Eating disorders have become a media obsession in recent years, fuelled by the struggles of celebrities such as Mary-Kate Olsen, Geri Halliwell and Paul Gascoigne. Confessions of compulsive binging, secret vomiting, obsessive exercise and laxative abuse make sensational reading, while graphic images contrasting 'healthy' and 'skinny' celebrities appeal to our voyeuristic tendencies. Eating disorders also form part of the medical school curriculum. By the time we have completed an attachment in psychiatry, most of us can rhyme off the diagnostic criteria for anorexia nervosa and bulimia nervosa.

For many of us, eating disorders may appear to be irrelevant outside of these specific settings; something that happens to pop stars and others unfortunate enough to succumb to the pressures of a culture preoccupied with image. Sadly, this is not the case: when we learn that recent studies report that 20% of UK female medical students are suffering,[1] eating disorders suddenly become very relevant indeed. I recently spent a year volunteering as a support worker with Students Tackling Eating Problems (STEP) and gained some very valuable insight into the reality of the situation.

At least 1.15 million people in the UK suffer from an eating disorder.[2] It is frightening to think that so many in our student communities and our churches have illnesses that we know to be physically dangerous, psychologically distressing and socially debilitating. However, there are things that we can do to help, both as future health professionals and as Christians.

'It's not about food…it's about feelings'

The first truth that we must grasp if we are to reach out effectively to these people is encapsulated in the slogan of the Eating Disorders Association: 'It's not about food…it's about feelings.' We need to understand that preoccupation with calories and weight are merely symptomatic of much deeper issues; it is a grave injustice to a sufferer to assume that their eating disorder arose out of a desire to be supermodel slim.

While the roots of the problem will differ between individuals, there are certain recurring themes. These include feelings of low self-esteem, loss of control in life and a need to numb painful emotions, as sufferers from Queen's University, Belfast attest:

I felt that if my body were not skeletally thin, then I could not deserve food.

I wanted to shrink away so no-one would expect too much from me.

Losing weight is the only thing I can actually do. It helps me feel good about myself for a short time.

Anorexia was a much safer lifestyle. My self-worth and happiness depended on how many calories I ate, how much exercise I did, how much weight I lost and what percentage I got in each of my tests. There was no risk of being hurt or rejected, 'cos these were all things I could easily control.

I feel disgusted after I binge and throw up, but at the time it distracts me from my problems at home and with uni.

These brief snapshots show that an eating disorder fulfils a purpose: it is a coping mechanism. However, both starvation and bulimic behaviour distort thought processes. Sufferers begin to perceive themselves as much heavier than they actually are and to associate negative emotions with 'fatness'.

A vicious cycle is created as self-esteem falls and the drive to lose weight increases.

Christian sufferers experience an added burden of guilt because their behaviour is self-destructive and deceitful, and because they cannot relinquish control over their eating to God. They may also feel that God has let them down by allowing them to suffer such pain. Unfortunately, this distress is frequently compounded by a judgmental response from other Christians.

Called to be Jesus

As Christians, we are called to 'be Jesus' to the vulnerable in our society: to feed the hungry, to clothe the poor, to visit the prisoners and to care for the sick.[3] People with eating disorders are vulnerable because of their underlying distress and because they are slaves to a damaging pattern of behaviour. Jesus spent time with people at the fringes of society - people who were stigmatised, isolated and weak. If he were here today, perhaps some of his friends would have had eating disorders. He would have loved them unconditionally, accepted them non-judgmentally… and the realisation that they were lovable in his eyes could have healed them without the need for a supernatural touch.

How can we make a difference to friends?

You can help sufferers around you by building their self-esteem. Here are some suggestions:

• Remind them of how God sees them, perhaps by writing a card with a biblical truth, such as that found in Ephesians 2:10: '[You] are God's workmanship'.
• Let them know why you value them: if they have a good sense of humour, or are sensitive to the needs of others, tell them!
• Show that you value them by listening to them and accepting their point of view.

