‘We need to focus on what shapes disordered eating’

What inspired you to write your new book, The Construction of Eating Disorders?

I noted a gap in the literature. I wanted to look at the forces that are not necessarily encouraging disordered eating but helping to drive it and severing our natural relationship with food. I also wanted to bring things as up to date as possible in the ever-changing landscape of eating disorders… which is never easy, because every time you've finished a chapter, something else comes to light! 

This book feels different in that it looks at so many external influences on our relationships with food.

Yes, and I could have written three times as much! There is so much material on eating disorders, but many are self-help books. Not that I don't see a place for these, but I wanted to start with one big question; why is it that, in our society, something that is so natural, so pleasurable, and so intrinsic for our survival has become such a huge problem? How do we get to be disordered eaters?

So, we shouldn't be viewing an eating disorder as purely an internal, psychiatric issue?

I'm not dismissing anything, but I am saying that eating disorders (EDs) are multifactorial and I am aiming to expose influences that may not have been discussed enough within Psychology; food landscapes and policies, market forces and technological developments, cultural representations of ideal and disordered bodies, and the ways that the politics of the body defines or challenges definitions of normality.

Conventional research typically frames an eating disorder as a psychiatric issue. This view neglects the influence of larger systemic forces, including colonialism, capitalism, Western medical frameworks, the food industry, and the media.

If we're going to start to label and pathologise everyone, then where do we start and where do we draw the line? I reject the idea that weight and health are solely within individual control. When we talk about disordered eating, we're talking about much larger problems in society.

Does the idea that eating disorders mainly affect young, middle-class, white women still exist?

That belief certainly surrounds anorexia nervosa. For many years, anorexia was thought to only exist in Western cultures or those influenced by them. 

I dedicate a chapter to the history of anorexia, Anorexia Nervosa: The Making of the First Eating Disorder, which goes right back to how self-starvation in medieval times was seen as a religious practice, to looking at feminist theories about the role of chauvinistic society in laying the foundations for anorexia, through to the lived experiences of those with anorexia today. Some psychological literature suggests people who fall into the restricted anorexic category are more likely to be highly conformist in terms of education and achievement, but is this a stereotype? 

In the book, l look at the different types of eating disorders and how they fit with other changes in society. For instance, binge eating disorder is a relatively new addition to the official taxonomy of eating disorders. 

In fact, my interest in understanding how eating disorders emerge began with our studies of the proposed eating disorder, Orthorexia Nervosa (ON) (Fixsen et al., 2020). First noted in the late 90s and characterised by an extreme fixation on the quality and purity of someone's diet, ON has attracted much attention, and reflects the way that psychiatry is now focusing on lifestyle disorders. 

That made me reflect on how opinions on our food choices are everywhere now.

True! Our daily food choices provoke opinions like never before. Messages about which specific components of foods to eat or avoid are constant. One aim of the book is to highlight that disordered eating affects much larger numbers in society than we may realise and is often part of a much larger cycle of distress. The most substantial increase has been in Other Specified Feeding or Eating Disorder (OSFED) and Binge Eating Disorder (BED). 

And with this expansion, significant socioeconomic and medical treatment disparities show up. We know that disparities in healthcare and self-care accessibility persist across economic and geographical divides. Mass-produced cheap food is often the only option for low-income families, which exacerbates issues of chronic illness and reduced lifespan, yet health policies often focus on monitoring and surveillance on the individual level while neglecting potential systemic solutions. 

And that surveillance around our 'healthy' and 'unhealthy' choices impacts how we feel about ourselves and our diets.

Indeed! As I state in the book, for the modern consumer, working out how to eat well is a complicated enough process. Eating disorders have now reached epidemic proportions and many of the traditional discourses and rules around eating practices have broken down or been subsumed into more commercialised ways of obtaining and consuming food. 

Contradictions exist between how we are expected to respond to messages about healthy foods and so-called 'luxury' foods. Media and public health messages constantly reinforce the importance of making 'good' as opposed to 'bad' food and diet choices.

