Extreme relationship with food, wearing layers of clothes, constantly measuring her arm with two fingers to see how far away they are from touching the tip of each other, Ellen’s behavior in the movie To the Bone may not be strange to those who have had or know someone who has suffered from anorexia.
Despite criticism it has received, the movie did manage to cast some light on the underlying issues of the eating disorder, and offers patients, their friends and family hope that this can be cured. Nonetheless it was still heartbreaking to watch, especially the beginning of the movie.
Eating disorders, including anorexia nervosa, bulimia nervosa and binge eating disorder, have affected on average 8.4% women and 2.2% men in the world, according to a 2019 study[1]. Up to 4% women have had anorexia in their life[2].
What is Anorexia Nervosa?
Anorexia nervosa is characterized by weight loss or lack of appropriate weight gain in growing children, difficulties maintaining an appropriate body weight for height, age and stature, and in many individuals, distorted body image[3].
Photo by American Psychiatric Association
DSM 5, the 2013 version of the Diagnostic and Statistical Manual of Mental Disorders, states that the diagnosis of anorexia nervosa must include all of the following criteria[4]:
- Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significant low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
- Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
- Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
DSM 5 also uses BMI to indicate the level of severity – mild (BMI>17 kg/m2), moderate (BMI=16~16.99 kg/m2), severe (BMI=15~15.99 kg/m2) and extreme (BMI<15 kg/m2).
In the movie, Ellen is a typical anorexic. She has a very skinny body. She wears layers of clothes and develops lanugo because her body can’t generate enough heat. She is obsessed with sit-ups and running up and down the stairs, especially after eating. As what they call “calorie Asperger’s”, she memorizes the calories of almost everything on the plate. Because of her difficulty in maintaining body weight, she was in and out of recovery programs.
Two subtypes of anorexia nervosa are identified – restrictive anorexia and binge-eating/purging anorexia, based on whether the patient has binge eating and/or purging behaviors[5].
Ellen is a restrictive type. She is never into purging. On the other hand, two of the house members are the binge-eating/purging type. One is her roommate, who would hide a bag of vomit under the bed. The other is a pregnant woman, who miscarried her baby due to resuming purging after the 12-week mark, thinking that it would be safe to do so.
Photo by HelpGuide
You may wonder, what is the difference between the binge-eating/purging subtype of anorexia and bulimia? It lies in patients’ BMI. Patients with anorexia subtype are typically underweight (BMI < 18.5 kg/m2), while those with bulimia tend to be normal weight or overweight (BMI >= 18.5 kg/m2)[6].
Causes of Anorexia Nervosa
Many factors are thought to contribute to the onset of anorexia nervosa. This includes biology, psychology, environment and culture.
In an article called “Rethinking Anorexia” published recently by AAAS (American Association for the Advancement of Science), researchers found that the disorder is rooted in the genes. Psychologist Cynthia Bulik and other researchers identified eight statistically significant genomic regions related to anorexia, and overlapping associations with DNA controlling BMI, lipids and other metabolic traits[7].
Image by Arek Socha from Pixabay
Anorexia nervosa is said to be typically characterized by a fear of gaining weight, but same article revealed another interesting point from the psychologist. As what she mentioned in the article, to a lot of her patients, it was never about being thin.[8]
On the other hand, To the Bone touches on other causes of the disorder.
Ellen’s family environment is complicated to begin with. Her parents have divorced. Her mom came out as a lesbian and lives with her partner in a ranch. Her father later married another woman. Ellen used to live with her mom and the partner, but then the couple couldn’t stand her self-destructiveness anymore, so Ellen went to live with her stepmom and her dad, who never showed up in the movie.
Towards the end, Ellen’s mom cradling her and feeding her from a bottle revealed the fact that her mom had postpartum depression, which possibly caused absence of bonding after Ellen was born.
All of these environmental and parental issues may have promoted and sustained Ellen’s eating disorder. To her, not eating and the obsession of sit-ups may be the only way to relieve her culpability, or “fault and blame” according to Dr. Beckham, shut down from reality where love is lacking.
How to Help Someone with Anorexia?
Whether it’s Dr. Beckham’s condemnation of fault and blame, Ellen’s mom’s attempt to resolve bonding issues, or Luke’s encouragement, they all helped in supporting Ellen’s recovery along the way.
