promotion | Treatment

Anorexia Nervosa

About 0.5 to 1.0% of young women develop anorexia nervosa, and it can affect women of any age. Approximately 5% of people with anorexia are male. Significant weight loss due to self-starvation characterises anorexia, often with serious medical complications. About 10% of people with anorexia may die in the long term. Underlying causes of anorexia will differ between individuals, and will be related to a combination of factors. Many of the symptoms are caused by the "Starvation Syndrome". These symptoms will affect anyone who diets for long enough, but some people, at a vulnerable time of life or who have a biological predisposition, will experience greater physical and mental changes.

These may include chemical imbalances and reduced circulation in the brain which may contribute to body image distortions, rigid and obsessive thinking, and mood disturbance. However reversing starvation alone does not 'cure' anorexia nervosa. The emotional relationship and psychological factors that contributed to the condition need to be addressed. Recovery from the effects of starvation can take a long time, even after weight is stabilised.

Physical Characteristics

• Marked weight loss
• Pallor, unhealthy look
• Skin nail and hair problems
• Sensitivity to cold
• Loss of periods in females, in pre-pubescent girls periods may never start
• Growth of fine body hair (lanugo)
• Constipation or bloating
• Insomnia

Behavioural Characteristics

• Unusually low intake of food
• Odd eating habits / unusual food rituals
• Excessive exercise or activity
• Frequent measuring of body weight
• Obsessive reading of nutritional information on food containers
• Increasing withdrawal from social activities
• Vomiting or using laxatives
• Dressing in layers to hide body shape
• Odd eating habits and strange food combinations
• Avoiding places or occasions where food might be present

Psychological Characteristics

• Insecurity about abilities, regardless of actual performance
• Depression, possible suicidal ideation
• Perfectionism and obsessiveness
• Intense fear of becoming fat even though very thin
• Difficulty concentrating
• Mood swings, irritability
• Mood and sense of self-worth affected by what is or is not eaten

Danger Signs

If someone displays any of the following symptoms, they must be medically assessed as soon as possible:

• rapid weight loss (eg 7 kg in 4 weeks)
• recent loss of greater than 10% of healthy weight
• increase in frequency of vomiting
• overexercising while very underweight
• dizziness, fainting or disorientation
• slow heart rate or chest pain
• rapidly increasing weakness
• severe muscle spasms

Bulimia Nervosa

Bulimia nervosa usually starts with restriction of food intake that leads to uncontrolled consumption of large amounts of food (bingeing). Feelings of guilt and panic can follow, leading to attempts to get rid of the food eaten. This eventually becomes a cycle of food restriction, bingeing and purging. Some studies indicate that behaviours associated with bulimia could be found in as many as 30% of adolescents. Bulimia affects 1-3% of adolescent and young adult females, and about 10 to 20% of sufferers are male.

People with bulimia can have serious problems with self-esteem, and may have clinical depression, relationship problems, health problems and difficulty with day to day life. Some people with bulimia may also have problems with substance abuse. Purging is not only found in bulimia - when associated with significant weight loss, it may indicate anorexia and this combination is very dangerous.

Physical Characteristics

• Near average weight or slightly over or underweight
• Dramatic weight fluctuations with related fluid retention
• Swollen salivary glands (puffy cheeks) and chronic hoarseness
• Forced vomiting can cause blistering, tearing and bleeding of the throat and oesophagus
• Dental decay from stomach acid (erosion of enamel, dental cavities)
• Disturbance of menstrual cycle
• Hair, nail and skin problems
• Constipation (laxative, diuretics and emetics may contribute)
• Gastro-intestinal disorders

Behavioral Characteristics

• Episodes of consuming very large amounts of food
• Restriction of food intake, possible fasting
• Purging behaviours such as abuse of laxatives or diuretics, excessive exercise, vomiting, or fasting
• Secretive behaviour (hiding binge-purge behaviours due to shame)
• Social withdrawal (isolation, spending time on food related activities)

Psychological Characteristics

• Low self-esteem, poor self-image
• An overwhelming fear of becoming fat
• Great importance attached to being slender
• Constant pre-occupation with food
• Feelings of guilt, shame and self-loathing
• Depression and possible suicidal thoughts
• Mood swings and increased irritability
• May hide symptoms successfully for years

Binge eating

Binge eating disorder, also known as compulsive overeating, is very similar to bulimia nervosa, but without the purging behaviours. This kind of eating disorder is characterised by excessive consumption of food when not feeling hungry, usually to the point of feeling overly full and often more rapidly than usual. People with binge eating disorder will often describe a feeling of loss of control over their eating during a binge, followed or preceded by feelings of guilt, shame, disgust and depressed moods.

