Anorexia and bulimia nervosa in the midst of the pandemic

The increase in cases of anorexia and bulimia during the pandemic has been influenced by several factors, such as changes in daily routines related to eating, exercise, and sleep schedules. Added to this is the social isolation that the pandemic has imposed on young people, who have been attending classes online, without extracurricular activities, and without physical contact with their friends. Physical contact was replaced by increased use of social media, an environment where certain behaviors that contribute to eating disorders may be promoted.

One of the underlying factors in anorexia and bulimia is body dissatisfaction, to which messages on social media have contributed. It's worth remembering that the pandemic led to a surge in interest and general concern about physical fitness, fueled by social media.

All of these factors protect against this and other mental health problems, and they have been disrupted by the pandemic. This situation has led to an increase in risky behaviors.

The onset of anorexia or bulimia nervosa is multifactorial:

• Genetic factors.
• Psychological factors, such as self-demand, perfectionism, and low self-esteem.
• Social factors. Currently, we have a beauty ideal that values thinness; there is a lot of social pressure regarding body image, and social media reinforces these ideals.
• Family factors. The family should be a healthy role model in terms of body values and eating habits.
• Triggering factors. These are related to a negative emotional experience, such as confinement.

What is important is not to focus on the cause or look for culprits, but to put all our energy into solving the problem.

Anorexia and bulimia nervosa are not lifelong disorders. Those affected can recover with treatment from specialized professionals. Between 70 and 80% of people recover, and between 20 and 30% of cases become chronic, meaning the person lives with the illness. Approximately 5% of people with anorexia nervosa die as a result of this disorder.

Early detection, the initiation of specialized treatment, and family involvement during the therapeutic process are factors associated with a good prognosis. It is important to continue working on new therapeutic strategies to improve treatment outcomes.

The main symptoms of bulimia nervosa are:

• Repeated episodes of binge eating, that is, eating excessive amounts of food in a disproportionate manner and with a feeling of lack of control.
• Vomit.
• Take diuretics, both medications and natural diuretic foods.
• Do plenty of physical exercise
• Fast
• Showing excessive concern about body image and weight, with fear of gaining weight.

Bulimia nervosa can lead to physical complications, primarily resulting from purging behaviors (vomiting, laxatives, or diuretics), such as dehydration, which can lead to serious medical problems like kidney failure. It can also cause heart problems, such as irregular heartbeat or heart failure, severe tooth decay, gum disease, irregular or absent periods, and digestive problems resulting from binge eating.

Treatment for anorexia and bulimia is lengthy and complex. The treatment plan is tailored to each individual's needs to provide comprehensive care that addresses all the causes and consequences of the illness. The average treatment time for recovery is between four and five years.

Relapses from anorexia and bulimia are part of the recovery process. For this reason, it's important to stay calm and not blame yourself. Don't see it as a failure, but rather as a learning opportunity that is part of the recovery process. It's important to remember that one of the goals of treatment is relapse prevention.

When someone is recovering from anorexia or bulimia, it's crucial to be especially vigilant for potential relapses. These can occur when the person experiences a negative emotional event, such as a breakup, a loss, or a stressful situation that may affect their emotional relationship with food. In any case, we recommend avoiding living in a constant state of alert and fear of a possible relapse.

Anorexia and bulimia affect both men and women, although these disorders are more common in women, accounting for nine out of ten cases.

Anorexia and bulimia don't only affect teenagers. These disorders can appear in people of any age. However, it's common for them to begin during adolescence, as this is the period of greatest risk for developing these disorders. But we also find cases in pre-pubertal children (between 11 and 12 years old) and cases where the illness has started in young adulthood and adulthood.

Currently, work is underway to reorient the treatment model for eating disorders (EDs) towards home-based care, with the support of the family and professionals, in order to treat the person in their usual social and family environment and to address the root of the problem.

Obviously, serious cases must continue to be treated in the hospital, but without losing sight of the natural environment of the affected person.

In the recovery process from an eating disorder, such as anorexia and bulimia, you will go through several phases. The second phase, known as the contemplation phase, is when you begin to realize that something is wrong. But it's not until the third phase that you begin to mentally prepare yourself for the need to make changes in your life and seek strategies to do so. This is why, even though you may already have some awareness of the illness, recurring thoughts about it may still be present. Being aware of this is the first and most fundamental step in the recovery process.

Anxiety is an adaptive response of our body. We consider it a natural emotion that, at a mild to moderate level, helps us stay focused and face the challenges ahead. However, when this response is disproportionate, limiting, and prolonged, it becomes a problem because it blocks us and prevents us from being decisive in that moment.

In the case of anorexia and bulimia, anxiety can appear before, during, and after meals in the form of recurring thoughts about weight, body image, or the need to do compensatory exercise.

