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The rise of the eating disorder and poor body image

Over one million people in the UK are affected by an eating disorder largely due to poor body image. The complex aspects of these illnesses are challenging, and the primary care nurse can play an important role in treating these patients

Vathani Navasothy
AdvDipCouns MSc BSc(Hons)DipSpPsy
Eating Disorder Specialist
Awakening Dawn Eating Disorder Counselling & Training Services

Eating disorders such as anorexia, bulimia and binge eating are very much on the rise, increasing the likelihood of primary care nurses coming into contact with patients with these disorders in everyday practice.(1) The complex and hidden aspects of these psychiatric illnesses of developed societies are challenging.
Typically an eating disorder can be defined as abnormal eating habits associated with a fear of fatness, and a high sensitivity to change in weight, shape and/or size, often accompanied by an underlying distortion in the person's perception of their body image.
Four main eating disorders exist, each with their respective subgroups:

  • Anorexia nervosa (AN) describes the condition in which the patient has a morbid fear of fatness, and thus his/her behaviour focuses on the drive for thinness through avoidance of food, especially carbohydrates, severe dieting or even starving.
  • Bulimia nervosa (BN) centres on the patient's love-hate relationship with food characterised by their frequent bingeing and adopting a compensatory behaviour such as self-induced vomiting, taking diuretics, laxatives or overly exercising in an attempt to get rid of the calories before they result in weight gain.
  • Compulsive or binge eating disorder refers to episodes of excessive and uncontrollable consumption of food in one sitting, often resulting in great weight gain.
  • The fourth disorder is termed "eating disorders not otherwise specified" (EDNOS), and includes orthorexia (fixating on healthy eating to the extreme), childhood food phobias, Prada-Willi syndrome (a rare genetic disorder characterised by excessive hunger or hyperphagia and preoccupation with food), night eating syndrome, bigorexia (also known as Adonis complex or muscle dysmorphia, this mainly affects men and is a preoccupation with muscle development) and diabulimia (an eating disorder in which people with type 1 diabetes deliberately give themselves less insulin than they need, for the purpose of weight loss).

Box 1 demonstrates the clinical features and definitions of the four eating disorders, according to the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV).(2)


Box 2 illustrates the four major subscales of psychopathology associated with eating disorders found when examining negative body image. The Eating Disorder Examination (EDE) subscales such as food restraint, eating concerns, shape concerns and weight concerns were originally devised by Cooper and Fairburn in 1989, and later modified by Fairburn and Wilson in 1993.(3)


Healthy body image
Healthy body image, the evaluation one has of one's own body, is made up of three components - affective, behavioural and cognitive aspects - which all form our self-image. The self-image (or self-concept) is a set of beliefs and images we all hold to be true about ourselves. In contrast, self-esteem is the measure of how much we like and approve of our self-image.(4) A person's self-image will usually consist of a number of factors, including beliefs about appearance, how we look to others, size estimation and an intellectual intuition.
Body image consists of unchangeable and changeable features. The three unchangeable body types, or somatotypes, are:

  • Ectomorphs: lean and angular frame with long limbs, narrow joints, low body fat and muscles with few curves.
  • Mesomorphs: strong muscularity and reasonably compact frame and no specific weight concentration anywhere in the body.
  • Endomorphs: shorter limbed, lower centre of gravity, wider hips and larger joints with higher proportion of body fat to muscle mass.

Body image is a changeable feature that is assessed using various methods focusing on negative self-beliefs, unhelpful emotions and eating habits, along with various eating disorder cognitions. For the purpose of frontline assessment in the primary care setting, nurses may find some of these useful.

Body image distortion
Body image distortion has been commonly measured using these three techniques:

  • Distorting image technique with the use of a mirror or camera.
  • Body part size estimation.
  • Silhouettes of different body sizes.
  • There are various attitude measurement tools, such as the body shape questionnaire (BSQ), designed by Cooper et al in 1987. This correlates with the total score of another test, the widely used eating attitude test (EAT), formulated by Garner and Garfinkel in 1979. Another useful tool is a body satisfaction scale (BSS) invented by Slade et al in 1991.(5)

Having a healthy body image means accepting one's fundamental frame and body type and feeling happy about the way one looks. Nurses can ascertain how flawed a patient's body image is by asking some of the following questions:

  • Do you avoid looking at yourself in mirrors?
  • Do you find it hard to accept compliments on your appearance?
  • Do you wish you looked like someone else?
  • When you meet people, do you assess them first in terms of fatness and thinness, and only then by other aspects of their appearance or personality?
  • Do you feel more at ease with other women if they are "fatter" than you?
  • Do you have a "fat" wardrobe and a "thin" wardrobe?
  • Do you tend to turn first to the diet pages in a magazine?
  • Do you diet more than once every six months?

A majority of "yes" answers to these closed questions would indicate body image disturbance and faulty weight perception. More faulty cognitions will be apparent when further open-ended questions are asked.

Size overestimation tendencies
It is important to point out that not everyone with a poor or negative body image is prone to developing or maintaining an eating disorder. A UK survey conducted in 2002 found that a staggering 90% of women were dissatisfied or disgusted with their body, yet only 56% were clinically overweight (33%) and obese (23%). The tendency to perceptually overestimate size was more critical - 90% of the surveyed female teens were currently dieting, even though only 19% of them were found to be overweight enough to justify such drastic caloric-control behaviour. In contrast only 75% of the men in the same study were dissatisfied with their health, and no specific attributes to weight was indicated. A smaller percentage (25%) of men were found to be on some form of diet.(6)
Overestimation of size can vary according to the patient's negative mood, social situations, belief that they have eaten a high-calorie food, thinking about eating forbidden foods, seeing thin women (including media images), and premenstrual conditions.