You also examine the huge global disparities around food. How does looking at disordered eating through a WEIRD lens (Western, Educated, Industrialised, Rich and Democratic) affect our views?

Among the top ten countries ranked as the most obese, nine are in the Pacific Islands (World Health Organization, 2023). Much of this has been put down to a combination of poor diet, lack of exercise, and genetic predisposition. Less spoken about are the ill effects of colonialism, the medicalisation of obesity, and traditional Western ideas about gluttony and guilt. 

The new food environment in which some people have found themselves has led to an increased consumption of cheap imported foods and alcohol. Since binge eating disorder (BED) is medically linked to obesity, people in non-white countries may find themselves doubly stigmatised, not just for being overweight but for their perceived lack of psychological order. Eating disorders are a growing problem throughout the world.

Do you think it is helpful for someone with an eating disorder to consider all the influences that could have played a part in their struggles? That there's not something intrinsically wrong with them? Shame plays such a part sometimes…

I'm really interested in getting feedback from different people who are going through this to see whether they found it helpful, not always having it thrown back on them, that there's something that should have been fixed, something intrinsically wrong, which marks them out from other people. Of course, eating disorders are very serious. 

They have really serious implications. You can't dismiss them, and they can have a lifelong impact on people, and they can die as a result. But I wonder whether by constantly separating the 'expert' from the sufferer that we are not really helping the situation long-term.

Can you expand on that?

So, in the book and our other publications, we look at how eating disorders are interpreted by health professionals – including clinical psychologists (Fixsen et al., 2023) – but also by those who've been treated for an eating disorder. Anorexia nervosa is considered very difficult to treat, because the person usually doesn't see themselves as sick. Once they're in the system, a person takes on the role of the 'anorexic'. So, they might be acting the part of the 'good patient' in the clinic, then competing with others online to be the 'best' anorexic.

Another issue is that inpatient treatment for an eating disorder can be deeply distressing, traumatic and stigmatising. In one of the studies I cite in my book (Bannatyne & Stapleton, 2018), involuntary hospitalisation was perceived as traumatic and punitive, with an over-emphasis on the physical dimensions of the illness. Support beyond clinical 'recovery' is vitally important because the lives of people with disordered eating may continue to be blighted by past trauma, difficult life circumstances, and the longer-term effects of treatment.

You say that the body positivity movement, which has gained media traction over recent years, can still be problematic in terms of its effects. Why?

On the surface, there is now a more diverse range of ages, skin and body shapes in the media. Many advertisements, even if they are for banks or insurance, advocate for mental health awareness with a message that we can all 'just be ourselves'. But these companies are still trying to sell us something. The top line message may be equality, but we don't all have self-confidence and money; we're not all born with the same privileges. 

And so, if you have a celebrity sharing a glamorous image and talking about body positivity, there's still a danger that young people are going to feel like they're coming up short. Images in the media, even when there is a positive message on the surface, can leave us thinking that we're not good enough. I think a lot of young people have that feeling anyway, and the media can amplify that more.

And of course, there is now the discourse around weight-loss drugs. How are they affecting people with eating disorders?

I think people are realising that there are lots of unanswered questions about the use of Ozempic and other weight loss drugs. It will be a lifesaver for some people who are really struggling, but eating disorder charities are quite worried about their availability. We are also noticing that there is a push back from body positivity, and models are now looking a lot thinner again. 

The media/celebrity narrative is back to being ultra-thin. I mean, there are size 6 models, selling and advertising clothes to people who are a size 22, and that must have an effect on people's body image. One of our studies explored the effects of the ultra-thin ideal on female models themselves. 

They saw the fashion industry as callous – one described being treated like 'a piece of meat', another explained how young models who put on weight could have their pocket money cut or be thrown out in a strange city. Clearly, these messages rub off on other women in society.

Social media narratives of illness and recovery from eating disorders can also be problematic…

It's quite rightly become more acceptable to talk about our mental health struggles on social media, but it's also an industry. Posting on social media has become an art form on some level, and more and more young people are trying to make their living from it. 