About 30% of people treated for health problems associated with obesity have binge eating disorder, but binge eating disorder is also found in individuals at "normal" weight. Most people with this disorder developed the problem following attempts at restrictive dieting. The main associated health problems are depression and long-term risks for illnesses associated with obesity.

There are some very practical ways of helping alleviate the urge to binge, which may provide a starting point for further recovery:

• Never skip breakfast (or any other meal). Binge eaters who skip meals may find themselves bingeing later in the day - starvation is a powerful stimulus for bingeing behaviour.
• Many people advocate eating smaller more frequent meals, but the overriding principle is that nourishing your body adequately throughout the day may help prevent or reduce bingeing.
• Some people with binge eating disorder have found distraction techniques (hobbies, going for a walk, talking to someone on the phone) can help delay or even prevent a binge.
• Learn to listen to your body: relearn your internal cues for "fullness" and hunger. Support from a good nutritionist and moderate exercise can help.
• People in the obese weight range or those with cardiac or other health difficulties should always consult with their doctor before starting or changing their exercise patterns.

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Dieting

On any given day of the year, 30% of young women are on a diet. 31% of young women are underweight, and about 40% of those believe they should be thinner. Dieting has become an expected role behaviour for young women. The myths surrounding the health advantage of slimness (in fact, weight gain has been linked to longevity in females) and the increasing acceptance of an unnaturally thin body image ideal have contributed to this. A recent study in Australia found that almost half of high school girls had issues about their weight and body image that were just as intense as those of girls being treated for eating disorders.

Diets don’t actually work for most people; they cause weight gain in the long-term, with increasing loss of self esteem. Kilojoule restricting diets should not be promoted as a way to achieve health, or as a way to change body shape. A person’s heritage and lifestyle - whether they enjoy activities, have positive relationships, eat a variety of foods (including fats)- are what determines their health and their shape.

Continual use of restrictive diets as weight control is very strongly linked with health problems, regardless of the weight maintained. Weight loss is an industry worth $500 million a year in Australia alone. The people who push dieting don't have your well-being in mind - they have profit in mind and a hand in your hip-pocket. Remember: healthy lifestyle changes don't cost a cent!

Exercise

A person who seems to be exercising all the time may be displaying a symptom of an eating disorder. They may be trying to burn off calories after an episode of binge eating, or they may have an over-concern about having eaten a normal, or even below normal, amount of food.

Using exercise as a way to avoid mealtime or to curb appetite, and viewing exercise as compulsory even when ill, are also possible signs that there is a problem. Physical Education instructors and persons involved in sports activities should be very concerned about someone who works out daily, who keeps up activities even during breaks, or who continues to exercise even though looking tired and 'dragged out'.

Healthy exercise is activity which is done for fun. Exercise doesn't have to mean time spent in the gym, on the track or doing set routines. For most people those kinds of exercise are not sustainable over the long term. To get health benefits, a person only needs to be briskly active for about 30 minutes three times a week.

Dental Care

Why is it important?

Frequent vomiting will cause dental problems. Decay, erosion of the dental enamel and abrasion from grinding your teeth (bruxing) are the major causes of tooth loss. The increased acidity caused by vomiting or even untreated reflux can lead to severe erosion of the enamel surface of your teeth, especially in the upper jaw. When this enamel is eroded the softer inside part (dentine) is exposed.

There are observable signs and symptoms of dental and oral hygiene problems which occur with frequent vomiting, however some of these may only be identifiable by your dentist:

Chemical erosion of the tooth enamel (increased acidity due to vomiting);
Thermal hypersensitivity (which is when your teeth are cold or hot sensitive);
Enlargement of salivary glands;
Dryness of the mouth and decreased salivary flow;
Redness of throat and soft palate;
Reddened, dry lips, fissured at angle to lips.

So how do you look after your teeth?