Anxiety can occur at a physical, emotional, and cognitive level, and with different levels of intensity.

A good strategy for managing anxiety on a physical level is relaxation techniques. On an emotional and cognitive level, psychotherapeutic intervention focused on analyzing the emotions and negative thoughts related to the eating disorder is recommended.

If necessary, and if the strategies discussed above are not working, specialists can prescribe medication to help reduce anxiety levels.

If you have a high level of anxiety that you think may trigger an anxiety attack, we recommend finding a comfortable position and focusing your thoughts on a calming image that brings positive and liberating thoughts.

A good technique for controlling anxiety is deep breathing:

1. Take a breath through your nose, slowly and deeply, counting to three and filling your lungs completely with air.
2. Hold your breath for three seconds.
3. Slowly exhale through your mouth, counting to three again.

If the situation is not resolved, go to your reference center to be assessed by health professionals.

Women with anorexia or bulimia often experience menstrual irregularities as a result of being underweight or experiencing a sudden weight change. The absence of menstruation increases the risk of osteoporosis and can even impair fertility. Reproductive function usually returns once a healthy weight is achieved, although it can take up to six months for menstruation to resume. If menstruation has not returned after six months while maintaining a healthy weight, it is recommended to consult a healthcare professional.

Guilt is a very common emotion in anorexia and bulimia, and therapy is necessary to overcome this emotion and all the suffering that comes with the illness. It's important to remember that this guilt is a product of the thoughts associated with anorexia and bulimia, whose sole purpose is to harm us. We must ignore these thoughts and focus on everything we will gradually regain as we move forward: studies, friendships, leisure activities, future plans…

A key element in overcoming anorexia and bulimia is re-establishing a life plan and finding motivations such as studying, taking a trip, resuming leisure activities, having children, or caring for a pet. There will be as many motivations as there are people.

When someone recovers from anorexia or bulimia, they may experience occasional thoughts. It's important to consider two things: how these thoughts make you feel and what influence they have on your behavior. If they control your behavior or cause you distress, it will be necessary to seek professional help.

A person who has recovered from anorexia should not routinely experience such thoughts, and even less so suffer because of them or act on them.

The way to overcome recurring thoughts of anorexia or bulimia is through psychotherapy. It's important to remember that the average recovery time is around four or five years, partly because it involves addressing emotional and cognitive aspects that require time and ongoing therapeutic work with professionals.

When we notice anorexia or bulimia "talking," we should try to ignore it or lessen its intensity. A good strategy would be to practice alternative thinking.

Another strategy is to remind yourself of your motivations and future plans, and why overcoming this illness is essential to achieving them. It's also a good idea to ask a family member or friend for support during these difficult times. Talking about other things is another way to ignore that inner voice.

There is no miracle cure; each person has different ways of coping with these crises and thoughts, from listening to music, taking a walk, talking to a friend or family member, applying relaxation techniques, etc.

We recommend the illustrated book "I Also Wanted to Be Like Ana and Mia" by Leire Martín Curto. Also of great interest is the Instagram account @stoptca_sjd, run by teenagers receiving treatment at the Sant Joan de Déu Hospital's Day Hospital in Barcelona .

Remember that professional help is needed to treat these disorders.

Explaining to friends that you have anorexia or bulimia is always a personal decision. You might initially be afraid of how they might react. If you decide to tell them, we recommend doing so naturally, just as you would with any other illness. Consider also explaining it to your closest friends and family first.

If you are in treatment for anorexia or bulimia and receive an inappropriate comment, it's important to address it naturally. For example, you could say to the person, "Excuse me, I'm currently in treatment for anorexia or bulimia, and if possible, I'd prefer not to receive these kinds of comments, even if they're well-intentioned."

We can take advantage of these types of situations as an exercise in assertiveness, conveying this message in a way that is not offensive but constructive for both of us.

The difference between healthy eating and orthorexia is that, in the latter case, there is an obsession with healthy food.

To determine if you have an orthorexia problem, you can ask yourself two basic questions:

• Do food-related topics cause me suffering?
• Does food control my life?

If you answered yes to either of the two questions, seek professional help because you may be experiencing obsession.

The first warning signs that a family may notice regarding anorexia nervosa are:

• Extreme concern about body shape, diet, and weight
• Strange food rituals
• Significant weight loss in a short time
• Changes in eating habits.
• Loss of menstruation.
• Excessive physical exercise
• Obsessive interest in food.
• Showing restlessness, mood swings, isolation, or sadness.
• Making derogatory comments about one's own body.