…and in practical ways:

• If you are planning a church or CMF event that involves food, be aware that this will be a source of terror to people with eating disorders.
• Serve any meal as a buffet so that people can control their own portion size, and include 'safe' options such as salad or fruit.
• Let sufferers know what will be on the menu so that they can prepare themselves. If they choose not to come, suggest meeting them for a food-free activity, such as a walk, so that they do not become completely isolated.
• Don't alter your own eating pattern, since sufferers need to be able to see what 'normal eating' looks like.
• Try to steer conversation away from food and weight. Don't comment at all on their appearance: even 'You look well today', will be interpreted as meaning 'You look fat'.
• If you think someone may have an eating problem, broach the subject yourself - they may crave help but be too afraid to ask. Simply let them know that you understand and are willing to listen if they ever want to talk, this will usually defuse any hostility.
• If they are not already receiving treatment, be prepared to help them access professional help (see below).

You will not be able to 'fix things' for a sufferer on your own, but if you are prepared to stick by someone throughout what can be a long and frustrating illness, you will truly discover that 'Love never fails'.[4]

What can Christian doctors do?

When you encounter someone with an eating disorder either as a medical student or as a doctor, there are some additional factors to bear in mind.

First of all, it is worth remembering that a sufferer's fears about admitting to their problem will be multiplied in the context of a medical consultation where the power balance is weighted heavily towards the professional. They will be terrified that the single constant in their life - the eating disorder which gives them a sense of control and identity - is going to be taken away from them, leaving them defenseless. They may also be afraid that the doctor will dismiss them because they are 'too fat' to have an eating disorder, confirming their worst fears about their appearance. Many fear being labelled as a 'psychiatric case' or an 'attention seeker', and the potential implications that this could have for job or course applications.

Secondly, because of these fears, sufferers do not tend to present complaining of an 'eating disorder'. Sometimes they are brought to the emergency department in a state of collapse due to dehydration or electrolyte imbalances; sometimes they attend their GP or an outpatient clinic with menstrual abnormalities, constipation, unexplained weight loss or depressive symptoms. It has been shown that GPs miss an underlying eating disorder in 50% of their patients who attend with related symptoms.[5] As medical students and doctors, we need to be alert to the possibility that a patient with no obvious physical cause for these symptoms may have an eating disorder. The National Institute for Health and Clinical Excellence (NICE) recommends that we use simple screening questions – such as 'do you think you have problems with eating?' and 'do you worry a lot about your weight?' to help identify those at risk.[6] We can then make the diagnosis according to the ICD-10 criteria (which are helpfully summarised in a Student BMJ article available on-line)[7] and ensure that we make an appropriate referral.

Thirdly, bear in mind that many sufferers will have had negative experiences of discussing their problems with medical practitioners on previous occasions. Such experiences invariably arise because of a genuine lack of understanding on the part of the doctor, but can nonetheless have a devastating effect on the patient. The following real-life examples are not uncommon:

There's no point treating you. You have a destructive personality; you'll end up killing yourself some day anyway.

I'm not going to waste my time with you - there are people here who really are sick.

All you need to do is start eating chips and chocolate every day and you'll soon put on some weight.

Some sufferers will also have had distressing inpatient experiences involving behavioural regimens where weight loss is punished with bed-rest, while weight gain is rewarded with 'privileges' such as being allowed to have a shower under supervision. Patients can lose all sense of self-worth under such conditions and the psychological damage incurred is sometimes irreparable.

Fears, denial and past grievances are not the only challenges facing Christian doctors who genuinely want to help patients with eating disorders. One SHO had this to say:

The difficulty with eating disorders, for me, is that…each person has a hundred things that they need some help to work through – psychological things, not to mention the food and addictions and depression and suicidal feelings - goodness knows what else. All I have at the most is maybe five minutes with them. I mean, what can I do in five minutes that will make a meaningful difference?

Making minutes count

The above situation does indeed sound hopeless. However, a surprising amount of good can be achieved in five minutes. Dr Ken Yeow, a Christian eating disorders psychiatrist, suggests that adopting certain attitudes in our interactions with these patients can be therapeutic.[8] People with eating disorders are perceptive and highly sensitised to what others think of them. If you approach them with an open mind, aware of the complex issues they are facing, and with a genuine desire to understand rather than to judge, they will respond positively. Being gentle and kind, giving up even a few minutes to talk to a sufferer, will communicate that you value them, helping to build their self-esteem.