Rinse immediately after vomiting with sodium bicarbonate (one teaspoon to a half glass of water - spit it out, don't swallow it!) or at the very least, plain water). Daily brushing with fluoridated toothpaste and flossing are essential - however opinions vary on whether brushing immediately after vomiting is damaging so it might be best to consult with your dentist for the latest clinical advice. Some dentists may even recommend use of fluoride mouth rinse or fluoride trays to help repair teeth. Chewing a sugar-free gum will help stimulate saliva production to neutralise acid in the mouth. In the long term, you should consider restoration of teeth with resins or crowns if erosion of tooth enamel has occurred, as the exposed inner dentine is particularly vulnerable to chemical (acid) erosion.

Tooth loss is quite complex and treatment really does need to be tailored to the individual. It goes without saying that regular dental checkups will help identify problems early before irreversible damage occurs.

Health Promotion

Eating Disorders: Health Promotion and Prevention

Introduction

The prevention of eating disorders is seen as an important goal. It is however a topic that is surrounded by considerable disagreement and often clashing opinions. Much of this is due to the fact that we still have a lot to learn about the causes and cures for eating disorders. This lack of certainty causes disagreement about the ways and means by which to prevent these serious and widespread problems. In addition, very few studies have been carried out to try and show what might be the best ways to go about trying to prevent eating disorders.

There is also such a strong need for comprehensive and effective treatment services for people affected by eating disorders that the topic of prevention tends to get overlooked, in both the attention given to it and the funding provided. This latter complication can of course at first seem counter-intuitive given the probability that if more effort were to be put into prevention there would be fewer people developing the problems and fewer people who therefore need treatment! Nevertheless, in the market driven funding environment that encompasses today's health systems, competition for resources, both human and fiscal, is a reality. Despite the false economy often inherent in this situation, it does mean that the more long term, less acute areas of need are overlooked.

The need for prevention

Regardless of the difficulties it is essential that we do take seriously the prevention of eating disorders. Particularly when we consider four important points (Slade 1995) :

1. The Size and Impact of the Problem

Even using conservative diagnostic criteria it is estimated that at least 1-2% of adolescent and young adult females in developed societies develop one or other form of serious eating disorder;
In the United States anorexia nervosa is the third most common adolescent illness; and
Bulimia nervosa has been described as a "major public health problem";
However, it is not just the size of the problem that is important but also its impact. An eating disorder causes long-term distress not only to the sufferer but also to her or his family, friends, employers and others;
In addition it disrupts every aspect of the sufferer's life (personal, emotional, social, sexual, occupational, etc.) and that of the close family and friends. Such distress and disruption usually persist for years rather than months.

2. Treatability and Outcome

Treatment for eating disorders is often extremely difficult in the short term and the chance of relapse is high;
While medium-term follow-up studies (up to 10 years) generally reveal a 5-10% mortality rate, 20-year follow-up studies are now revealing a much higher mortality rate of around 20%;
Moreover, specialist clinicians are now very familiar with The phenomenon of the "chronic, stuck, untreatable patient with a high mortality risk".

3. Irreversible Physical Consequences

For both anorexia nervosa and bulimia nervosa the physical complications are numerous during the illness, but surprisingly limited for those who recover. Physical complications include cardiac disorders, kidney disorders, gastro-intestinal disorders and psychological disorders. Among the more persisting physical consequences are dental tooth wear and osteoporosis.

4. Implications for Reproduction and Childbearing

In anorexia nervosa, markedly reduced fertility rates have been found in long-term follow-up studies. Moreover, when they do conceive, women with anorexia are likely to give birth to low-weight babies, with the consequent complications;
In bulimia nervosa, various obstetric complications have been reported, including an increased risk of miscarriage and an increased risk of foetal abnormality;
There is some evidence that mothers who have an eating disorder may have special problems in feeding their children properly and in nurturing their offspring appropriately.

Clearly these are problems of extreme importance for society as a whole. We must therefore look carefully at all possible ways of preventing or minimising these pernicious disorders.

So, what do we do?

The practice of prevention, as well as the theoretical positions taken in this area, have lead to considerable discussion of the topic in the eating disorder literature. Early opinion suggested that not enough was known about the causes of eating disorder to enable effective attempts at prevention. The emphasis was on the necessity of knowing all the links in the aetiological chain before taking action to interrupt the development of the disorder.