Regarding bulimia nervosa, the following warning signs should be highlighted:

• Going to the bathroom immediately after meals and very frequently.
• Making derogatory comments about one's own body.
• Sudden weight changes.
• Frequent mood swings.
• Excessive and unjustified expenses, which may include buying food in secret.
• Frequent diarrhea for no apparent reason.

The first assessment is carried out from the primary care center (CAP) by professionals in family medicine, pediatrics or nursing.

If the diagnosis is confirmed or the suspicion persists, from this center you will be referred to the child and adolescent mental health center or the adult mental health center for evaluation by mental health professionals (psychologist or psychiatrist).

When we talk to teenagers about risky behaviors related to anorexia and bulimia, it is important not to judge them.

The important thing is to convey information about these risks and ensure the affected person understands our concern so they can seek specialized help. One of the main characteristics of these disorders is the affected person's lack of awareness of the problem.

From a very young age, children have a formed body image in their minds and are able to sense whether that image is socially accepted or not, but the cognitive and emotional mechanisms necessary for anorexia to occur have not yet developed.

In the event of anorexia in a child under 12 years of age, it is important to bear in mind that the treatment must be adapted to this age, given that individual characteristics are quite different from those of adolescents and the role of the family as an active part of the treatment is even more important.

The first step a family should take when they suspect anorexia or bulimia is to obtain a diagnostic assessment and a proposed intervention from a specialized team if the diagnosis is confirmed.

The starting point is the professionals at the primary care center (family doctor, pediatrician, or nurse). In cases of anorexia and bulimia, early detection is important to gain time and can facilitate treatment.

From this point on, it is crucial that the family receives psychosocial support to manage their own anxiety, as well as information about the illness itself. Understanding aspects of the treatment's progression, the challenges they will face, and their role in the process is fundamental, as is trusting and collaborating with the professional team. It's important to remember that a family that receives information and support can contribute to a positive prognosis.

You can also consult the Guide for families of people affected by an eating disorder .

If a family observes obsessive behavior regarding calories and physical exercise in their teenage sons and daughters, it's important to reflect beforehand: Could they have a problem with social acceptance? Do they feel loved? Do they feel valued?

Our son or daughter may feel insecure about their body image, about themselves, about the life project they are starting, etc.

Once we've established this, it's essential to have a conversation, focusing primarily on their emotional state: how they feel, if they have any worries, what plans they have, what their hopes and dreams are, etc. We should speak to them honestly and respectfully about our concerns and the need to seek professional help.

It is important for families to seek support from an organization that assists families dealing with anorexia or bulimia. One can consult the Spanish Federation of Associations against Anorexia and Bulimia.

In Catalonia, the Association Against Anorexia and Bulimia (ACAB) offers an information service, psychosocial support, and specialized assistance for families of individuals with eating disorders. This includes personalized attention, support groups, and specific training on how to respond at home when a son or daughter has an eating disorder. The stress experienced by families of someone suffering from anorexia or bulimia is high and prolonged, which is why it is important for them to seek support from an organization like ours.

First and foremost, and although it seems obvious and simple, it's actually quite important to remain calm. Here, we must apply the saying "dress me slowly, I'm in a hurry." We must act quickly because of the need to detect and intervene early, but the steps we take must be conscious, confident, and with a clear plan.

The first step is to receive a diagnostic assessment and a proposed intervention from a specialized team (by visiting the primary care center). Once this step is completed, we should receive information about the disorder and the treatment, and then get started, always working as a team between the affected person, the therapeutic team, and the family. In this regard, it is essential to trust and collaborate with the team of professionals.

As the person progresses, so will the family, learning and improving how to manage the situation at home, especially, we insist, if they receive information and support.

The role of the family in cases of anorexia and bulimia is fundamental due to the emotional bond they share with their child. It is very important that they show their affection and support to the affected person while also remaining firm in the face of the disorder. The message the affected person needs from their family should be something like, "We love you, we believe in you, and we are by your side no matter what. Together, we will overcome this illness."

Anorexia and bulimia are disorders that make a person feel alone and, in many cases, lead to isolation from their surroundings. In fact, very often, the more isolated the person is, the stronger the disorder becomes. At this point, the support they receive from family and the therapeutic team will be crucial because, in reality, loneliness is one of the inherent consequences of the illness, and the way to avoid this loneliness is to undergo specialized treatment to regain a normal social life.

When someone with anorexia or bulimia feels unwell after meals, the first thing we must do is remain calm. If we lose our temper and composure out of desperation at their refusal to eat or at seeing their suffering during or after meals, we won't be able to help them.

When you notice this suffering in the affected person, it's important to connect with them emotionally and show your support. A good message might be something like, "How are you feeling? What can I do to help?"

It can also be helpful to remind the person of the treatment goal and the effort they are making, encouraging them to connect with their motivations and future plans. We should also remember that the therapeutic team can provide more specific guidance on how to respond to these situations.

