Anorexia Nervosa

Finding the Will to Eat

In our culture we are surrounded by images in the popular media that idealize a very thin female body type that is unrealistic for most women in society to obtain.

A group on eating disorders and HIV for gay males is forming.
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Just look at any magazine and try to locate a model that is bigger than a size 6; and more likely a size 2! For men, the image portrayed is Calvin Klein model types with hard bodies.

The cultural projection of the super-thin body type has a large influence on society. The message underlying the mass media siege is that the rest of us are just not good enough. They want us to believe this so that we will buy more "beauty products" and services.

The trend toward a super-thin society began in the 1960s and continues to influence how we judge ourselves, and certain regions of the country emphasize these perfectionist expectations more than others.

California is known to have particularly harsh standards. Actors and dancers are particularly pressured to achieve and maintain the "ideal" body. For gay men, the phenomenon known as the "WeHo syndrome" sets standards of shape for men that are increasingly demanding and unrealistic. Think about how these messages affect the way you feel about your looks, body type and general overall acceptance of yourself.

Anorexia and Adolescents

Anorexia is generally a loss of appetite leading to weight loss.

Anorexia nervosa however, is a preoccupation with dieting and thinness that leads to excessive weight loss without loss of appetite. While anorexia nervosa generally begins to emerge in adolescence, concerns about weight usually begin earlier.

A study of 197 five-year-old girls done by Birch and Davison at Pennsylvania State University concluded that as early as five years of age, lower self-concept is noted among girls with higher weight status. In addition, parents' concern about their children's weight and restriction of access to food were associated with negative self-concept among young girls.

Adolescence is a time of transitions, increased independence and dramatic bodily changes. Young women with low self-esteem and difficulty coping with the demands of adolescence are more at risk of developing eating disorders. Boys and girls involved in certain activities such as gymnastics, dance, wrestling or other sports where there is an emphasis on a small body frame or light weight may feel pressure to begin dieting. Young women may find their developing breasts and hips impossible to accept and the body itself becomes an enemy that they want to destroy. Obsessive preoccupation with food, weight and dieting is a way of bringing a sense of control to the adolescent who fears the rapid changes and anxiety of the increased expectations of adolescence.

Anorexia nervosa is one of the most serious eating disorders with a mortality rate as high as 15 percent. The characteristic of the disorder is excessive weight loss not caused by organic disease. In addition, it is typically associated with the loss of menstrual periods (amenorrhea) for young women and other medical abnormalities, including electrolyte imbalances.

Restricting and binge eating/purging are two subtypes of anorexia nervosa. Those with restricting anorexia nervosa do not engage in binge eating or purging behaviors. Those with binge eating/purging anorexia nervosa binge eat and then attempt to lose weight through purging behaviors.

Theories on the causes of anorexia nervosa have identified social, biological, family and personality factors.

Social factors have been mentioned in regards to the media, but in addition, adolescents may begin dieting to receive positive comments from peers. There may also be a genetic component to the disorder. Studies have suggested that the personality factors of anorexic patients tend toward perfectionism and patients often feel personally ineffective in their lives. They lack awareness about internal emotional states, often not recognizing when they are feeling anger. Family interaction patterns such as overprotectiveness, inability to express and resolve conflicts, enmeshment and lack of empathy and affection are common in families with an anorexic child. People with anorexia nervosa consider themselves experts at dieting, giving them a sense of mastery and control.


Anorexia nervosa is a chronic ongoing illness that may require lengthy treatment.

Patients often do not view their severe weight loss as a problem and they do not want to change, therefore they do not generally seek help on their own. Parents need to be aware that teenage dieting can escalate out of control. They need to be concerned if their daughter's menstrual period has stopped or never began due to dieting and weight loss. Medical and professional mental health intervention may be required.

Working as a team is important for the medical doctor, nutrition specialist and the mental health therapist. Depending on the severity of the weight loss, hospitalization may be necessary. The focus is on weight gain initially and gradually progresses to psychological issues. It is critical for the therapist to establish trust with the patient.

Psychotropic medications are sometimes prescribed to treat underlying depression, and to lessen binging and obsessive thinking. Different behavioral techniques can be used to change behavior such as monitoring eating behavior and rewarding weight gain with activities that are pleasant to the patient.

Studies have shown that it is very helpful to involve the family in therapy if the patient lives at home. Patterns of family dynamics can be adjusted so that the eating disorder is not maintained. Education about the disorder, starvation, proper nutrition are all very important.