Those that have proceeded down the path of prevention in other countries have usually chosen one of two ways: either via broad, population-based programs as seen in northern America, or more targeted, secondary attempts as in the UK.

More recently however, this view has been challenged. Many practitioners in the field have asked the question, 'Do we have to be able to answer all the why questions before we decide what we need to do in relation to these devastating problems?' In addition, with the rise of the relatively new discipline of health promotion, a subtle but significant shift in the debate can be detected. The discussion now often includes not only the question of prevention of disease, but also a focus on the maintenance of health to begin with. This more 'up stream' approach insists on the consideration of the relative influence of the individual, group and community factors that maintain health and well-being and not just answering the question as to which factors increase the risk of disorder.

The result is increasing awareness and understanding of more broadly-based influences that contribute to the development of eating disorders, as well as the identification of protective factors such as good self esteem, enhanced resilience in children, improved coping strategies, and more critical consumption of the images from popular culture. This has meant a change in role for health and education professionals who are committed to reducing the prevalence of disorders such as anorexia nervosa and bulimia nervosa in the community. Previously primary and secondary prevention was the domain of those in primary health care, and tertiary prevention was limited to specialist treatment settings. The activities of health promotion, however, have become everyone's business.

Why a health promotion focus?

Technical advances in the medical field often receive the most publicity when health is covered in the media. Yet it is advances in prevention and improvements in lifestyle that have produced the biggest effects in population health. The major health improvements to have occurred this decade are not medical treatments, but health promotion efforts, for example, changes in tobacco use, improvements in blood pressure control, and the expansion of safety measures such as seat belts (Australian Consumer's Association 1996).

What exactly is health promotion?

Notwithstanding the World Health Organisation's description of health promotion as "the process of enabling people to increase control over and to improve their health" there is no single definition of health promotion that encompasses all the activities undertaken in this area. For some, health promotion remains closely related to disease prevention. For others, it is about the "big stuff" of unhealthy social practices and conditions such as pollution, and power inequalities. Practice in health promotion usually involves five basic tenets:

developing individual skills;
creating supportive environments;
strengthening community action;
reorienting health services; and
building healthy public policy.

This reflects the belief that individual health status is affected by a number of interrelated factors, often referred to as the 'determinants of health' which include: genetic/biological make-up; the environment in which people live; social and cultural attitudes; economic and political circumstances; and the availability and use of health services. Health promotion offers a systematic approach to influencing these determinants to improve health.

From a health promotion perspective, health is therefore defined in the broadest of terms. It is not the objective of living, but rather a resource for everyday life. Implicit in this definition is the notion that the health status of individuals goes beyond illness and that it is possible to enable individuals and communities to affect change in their current health status.

Prevention, in comparison, is usually described as three different activities: 1. Primary prevention refers to measures taken before illness begins and which is aimed at decreasing the incidence of illness, for example, rubella immunisation; 2. Secondary prevention is concerned with limiting disease by early disease detection and focuses on decreasing the duration of the disorder through early diagnosis and effective treatment, for example, screening for cervical cancer; and 3. Tertiary prevention refers to attempts to stop deterioration and is aimed at decreasing the impairment that may result from an established disorder, for example, rehabilitation programs for osteoarthritis.

In the field of eating disorders, the pathogenic orientation of preventive efforts to date has meant a focus on diagnostic categories and concentration on minimising presumed risk factors. Work therefore is done with high-risk-for-eating disorder-persons, that is, young women or dieters. This is primary prevention. General practitioners and mental health services work on secondary prevention via attempts at early identification and intervention. Attempts to limit the effects or stop an eating disorder from progressing to a chronic stage, for example, specialist eating disorder centres running inpatient or day patient programs and specialist outpatient services, are engaged in tertiary prevention, usually referred to as treatment.

People engaged in health promotion may do any of these things but might also, or exclusively, work with a 'community' of people for example, in schools, gyms, and with the media, fashion and advertising industries, or with the general community in a given locality.

The community organisation principles in health promotion emphasise the process by which community social forces influence individual behaviour, that is, how behaviour is formed and influenced by the dominant culture. In the field of eating disorders there is believed to exist a "significant cultural determination" in the development of body image dissatisfaction, dietary restriction, and other unhealthy weight control behaviours that characterise problems such as anorexia nervosa and bulimia nervosa.