Considerations for nurses
When commencing work with patients with eating disorders, here are some key variables that nurses should be aware of:

  • Cultural ideals.
  • Gender differences.
  • Ethnic differences.
  • Age differences.

According to Garner and Garfinkel, our desired and ideal weight is constantly decreasing, while the actual weight of the world population is progressively increasing. In the last few years we have witnessed the plague of size zero (UK size 4), which is very different from the much-desired shapely look of the 1930s and 40s, or the curvaceous figures of the 1950s.(6)
Body aspirations, body image experiences, body behaviour and the importance of body image can vary depending on whether your patient is male or female, whether s/he is from a Caucasian, Afro-Caribbean, Indian or Pakistani background. For example in the Afro-Caribbean societies large women are considered sexy and fertile; while among the Asian communities curves on a woman are celebrated.(6)
It is easy to lose perspective on just how thin is "thin enough" and how fat is "too fat", when cultural ideals of beauty are very much centred on the value attached to being slim. Often slimness is associated with
self-control, elegance, social attractiveness and youth, while being fat is associated with undesirability, laziness, disorganisation, unsuccessfulness, unpopularity, and even being dirty and dishonest.(6)
Poor body image is usually thought to first appear in adolescence between the ages of 11 and 25, which is also the most prevalent age for the majority of eating disorders. Peer pressure, the power of the media and low self-esteem have contributed to this drive for thinness. Females are led to believe that being feminine means being slim and young, with big breasts and a small waist and a model body mass index (BMI) of just 18. Young girls are growing up associating being slim with being confident and in control.(6)
Similarly young males believe that being masculine means aspiring to be fit and healthy, with a V-shaped back and muscles, plenty of hair and well-endowed sexual organs. The quest for masculinity requires confidence and a sense of control achieved through being fit, but not slim.(6)
Regardless of age, body image is strongly linked to self-esteem in women, and performance in men. This partly contributes to the epidemic of body dissatisfaction among the women we see in both the clinical setting and the world outside. This deep-rooted desire to be thin stems from the desire for status and approval from "other women"; not by men as often falsely assumed.(6)
There are various methods of regaining a sense of control when it comes to poor body image, for

  • Avoidance behaviours, eg, avoiding changing rooms, buying clothes, going swimming, mirrors, going out and avoiding eating in public.
  • Safety behaviours, eg, dieting, wearing black, using corsets, weighing frequently, pinching body parts, mirror scrutiny.
  • Abusive behaviours, eg, self-harming, surgery, self-criticism, emotional eating.
  • Escape behaviours, eg, taking drugs (including alcohol and smoking) and compulsive exercising.

What predisposes people to an eating disorder?
According to Fairburn, factors influencing eating disorders include:(7)

  • Peer pressure and the media.
  • Family attitude and background.
  • Genetic factors.
  • An adverse life event such as trauma preceding onset, including history of sexual abuse.
  • History of obesity.
  • Onset of early menarche.
  • Certain personality traits such as low self-esteem, histrionic and perfectionism.

Figure 1 shows the treatment intervention model by Navasothy in 2006, when working with a patient with an eating disorder.8
A trained professional may begin by helping a patient form a compassionate picture of themselves, facilitating them to externalise cultural influences, and accept certain realities that overestimation is the norm. This involves challenging irrational thoughts, changing responses so the patient is able to tackle the feelings that lie beneath their poor body image, and fostering better coping and problem-solving abilities.
Much of this work is centred on honouring the patient's feelings, while still being able to challenge various faulty thoughts such as magnification, catastrophising, all-or-nothing thinking, negative slants to meaning, labelling, wishful thinking and so on using a cognitive behavioural therapy model.(9) Successful work will emphasise changing the patient's image of self, rather than appearance, while ultimately building their self-esteem.


Body image distortion can present itself in many complex ways, requiring health professionals to be empathetic towards the patient and her/his family. The ability to make a timely referral to a local eating disorder specialist or outpatient clinic to facilitate the assessment and correct diagnosis is therefore vital. Having information on hand about charities and organisations that specialises in eating disorders to hand will allow you to focus on providing that all important emotional support, advice, and guidance to your patient (see Resources). Taking up professional training to gain detailed knowledge, qualifications and skills could enable you to be become part of the care plan for your clients in the future.

Reader offer: free Q&A teleseminar on eating disorders
Vathani Navasothy will arrange a free one-hour teleseminar for all NiP readers. Ask your questions on eating disorders or simply listen to some useful advice.
For more information and registration go to:


  1. Beating eating disorders. Available from:
  2. American Psychiatric Association. Diagnostic and statistical manual of the american psychiatric association (DSM-IV). Washington DC: APA; 1993.
  3. Fairburn CG, Wilson GT. Binge eating - nature, assessment and treatment. London: The Guildford Press; 1993.
  4. Cleghorn P. The secret of self-esteem. London: Element Publishers; 1996.
  5. Williamson DA. Assessment of eating disorders. London: Pergamon Press; 1990.
  6. Jade D. The curse of zero. Nursing in Practice Events. 2007. Available from /article_7594
  7. Perry M. Eating disorders for the primary care team. London: Mark Allen Publishing; 2002.
  8. Navasothy V. Conquer bulimia success programme 2006. Available from:
  9. Gilbert S. Counselling for eating disorders. London: Sage; 2000.

NICE. Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. London: NICE; 2004. Available from:

Beat - Beating Eating Disorders
T: 0845 634 1414

National Centre for Eating Disorders
T: 0845 838 2040