The risk is that these narratives can become romanticised, because, of course, if you are doing a film about yourself, even if you've got pictures of you when you're starving, you want it to look well-produced and watchable. Of course, these prettified versions will have influence on viewers in some way – they also have an economic value and generate income for influencers and advertisers. 

Also, there are many, many sites on social media which are actively promoting disordered eating – these need to be regulated because in the space of a few clicks, algorithms direct young people to them, and we know they are sites for predators (Tragantzopoulou et al., 2024).

Is there any good news surrounding eating disorders we can highlight?

Thankfully, there's much less blaming of parents than there was years ago. I think psychology has been good at shifting that incorrect and dated narrative. Treatment is much more tailored, families are involved, and patients are asked what might be helpful. I'm currently interested in how families of people with eating disorders can be better supported. 

Families can do so much good, they're right in the thick of it, they are often in despair themselves and need a lot of support to not be traumatised by the whole situation. Caring for and living with a family member with an eating disorder can be mentally, physically, and emotionally exhausting, also many adults with eating disorders are parents themselves. 

There are lots of misconceptions about eating disorders. For example, they're still viewed as disorders of low body weight, so people with a higher weight can be missed – they also experience both weight stigma and stigma around an eating disorder diagnosis. 

Recovery without the right support is very difficult. But because eating disorders are embedded in social processes and social connections, these can be used in a positive way to counter the negative messages in society. Meaningful, everyday connections to things such as groups and clubs, like art, cookery exercise, can have a positive effect. This fits with the ethos of social prescribing – GPs and social prescribers refer people with psychosocial challenges to these local community activities. 

Our studies of social prescribing (Fixsen et al., 2022; Fixsen & Barrett, 2022) found these schemes to be very important community assets, especially in areas of high socio-economic deprivation. That said, social prescribing shouldn't be used as an alternative to government funding of mainstream eating disorder services. 

What else needs to change in eating disorders?

For treatment, it comes back to money and scale. Services need more money and more resources. The professionals who treat people work so hard, but there has to be enough funding for this not just be short-term treatment. It's no good if someone just coming out of hospital and being left to their own devices.  

And on a larger scale, we must continue to explore our relationship with the food we eat, including the way we manufacture and sell our food. We can't go back to the past, but we also need to be wary of forgetting what it means to be human. If children were taught how to garden and grow their own food, could it change their relationship with food in some ways? We haven't really experimented with these things on a significant scale. So, it's a question of having the infrastructure to help people to do it. 

- The Construction of Eating Disorders: Psychiatry, Politics and Cultural Representations of Disordered Eating (Palgrave Macmillan) is out now. 

Key sources

Fixsen, A., Cheshire, A. & Berry, M. (2020). The social construction of a concept—Orthorexia nervosa: Morality narratives and psycho-politics. Qualitative Health Research, 30(7), 1101-1113.

Fixsen, D.A., Barrett, D.S. & Shimonovich, M. (2022). Supporting vulnerable populations during the pandemic: Stakeholders' experiences and perceptions of social prescribing in Scotland during Covid-19. Qualitative Health Research, 32(4), 670-682.

Fixsen, A. & Barrett, S. (2022). Challenges and approaches to green social prescribing during and in the aftermath of COVID-19: a qualitative study. Frontiers in psychology, 13, 861107.

Fixsen, A., Ridge, D., Ponsford, O., Holder, M., & Saran, G. (2023). Battles over 'unruly bodies': Practitioners' interpretations of eating disorders and the utility of psychiatric labelling. Sociology of Health & Illness, 45(3), 560-579.

Tragantzopoulou, P., Fixsen, A., Ridge, D., & Cheshire, A. (2024). 'You Are Not Alone, We've Got You': Power Plays, Devotion, and Punishment on Healthy Eating and Pro-Eating Disorder Websites. Qualitative Health Research, 34(12), 1216-1230.