Recognising this and promoting healthy long-term eating habits, active living and self (size) acceptance, as well as highlighting the dangers of inappropriate weight reduction dieting, identifying the pressures on people to conform to a certain 'ideal', and encouraging the acceptance of a diverse range of body shapes and sizes are all examples of health promotion.

Health promotion and eating disorders

The activities of health promotion can be clearly seen in the changes that have occurred in other health priority areas such as smoking, sun safety and drug and alcohol use. In these areas public policy activists have used creative epidemiology to capture the attention and achieve a high level of success in shifting public opinion and beliefs regarding the effects of these behaviours. The norms for cigarette smoking have changed dramatically in the past 20 years. This is a result of both individual, community and policy initiatives including warning labels on packs, advertising restriction, product liability suits, and increased health information. It may be possible to change the norms about dieting and thinness with many of the same measures. To this end, health promotion offers a range of strategies:

Develop healthy public policy - Use the advertising and broadcasting standards to challenge sex role stereotyping. Support the development of national guidelines for physical activity in order to clarify what are appropriate types and amounts of activity for the general population to maintain health and well being. Advocate for consumer rights legislation and codes of practice for weight loss industry, as well as uniform competency standards for the fitness industry.
Create supportive environments - Ensure that positive role models are provided in all health and educational materials. Supply nutritional information for consumers to make healthy food choices at the point of selection such as supermarkets and tuck shops. Encourage parents to allow their children to respond to their own appetites. Support physical activity for enjoyment and other health benefits and not merely for affecting appearance. Advocate for more affordable and accessible recreation facilities for families and individuals.
Strengthen community action - Enhance access to information, learning opportunities and funding support for education about body image and eating behaviours. Endorse self help and consumer support mechanisms in relation to body image and weight control problems. Apply the principles of community development to strengthen consumer and community involvement in programs and services for eating disorders.
Develop personal skills - Ensure that consumers are informed to make choices conducive to health. Enable the provision of assistance for people preparing for different life stages. Facilitate the deconstruction of media stereotypes to enhance the development of individual resilience to restrictive body beautiful ideas. Advocate for resources for further education and skill development in schools and the community. Discuss the importance of maintaining weight within a healthy range, highlight the dangers of inappropriate weight reduction dieting, identify the cultural pressures on people to confirm to a certain 'ideal' and promote healthy long-term eating patterns, active living and self acceptance. Promote the development of protective factors, such as good self-esteem within ourselves and others, and work to enhance resilience to body image lore, especially in children. Develop effective stress management and alternative coping strategies, and practice and advocate for more critical deconstruction of stereotypical images of appearance.
Reorient health services - Advocate for the health sector to move beyond responsibility for providing clinical and curative service and towards the promotion of health; for the range of treatment, rehabilitation and support options available to people with eating disorders and their families to be expanded; for the development of 'best practice' models and accepted standards of quality of care that incorporate a preventative focus; and for changes in professional education and training.

Health promotion in practice

It has been argued that primary care practitioners, such as GPs and school health workers, are ideally placed in the health-care system to provide preventative care but that considerable barriers exist for realising this health promotion potential in practice . As noted, preventative actions with demonstrated effectiveness in decreasing morbidity and mortality have been developed for two of the most prominent contributory factors to the current ill health, tobacco use and alcohol consumption. However, diet and activity patterns, strongly linked to cardiovascular disease and obesity, seemed to have changed far less. Given the high rates of CVD, the well documented failure of traditional treatment strategies for obesity, and the evidence that populations in the west are getting fatter (despite decreases in energy intakes especially amongst children), work in this area is becoming increasingly important. There is also evidence that the desire towards thinness is intensifying. The unsurprising result is that many people currently feel too fat and are dieting to control their weight - a task made harder by their increasing affluence which normally results in an increase in body weight.

Is body image dissatisfaction a risk factor for eating disorders? Maybe not, as some males show body image dissatisfaction too. Rather it seems that it is the actual behaviour chosen to express the dissatisfaction, ie dieting, that increases the risk of developing an eating disorder. Psychological, behavioural and biological pathways have been investigated by researchers questioning this link between dieting and eating disorders. There is now considerable evidence that a period of weight-reduction dieting is a major risk factor for the development of eating disorders; severe dieting has being associated with an eight fold increase in the probability of later eating disorders developing in adolescent females.

