Anorexia nervosa is a complex eating disorder, where people refuse to eat or severely reduce their food consumption to achieve extreme weight loss. Research suggests it is a way to try to cope with mental distress associated with a negative, distorted body self-image and fear of weight gain.

Individuals suffering from anorexia, rather than seeing food as a temptation to be avoided, are more likely to be disgusted by food and often continue to see themselves as overweight however many pounds they lose. This can have profound effects on their long-term health. In its most extreme form, anorexia weakens the heart, which loses muscle mass along with the rest of the patient’s underweight body. This is one reason anorexia is known to have the highest death rate of any mental illness. Up to 18% of people with anorexia eventually die from the condition.

Who is Most at Risk of Anorexia?

Anorexia tends to emerge in teenagers and is four-times more likely to affect women than men . One possible reason for this gender difference is societies where greater importance is attached to the outward appearance and physical attractiveness of women than for men, especially where there are also differences in the criteria associated with feminine and masculine attractiveness, for example a greater association with muscularity in men and slenderness in women.

More disturbingly, there has been a trend over the past several decades of using ever-thinner models in women’s magazines, especially in fashion, where the ideal of beauty is increasingly associated with slimness. From size zero models to airbrushed images in magazines, the messages about the value of thinness is largely directed at girls. One report suggests some other consequences of this i.e. “women have been shown to be more likely than men to report body checking behaviors (sic), such as ritualistic weighing or trying on special clothing to check for fit, or to engage in body avoidance behaviors (sic), such as not wearing form fitting clothes that would make the wearer more aware of her body shape”.

It has been suggested that anorexia is less likely in cultures where a fuller, curvier female figure has tended to be considered attractive, as in parts of Africa and Latin America and among African Americans and Latinos. This may simply reflect a lack of research into anorexia among non-White populations, although it is probably an area worth researching further.

Factors increasing the risk of Anorexia 

Suggested factors include:

• Traumatic early life experiences: Studies have shown that eating disorders (in general, not just anorexia) tend to have a higher occurrence among those who have experienced maltreatment as children, and women with eating disorders, including anorexia, have reported higher rates of sexual abuse.
  
• Parental relationships: One review suggested that “difficulties in parent-child relationships predispose women to eating disorders.”
  
• The “glorification” of thinness in society and culture: Studies have shown that a person’s attitude towards their own body and weight can be shaped by the media, peer groups and family. When this influence results in a negative self-perception, it can increase the risk of anorexia. There can be significant consequences to the “glorification of slenderness and thin people, leading to and supported by internalization of a slender… beauty ideal.” For example, if someone is raised to define themselves in terms of their weight or appearance, or grows up in an environment in which there is a preoccupation with weight, or learns to associate “irrational anxiety about body fat and gaining weight” or “prejudicial, stigmatizing beliefs about fat people,” this can put someone at risk of developing anorexia. This influence is probably greater in our social media age, which has been shown to heighten feelings of bodily dissatisfaction among teenagers through the representations and images conveyed.  Most concerning is the existence of pro-anorexia websites, which promote unhealthy, underweight ideals and images. A number of studies over the years have also pointed to a significant association with social class, with the condition particularly linked with girls from middle and upper middle class backgrounds. However, this association has been questioned and a Swedish study of 2 million males and females found a stronger association with levels of parental education than with social class.
  
• Anxious and controlling personality traits: One study suggested that anorectics tend to exhibit “perfectionism, high harm avoidance, high persistence”, while another pointed to personality traits including “high levels of social anxiety, guilt, shame, and irritability… impossible standards, experienced as internalized ‘musts’ and ‘shoulds’… [and] extreme attempts to compensate for failure.”
  

Reducing the Risk of Developing Anorexia 

There is ample literature on the treatment of anorexia once diagnosed. However, here we are focusing instead on prevention, where a number of approaches have been investigated:

• Media literacy: Researchers have found that media literacy programs are one of the most promising interventions to help prevent anorexia. These programs combat the “glorification of thinness” by helping people understand, learn and think critically about the ways in which they are affected by media and the images that it portrays.
  • The Media Smart curriculum, developed in Australia, involves a series of lessons where students examine various ads, magazines, social media posts, etc., and then work together to “rehearse ways to resist negative appearance comments, weight/shape-related teasing” and other “distorted attitudes.” A UK-based version of this program provides materials and teaching resources for young people, parents and educators.
    
  • The Body Project: This American program has been shown to be effective in reducing body dissatisfaction and unhealthy eating & dieting tendencies among women and girls. It is a “group-based intervention that provides a forum for women and girls to confront unrealistic beauty ideals and engages them in the development of healthy body image through verbal, written, and behavioural exercises.”
    
• Building coping skills and a sense of self-esteem: A comprehensive guide to the prevention of eating disorders describes a concept called “ego-oriented individual therapy” as being effective in preventing anorexia in young people. This therapy “focuses on building coping skills, developing one’s identity (i.e. beyond the pursuit of thinness) and on addressing interpersonal issues regarding physical, social, and emotional maturation.” 
• Cognitive behavioural therapy: Therapy in which people engage in “counter-attitudinal exercises that target potential risk factors for eating pathology (e.g. body dissatisfaction and internalisation of the ‘thin-ideal’)” is considered a promising intervention for the prevention of anorexia, although the long-term preventative effects of such therapies have not yet been assessed.
  
• The role of families: The role of families in preventing anorexia has not yet been studied in-depth. One review of prevention programs noted, “interestingly… [it had] failed to identify any controlled trials investigating prevention strategies involving families,” but that there could be strong potential for educating and creating awareness in parents to identify the early signs of anorexia and prevent its onset.
• School-based programmes: Eating disorders can potentially be reduced through school-based initiatives, if teachers make opportunities to disseminate appropriate messages and address issues that are impairing the quality of life of many students.
• Policy changes: Researchers have proposed that “sanctions of unrealistic body types and legislation of healthy role models [be] put into place,” most especially to limit the negative impact of pro-anorexia websites on adolescents. 

Conclusions

• Anorexia is a serious mental illness, which can lead to people starving themselves to death. 

• It is believed to be most common among white teenage girls (although more research is needed into other ethnic groups). 

• Anorexia had been particularly linked with girls from middle and upper middle class backgrounds – but this link is now being questioned. 

• It appears more common in societies where there is a glorification of thin females in the media and culture.

• Risk factors include childhood trauma (like sexual abuse); difficulties in parent-child relationships; and anxious and controlling personality traits. 

• Action to reduce the risk of anorexia is needed by families, schools, health professionals and government – including the potential of media literacy programmes and cognitive behavioural therapy.

Jennifer Jamieson, May 2018. Next review date, May 2022.