How did this all begin?’ I ask. The young woman sits in front of me, quietly crying. She is painfully thin, her cheekbones jutting out and I can see her clavicles poking through her sweater. Her skin is dry and her hair is starting to fall out because she is so malnourished.
‘Well, I started dieting after seeing posts on social media,’ she begins. For a doctor working in eating disorders, as I have done for the past ten years, this is a fairly standard response. I see the dark underbelly of social media every day. I see the negative consequences of a world increasingly dominated by thoughtless posts, malicious messages and hidden agendas.
The rise of social media appears to have led to a corresponding rise in eating disorders and body image issues. According to a major NHS study published this week, the number of people with eating disorders has doubled over the past ten years. One in six adults in England could have an eating disorder, with figures rising to a quarter of women aged 16 to 24.
One in six is a staggering statistic, but there’s an important clarification to make here: this is a survey and therefore based on self-reported symptoms in response to a questionnaire. Those surveyed haven’t been formally diagnosed with an eating disorder. Poor body image, while often distressing, is not in itself a mental illness. There’s always a risk with research like this that general body dissatisfaction becomes medicalised and people are wrongly put in the same category as those with a diagnosable eating disorder.
Dr Max Pemberton (pictured) has been helping deal with patients who have eating disorders for the last ten years
That’s not to downplay the severity of the findings, but rather to question whether there really has been such a dramatic increase in new cases, or if something else is going on.
There is some evidence that, as there has been more awareness of mental health conditions such as eating disorders, more people are seeking help.
For years, people with eating disorders suffered in silence. They were too ashamed to find help and if they did, they were often dismissed by ignorant doctors as being shallow, vain or not seriously unwell. But in the past few years I’ve noticed more and more doctors recognising eating issues as a mental illness and making the necessary referrals.
I see the dark underbelly of social media every day
Undoubtedly this will save lives — eating disorders have the highest mortality rate of any mental illness, with one in five patients dying as a result of their eating disorder. The risk of death dramatically reduces if patients receive prompt treatment.
Social media certainly plays a role. The accessibility of smartphones means most of us — and particularly the tech-savvy young — now have constant access to a camera, and one linked to the internet. This has fuelled the development of an increasingly visually dominated society, where we’re encouraged to share images of ourselves.
But this isn’t the whole story. For decades, magazines and adverts have airbrushed images in order to sell products. And now, selfies posted online can be similarly tweaked and manipulated, meaning youngsters are being bombarded with images that appear to be taken spontaneously, but in reality have been carefully perfected.
He believes the rise in popularity of the internet and social media has directly impacted on the number of people who have eating disorders (stock image)
Airbrushing, adding a filter to smooth skin tone and enhancing the contrast all result in impossibly perfect and unobtainable bodies. In an effort to match these images, young people often turn to diets. In those who are psychologically susceptible — frequently due to underlying psychological and emotional difficulties — going on a diet can then develop into an eating disorder.
Many of my young patients say they have become obsessed with images seen online, focusing particularly on details such as ‘thigh gaps’ (a space between the tops of the thighs). Yet they fail to realise these are usually a result of digital manipulation. Most people simply don’t have that body shape.
What’s more, fad diets are easily spread on social media. There’s an element of ‘contagion’, where people are constantly seeing certain ideas or mantras — that carbohydrates are bad, for example — and so assume there’s truth in it (there isn’t), especially if it has the endorsement of a celebrity. They then try these kinds of highly restrictive, elimination diets.
For a group of susceptible individuals, this resonates with a deeper need to feel in control and soon stops being about dieting and morphs into a full-blown eating disorder.
The Health Survey for England found that as many one in six people could have an eating disorder (stock image)
However, I saw evidence of dieting leading to eating disorders long before social media. In a society that venerates thinness, there is always a cohort for whom this will trigger an eating disorder.
Another important consideration is the role food plays in how we manage our psychological difficulties. Underpinning many eating disorders is the need to be in control. It’s not always about body image. One of the most basic things we can control is what we put in our mouths.
By creating rules around what you can and cannot eat, people gain a sense of control they are often lacking elsewhere in their lives. The anthropologist Mary Douglas argued that what we eat not only defines who we are as people, but helps us to feel as if we have mastery over an otherwise chaotic and random world.
By sorting food into what we can and cannot consume, she argued, we create meaning and boundaries that provide order in our lives. While traditionally this was done through religion governing what people could and could not eat, in our increasingly secular lives the focus has shifted to the fad for restrictive diets.
Dr Max Pemberton says that many eating disorders are underpinned by the need to be in control (stock image)
It’s interesting why so many of us — particularly young people — feel the need to be in control. I wonder if there isn’t something here about us failing to equip the younger generation with the necessary skills of resilience. Without this, the world feels scary and chaotic and young people feel they have to adopt coping strategies to help them feel more in control.
Interestingly, the new survey didn’t only uncover a potential rise in anorexia. It also identified people who binge eat. There are complex commercial messages around food — we are told to ‘indulge’ and ‘treat’ ourselves, yet the thin body is idealised. I think this conflict results in many comforting themselves with food and then feeling shame. This cycle of indulgence and guilt has become so entrenched in our society, we barely even see it as abnormal now.
Some might even make themselves sick or over-exercise to compensate (bulimia), while others might seek solace and comfort in yet more food (a return to binge eating).
Looking at the figures from this survey one thing is clear: society desperately needs to reappraise its not-always-healthy relationship with food.