The potential for health and education professionals to impact on the number of people practising dieting, a possibly modifiable risk factor for eating disorders, has only begun to be recognised. 69 per cent of Australian women are known to visit their general practitioner in a six-month period and 80 per cent of all adults do so annually . The effectiveness of health promotion strategies in primary care settings such as GP surgeries and schools is supported by a range of empirical evidence from other areas. For example, smoking cessation programmes designed for implementation within the primary care consultation have demonstrated effectiveness, and research into early intervention for harmful alcohol consumption has also shown good results. Other, more informal, 'opportunistic' strategies for health promotion and disease prevention (such as cervical cancer testing) have also been shown to work well in primary care.

It should be recognised however that there are substantial barriers to health and education professionals increasing their role in health promotion activities. The 10.5 minute length of the average Australian GP consultation and the ever increasing content of the school curriculum need to be considered. There may also be a sense of low self-efficacy in relation to difficulties associated with lack of health promotion knowledge and skills in prevention.

In relation to eating disorders this may not be an uncommon, or unfounded, perception among health workers. A study in the UK found family doctors have a low index of suspicion for eating disorders and had difficulty recognising possible eating disorder in patients, even those with marked symptoms . When reported, the wish to diet was often taken at face value, despite the normal weight of the person. The failure to link such non-specific symptoms with the possibility of eating disturbance or body image dissatisfaction may indicate that doctors see such requests in light of a broader cultural expectation that women, of any weight, will be concerned with weight loss.
The opportunity to intervene in a preventative manner is therefore lost.

We can not afford for this to remain the case however. Community workers, counsellors, dieticians, general practitioners, guidance officers, mental health professionals, nurses, psychiatrists, psychologists, social workers, teachers and all others in the health and education fields must become more aware of the damaging effects of body image dissatisfaction and the resultant body changing behaviours. Strict dieting, steroid abuse, cigarette smoking, vomiting and so on are all potentially dangerous activities. Their prevalence in young people especially means that our efforts at prevention, and the energy we put into health promotion, need to be unrelenting. As Richard Tinning has written, perhaps for some sectors ignorance is a legitimate excuse but the silence of those not ignorant is morally far more reprehensible. It is difficult to accurately determine the reasons we are silent about the social forces that promote thinness, however, it is equally clear that our professions should speak out loudly against the negative manifestations of the cult of slenderness. To remain mute is to implicitly support such practices and is tantamount to being a morally bankrupt profession, a profession without a social conscience.

Treatment

Although there is some disagreement about what kind of treatment works best for eating disorders, there is fairly widespread agreement on some issues:

Treatment should ideally have multi-disciplinary input, be available in different settings and different intensities i.e. community support, day programs, outpatient, partial hospitalisation, residential, in-patient. Experts are needed to work in specialist units that provide care for people with the most complicated illnesses, and to consult with and support professionals who are providing support and care in generalist services. Systems of care which are comprehensive enough to encompass these options actually cost less than systems which are inadequate, due to higher rates of relapse, more use of expensive hospital beds, more complications and more chronic disorders that result from inadequate systems of care, such as the system in Queensland. Comprehensive systems of care result in much higher rates of recovery and much lower rates of morbidity and death.
Treatment should be tailored to an individual, based on a thorough assessment of their developmental stage, the factors contributing to their illness, the stage of their illness, and their physical state. Use of different approaches at different times for the same individual is often necessary.
Effective treatment for eating disorders deals with symptoms (bio-psycho-social, including food and weight beliefs and behaviours) specific to eating disorders, as well as dealing with underlying issues. To leave out either aspect of treatment is to reduce the effectiveness of the treatment and decrease the chance for recovery, although at different times one issue may need more attention than others.
Eating disorders cause changes in thinking and erode self esteem, and the effects of starvation/erratic eating can change brain/body chemistry in a way that effects thought and emotion; if not dealt with specifically these things can cause problems even when other issues are dealt with. Conversely, dealing only with the eating disorder, and not addressing underlying issues, also leaves a person vulnerable to relapse.
The therapeutic relationship is of utmost importance in the treatment of eating disorders, at all levels. An alliance based on honesty and trust must be established. Wherever possible, (except in regard to self-starvation and endangerment) the person with the eating disorder must be allowed some choices and control of decisions about treatment.