Relapse of anorexia nervosa may occur at times of job stress, when beginning college or graduating from college, pregnancy, illness, relationship problems including domestic violence, or environmental changes such as moving. Preparing for relapse is important for families and those suffering from anorexia nervosa. Coping skills can be taught to help deal with transitions to avoid a setback. Twelve-step programs can sometimes be helpful to maintain stability and prevent relapse.

HIV/AIDS and Anorexia

Anorexia associated with AIDS wasting is somewhat different. The person just does not have the desire to eat.

Nausea, vomiting and diarrhea may coincide with a diminished appetite and cause a lack of intake leading to dehydration and malnutrition. Side effects of HIV medications may also interfere with eating and general level of energy. Fatigue associated with HIV/AIDS may also be a factor.

Depression, feelings of low self-esteem and other psychological problems can affect eating. Sometimes the reduced appetite and weight loss may seem welcome to someone who has been struggling to lose weight for much of their life. Unintentional weight loss, however, can lead to or be a sign that there is an opportunistic infection. It is not to be ignored.

Those with anorexic nervosa may be using amphetamines to lose weight. Using harmful substances for any reason may be an attempt to deal with inner pain and issues around being HIV-positive. It may be a way to avoid stress that has become habitual. Addictive behaviors can cause complications with interactions among substances and medications. It is likely that using substances interferes with eating healthy meals, and drinking enough fluids as well as remembering to take medications on time.

An unintended weight loss in HIV patients is to be avoided. As little as a 5 percent weight loss over a four-month period is associated with increased risk of death and opportunistic complications. Determining the underlying medical cause of weight loss is important. If there is an underlying psychological reason for serious weight loss/wasting, binging, purging or obsessive thoughts about body image and weight, seek the help of a mental health specialist; the sooner the better.

Good nutrition is essential for people living with HIV/AIDS.

Weight loss is one of the most common indications of HIV infection and in many cases it is treatable. One of the major goals of nutritional intervention is to preserve lean body mass or muscle protein.

Here are some suggestions to counter HIV/AIDS related anorexia.

  • Eat small frequent meals every two to three hours or less.

  • Maximize caloric intake by keeping nutritional snacks around such as peanut butter and crackers, cheese, cereal, yogurt, fruit nectars and commercial or homemade breakfast drinks.

  • Eat your favorite foods; you are likely to eat more of these.

  • Try walking before a meal to increase appetite.

  • Avoid coffee, cigarettes and candy. Coffee, cigarettes, cola, chocolate and alcohol dull your appetite.

  • For diarrhea and vomiting, drink plenty of fluids to avoid dehydration, replenish sodium and potassium loss by eating bananas, potatoes, fish, meat, apricot nectar, tomato juice and sports drinks. Eat soluble fiber foods such as white rice, oatmeal, pears and mashed potatoes. Avoid insoluble high-fiber foods like wheat bran, brown rice and popcorn.

  • For nausea, dry salty foods like crackers or pretzels are usually tolerable as well as simple foods like scrambled eggs, toast, noodles and bananas.

  • Protein is essential for the immune system. Four small servings a day are suggested for people with HIV. Try adding diced meat, hard-boiled eggs or cheese to your diet. Protein powder can also be used and added to beverages, hot cereal or casseroles. Peanut butter is a good source of protein. However, avoid peanut butter made from raw peanuts. Instead, use one made from roasted nuts.

In addition to these suggestions, speak to your doctor and a registered dietitian specializing in HIV nutrition about the specifics of your situation. Try to identify what is going on in your life that may be contributing to the loss of appetite. Seek advice from professionals. There are appetite stimulants available such as Megace (to be used as a kick start for a short duration), Marinol and other possible treatments for diarrhea and nausea. Ask your doctor for information and a referral for a consultation with a registered dietitian specializing in HIV nutrition. These consultations are available through AIDS Project Los Angeles and Project Angel Food.

For more information about HIV nutrition, contact AIDS Project Los Angeles' Nutrition and HIV Program. Marcy Fenton, M.S., R.D. can be reached by calling (213) 201-1611 and Janelle L'Heureux, M.S., R.D., can be reached by calling (213) 201-1556.

Happy and healthy eating!

Marcy Fenton, M.S., R.D., assisted with research for this article.

Back to the August/September 2001 issue of Positive Living.

This article has been reprinted at The Body with the permission of AIDS Project Los Angeles (APLA).