If the person with anorexia and bulimia is already in treatment and the family has doubts about how to act during meals, they should ask the therapeutic team what they should and should not do.

If, on the other hand, the person is not yet receiving help, it is important to keep in mind that the main objective should be to get them into treatment rather than just getting them to eat.

It's crucial to understand that for someone to regain a normal eating habit, they need treatment. This is a goal that we, as family members, won't achieve on our own. Therefore, it's not worth putting energy into trying to get them to eat. If we focus on that, the most likely outcome is that, besides exhausting ourselves, we'll only end up creating conflicts with the person. For all these reasons, it's important to empathize with the person, understand their suffering, and try to connect with them on an emotional level.

Anorexia and bulimia have a multifactorial origin and a genetic component. This means that siblings share a risk factor for developing an eating disorder.

It's helpful to know, but we shouldn't live in constant fear that one of our children will develop anorexia or bulimia. Simply be alert to possible warning signs and talk, naturally and in an age-appropriate way, about the illness your brother or sister is experiencing.

The decision to limit or not limit physical exercise in cases of anorexia or bulimia is one that must be made by the therapeutic team. It is very common for physical exercise to be limited, even completely, at the beginning of treatment because the patient needs to regain weight and be able to engage in physical activity without it being related to the unhealthy desire to burn calories. It is important to keep in mind that as the person improves, they will gradually resume the activities they previously enjoyed.

It is very important that you show her your affection and support, while at the same time standing firm against anorexia.

You must keep in mind that your partner is experiencing a very stressful situation, and for this reason, you should be understanding and show them as much support as possible. Avoid making judgments about any complex situations that may arise at home related to the illness. If third parties try to interfere with the treatment plan, it can create more confusion than help.

If you suspect your friend may have anorexia or bulimia, the first thing you should do is avoid getting angry with them. Show understanding and listen to the person so you can encourage them to seek professional help.

This is crucial for someone to recover from an eating disorder. If, despite your insistence on the need for treatment, the person continues to refuse, the best course of action is to explain that you will need to speak with their family members, especially if the affected person is a minor, so they can seek professional help. Taking this step may initially upset the person, but they will later understand and sincerely appreciate it.

Many people with anorexia or bulimia appreciate being treated normally. That is, not having to do anything different. It is recommended, however, to suggest activities and talk about topics unrelated to weight or body image. Being there for the person with this disorder, listening to them, and showing support is very helpful.

The internet and social media are a breeding ground for numerous false reports and even spaces that promote anorexia and bulimia.

The best way to avoid misunderstandings and false information is to pay attention to certain details on the websites or social media profiles we are consulting .

Some clues:

• Verify the source of the information: Is it a well-known media outlet?
• Check the publication date to make sure the information is not outdated.
• Don't trust eye-catching headlines; they are designed to grab your attention, but may contain misleading or false information.
• Observe the quality of the text: Are there spelling mistakes? Is it formal language?
• Check the source of the information being cited: Is it reliable and well-known? Is it an official source?
• Be wary of photographs that show body changes; they may be retouched.
• Be wary of miracle cures and information that clearly aims to sell you a product.

When it comes to health, scientific evidence is the proof of efficacy and safety. Keep in mind that diets and medications should always be prescribed by qualified professionals. And don't forget to verify information with official sources (government agencies and health centers).

In an ideal world, it would be necessary to influence the sociocultural factors of the disease; that is, the fashion, beauty, and consumer industries, as well as advertising and the media, would commit to health and respect for body diversity by promoting a lifestyle and beauty model consistent with these rights and values.

It would also be necessary to finally break down current gender stereotypes that promote the belief that women should be "pretty, helpful and submissive" and men "strong, dominant and economically powerful".

We are still far from achieving this paradigm shift, but there are some things we can do:

• Promote early detection and intervention in incipient cases, since the sooner we act, the better the prognosis for recovery will be.
• Strengthening all those aspects that act as protective factors against eating disorders is crucial: healthy self-esteem, a positive body image, respect for body diversity, and a critical perspective on societal pressure to conform to a certain body type and role. Families play a vital role in this regard through their example and by adopting simple habits such as eating one meal a day together as a family.

The public healthcare system in Spain has excellent professionals, but more resources are needed, especially in primary and community care. Primary care centers and mental health centers often have more cases than available resources, which means they must prioritize severity and urgency. For this reason, it is common that, unless weight is severely affected or there are risk factors such as suicidal behavior, additional time or specialized care cannot be offered.

It is important to have a healthy relationship with our body and stop associating thinness or weight loss with success or a desirable aesthetic goal.

Instead, we should prioritize respect for body diversity and reclaim body beauty as something that goes far beyond weight or size.