Anorexia nervosa is a serious condition. If you or someone you know is struggling with an eating disorder, here are some eating disorder organizations that you can seek help from around the world:
The National Eating Disorders Association (NEDA), USA
Helpline: (800) 931-2237
Beating Eating Disorders (BEAT), UK
Helpline: 0808 801 0677
Helpline: 1 800 33 4673
The National Eating Disorder Information Center (NEDIC), CA
Helpline: 1-866-633-4220
Bodywhys, Ireland
Helpline: 01-2107906
Eating Disorders Association of New Zealand, New Zealand
Helpline: 0800 800 717
Eating Disorder Organizations in Other Countries
Anorexia Nervosa Statistics and Facts
- The mortality rate of anorexia nervosa is up to 10%[9], compared to 4.3% in type 2 diabetes[10], and 0.04% in opioid overdose[11].
- Lifetime prevalence for anorexia nervosa is up to 3.6% in women, and 0.3% for men[12].
- 75% of those with anorexia nervosa had early onset (before the age of 22).[13]
- While American continent has the highest average prevalence for all eating disorders (4.6%), Asia has the highest prevalence for anorexia, followed by Europe and America[14].
- Heritability of anorexia is 50% to 60%, while breast cancer is about 30%, and depression is roughly 40%[15].
- With current treatments, about 50% of anorexic adolescents recover, and another 20% to 30% are helped[16].
- 20% of people suffering from anorexia will prematurely die from eating disorder related complications, including suicide and heart problems.[17]
- Only 34.5% of people with anorexia nervosa ever seek help in the US.[18]
- Eating disorders programs are underfunded. On average less than $1 was allocated to people diagnosed with eating disorders, compared to $109 given to people diagnosed with autism and $69 to people diagnosed with Schizophrenia.[19]
- The prevalence of clinical eating disorders among female elite athletes ranges from 16% to 47%.[20]
[1] Marie Galmiche, Pierre Déchelotte, Grégory Lambert, Marie Pierre Tavolacci, “Prevalence of eating disorders over the 2000–2018 period: a systematic literature review”, The American Journal of Clinical Nutrition, Volume 109, Issue 5, May 2019, Pages 1402–1413. https://doi.org/10.1093/ajcn/nqy342.
[2] Anna Keski-Rahkonen, Linda Mustelin, “Epidemiology of eating disorders in Europe: prevalence, incidence, comorbidity, course, consequences, and risk factors”, Curr Opin Psychiatry. 2016 Nov;29(6):340-5. doi: 10.1097/YCO.0000000000000278.
[3] “Anorexia Nervosa”, National Eating Disorders Association.
[4] See 1
[5] Poterasu Mihaela, Rowland David L., Ciobanu Corina, Fica Simona, “Anorexia nervosa and reproduction: connecting brain to gonads”, Journal of Mind and Medical Sciences, 2020, Vol. 7 : Iss. 1 , Article 2. DOI: 10.22543/7674.71.P18.
[6] “Eating Disorder”, Wikipedia.
[7] See 6
[8] Jennifer Couzin-Frankel, “Rethinking Anorexia”, Science 368 (6487), 124-127, DOI: 10.1126/science.368.6487.124.
[9] Maria M. Leti , Anca L. Pop, David M. Garner , Iuliana Dobrescu, “Eating Disorders in Children and Adolescents. An Updated Review on Screening Methods”, Preprints 2020, 2020080461, doi: 10.20944/preprints202008.0461.v1.
[10] Alison K. Wright, Evangelos Kontopantelis, Richard Emsley, Iain Buchan, Naveed Sattar, Martin K. Rutter and Darren M. Ashcroft, “Life Expectancy and Cause-Specific Mortality in Type 2 Diabetes: A Population-Based Cohort Study Quantifying Relationships in Ethnic Subgroups”, Diabetes Care 2017 Mar; 40(3): 338-345. https://doi.org/10.2337/dc16-1616.
[11] “Drug Overdose”, Ohio Department of Health, January 04, 2021.
[12] See 1
[13] See 1
[14] See 1
[15] See 7
[16] See 7
[17] “Eating Disorder Statistics”, South Carolina Department of Mental Health.
[18] Jaime A. Coffino, Tomoko Udo and C.M. Grilo, “Rates of Help-seeking in U.S. Adults With Lifetime DSM-5 Eating Disorders: Prevalence Across Diagnoses and Sex and Ethnic/Racial Differences”, Mayo Clin Proc. 2019 Aug; 94(8): 1415–1426. Published online 2019 Jul 16. doi: 10.1016/j.mayocp.2019.02.030.
[19] See 7
[20] Taraneh Gharib Nazem and Kathryn E. Ackerman, “The Female Athlete Triad”, Sports Health. 2012 Jul; 4(4): 302–311. doi: 10.1177/1941738112439685.