The time when you might be responsible for treating a patient with an eating disorder may seem like a long way off, but even as a medical student you can make a difference. Non-specialist consultants caring for someone with an eating disorder-related complication may be unsure of what to do aside from treating the physiological problem and would often appreciate input from an informed student. Students can also fight against the stigma associated with eating disorders, respectfully reminding those who denigrate patients that these are real illnesses which sufferers cannot control.

Where management is concerned, there are a number of guidelines that are worth familiarising yourself with.[9] These emphasise the importance of a holistic approach including attention to physical problems, effective psychological therapy and provision of social support. Christian doctors should also be aware of their patients' spiritual needs.

Medical students and doctors often find it difficult to explore whether a patient is interested in spiritual issues, but one way to do so is to offer a leaflet from Anorexia and Bulimia Care, a Christian organisation (see box). This is in line with NICE guidelines as long as you also provide information on secular sources of help, such as the Eating Disorders Association (see box). It is worth remembering that Christians are over-represented amongst eating disorder sufferers and may be reluctant to volunteer that they have a faith. Conversely, many non-Christian sufferers, disillusioned with conventional treatments and feeling a loss of meaning and purpose, are open to discuss spiritual issues. It is a good idea to explore whether sufferers would like to be referred to a hospital chaplain, and you could offer to pray with them yourself.

When doctors and medical students take time with people who have eating disorders, it makes a difference, as this 21 year old with anorexia testified:

In seven years of treatment… the thing I remember most was this one doctor. She'd been on the ward one night when they had to put a tube in to feed me, which was really horrible. I know I didn't make it easy – I went mental and every time they put it in I would pull it out… she had to keep putting it back in. Anyway, the next day, I guess after she had had a sleep, she came to see me after her shift had ended. She'd brought me a magazine to read, and a card. She sat with me for a while, and chatted to me. She said how hard it was for them to have to make me have the tube, and explained that it was just because they cared and did not want me to die. Often, when things get hard, I think of her and of what she said. I knew she really cared and that touched me.

Image and identity: the challenge to Christians

We have seen that eating disorders are not simply the result of succumbing to a desire to look like a supermodel, or to the latest diet fad. So what role does our appearance-obsessed society actually play in this issue, and is there a Christian response?

First of all, there is evidence that living in a culture which idealises thinness is a risk factor for the development of an eating disorder. The media and fashion industries cannot be held responsible for the fact that a person feels out of control in life or needs to numb emotional pain, but they do contribute to the tendency for sufferers to associate negative feelings with 'fatness'. Similarly, while dieting in itself does not cause eating disorders, it has been shown to be a potential trigger in individuals who are already at risk.

Regardless of its relevance to the specific problem of eating disorders, Christians must be suspicious of media preoccupation with image because it creates a culture of conditional acceptance. This applies not only to appearance but also to career success, social status and lifestyle choices. We are constantly assimilating messages such as, 'you must wear size 10 designer clothes to be accepted…you must have a degree from a big-name university to be accepted…you must earn £60,000 a year to be accepted…you must go clubbing and sleep around to be accepted…' These messages inevitably construct a social hierarchy and those who do not reach the mark feel worthless and rejected. Some become depressed; some, sexually promiscuous; some turn to alcohol or drugs…and some develop eating disorders.

Christians are not immune to these messages. A recent survey carried out amongst Christian university students showed that they felt just as much pressure to establish an acceptable identity as non-Christians did. As Christians we are failing to grasp the truth that the very foundation of our faith is unconditional acceptance: as Philip Yancey famously wrote, 'There is nothing we can do to make God love us more. There is nothing we can do to make God love us less.'[10] We are also distracted from the fact that God created us in his image[11] and that he looks on the heart, not the outward appearance.[12]

Medical students may feel pressurised to 'dress to impress' and subscribe to a certain value system or social hierarchy. We can easily be tempted to find our self-worth in the fact that we are pursuing a venerated profession, but such a position renders us vulnerable to a crisis of identity should we fail exams, become ill or simply realise that medicine is not for us. We need to remember that as Christians we are called to be counter-cultural: to find our identity in whose we are, rather than who we are, for then we will never be shaken.

With thanks to Dr Kate Middleton and Dr Ken Yeow.