Weight Gain Programs for Anorexia Nervosa in the Starvation Stage

The Eating Disorders Association objects to the use of restrictive operant behaviour modification programmes for the treatment of Anorexia Nervosa in the starvation stage, except in exceptional circumstances in which there is good reason to believe that it might work where other methods have failed. Queensland Health via the Eating Disorders Outreach Service have developed policies and treatment guides that do not advise the use of restrictive operant behaviour modification programmes, in line with current practices. If you become aware of these practices, please alert the Health Complaints Commission.

This type of programme seriously infringes on the human rights and dignity of the person in the programme. Their personal property is removed, they are not allowed to wear their own clothes, to engage in any activity they enjoy, to have contact with anyone significant to them, even to use a toilet. Deprivation of liberty is a serious matter.
If this type of programme was necessary, it could be accepted, but it has been known in some settings for over 20 years that it is usually not necessary. Informed practitioners have not been using this type of programme as a preferred treatment for over 10 years, even in Queensland. Research has shown that the only part of the programme which motivates most persons to gain weight is that leave/discharge from hospital is contingent on weight gain. The rest of the programme is inhumane and unnecessary. Those who still use it as a first line, standard treatment are not using informed practice.
The use of restrictive behaviour modification to treat people in the starvation stages of Anorexia Nervosa goes against a basic principle of behaviour modification theory - it doesn't work on people who have an altered mental state or psychotic state of mind. People who are in the starvation stage of anorexia hold beliefs which are delusional in intensity and have obsessive compulsive thoughts and behaviours; their mood and thought processes are significantly altered by chemical imbalances and changes in circulation in the brain.
A restrictive behaviour modification programme reinforces the pathological aspects of anorexia nervosa; increases focus on weight and food; increases conflict between carers and the person with the disorder; exacerbates depression; further undermines self-esteem and reinforces feelings of worthlessness; sabotages the building of trust and rapport and makes the treatment process into a daily contest to see if the person with the disorder can outwit the treatment team.
All of these factors contribute to the difficulty of helping someone with an eating disorder, and to the reluctance that many health professionals have towards getting involved in their treatment.
Many people have spent months on these programmes without getting anywhere, doing great damage to their relationships, their self-esteem and their long-term chances of recovery.
With an illness like Anorexia Nervosa, which affects so many people, for which treatment is very difficult, and which has a relatively high fatality rate when inadequately treated, we can't afford to be using outdated treatments with harmful side effects.
Most people with anorexia will respond better to treatment programs in which trust is fostered, support is given at meal times, anxiety is managed professionally and with empathy, and aspects of the program are negotiated. Weight gain is expected and reinforced, and limits are placed on inappropriate behaviour, but this should be managed in a way that is respectful of the person being treated.

Cognitive Behavioural Therapy (CBT) and Eating Disorders - a brief explanation

Many therapists working with people who have eating disorders use CBT. This therapy is based on the premise that thoughts influence feelings. For instance, if someone you know walks past and does not acknowledge you, then you might think 'they don't like me'. That would probably make you feel hurt and sad. On the other hand, if you thought 'they are on another planet, I wonder what's going on?', then you would feel differently. Learning to recognise negative thinking and how it affects you is part of CBT.

Understanding how the feelings are linked to parts of eating disorder cycles, and how the links can eventually be broken, is also part of CBT.

A therapist using CBT works with his or her client in collaboration; it should be a co-operative relationship rather than an authoritarian relationship. Both parties learn about the client's thoughts and feelings through an exploratory process.

The therapist uses his or her experience and knowledge to guide the client in this exploration, but the client is the 'scientist' who is trying out different ideas and developing an understanding of self. As the 'scientist', the client experiments with different ways to develop positive ways of thinking, or ways to decrease the effects of negative thoughts.

Diaries are used as a tool for discovering the links between parts of an eating disorder cycle and events/thoughts/feelings that act as triggers. These events/thoughts/feelings are discussed and the client experiments with different ways of dealing with them. With the therapist's support, the client builds skills and knowledge that help to deal with many different issues, so that the client is in control instead of the eating disorder.

The client and the therapist work together to set goals and agendas for each session, and give each other feedback at all stages of the process.

EATING DISORDERS ASSOCIATION Queensland