Running on empty: An eating disorder in disguise

"Being around food is intensely stressful for me. I think I hide it from my daughter pretty well, but I get anxious when she rejects food, or won't finish everything on her plate."

At the UK's leading private rehab and addiction centre a group of women ranging in age from 34 to 76 are gathered to talk about the effect their eating disorders are having on their children. All are university-educated, with successful careers. Sophy, aged 42, is bringing up her three-year-old daughter alone.

"I've had anorexia since the age of 20, and I'm terribly worried that she'll develop an eating disorder," she says. "I try to give her a balanced diet but I'm not the most imaginative when it comes to putting meals together. Also, I worry about her eating alone: most nights I just have some cottage cheese and a glass of red wine after she's gone to bed, but I don't really sit at the table as such. The problem is it's just the two of us ... it would be good if we could eat together, I know. At least she eats with other people at nursery."

Fran is 53 with two teenage sons. "Thank God I had boys," she says. "I couldn't have coped with daughters and all the anxiety around bodies and weight. I spend all my time in the kitchen, cooking and feeding up the three men in my life – they're very sporty and have huge appetites – and no one notices that I'm not eating much myself."

These women are right to be concerned that their inability to sit down and eat may be transferred on to their children. Studies show that anorexia and bulimia can be inherited diseases. But it's not only women with a medical history of disordered eating who worry about feeding their children. A colleague who suffers from neither condition, pregnant with her second child, tells me: "I've been wondering how I might treat my baby differently if she turns out to be a girl. I already have a son and happily fill him up with bread, cheese and carbs – as a boy he needs all the energy for running around – right? But would I feed a baby girl in the same way?"

Generation clean

Her fears are not uncommon. All over Europe, a generation of professional, middle-class women – and some men too – is exhibiting increasingly disordered eating habits, a condition now starting to be recognised as orthorexia nervosa. In their search for the perfectly balanced lifestyle, they combine restrictive diets with punishing exercise regimes, are fanatical about calorie-counting, green juicing and honing their gym-bodies.

These women appear normal to the untrained eye, usually with successful careers and families. But they are also obsessively vigilant about their food and weight, and most of them are hungry all the time. Their habits can last a lifetime: there's no obvious crisis, no emergency hospitalisations or nasogastric feeding.

These women seem fine, just rather thin. And the health risks are mostly invisible – infertility, amenorrhoea (cessation of periods), insomnia depression, and osteoporosis, severe loss of bone density, electrolyte imbalance and kidney and heart problems in bulimia. You can't see these things from the outside, so the physical damage may remain as hidden as the mental anguish.

If these women are not clinically anorexic, they are verging on the orthorexic. Orthorexia overlaps with anorexia and other eating disorders, and is increasingly mainstream, somewhere on the blurred boundary between being health-conscious and a health obsessive. Orthorexia is defined as a "fixation with righteous or correct eating" – but what begins as an attempt to improve one's lifestyle can morph into an unhealthy fixation. It can lead to self-loathing, low self-esteem, social isolation and even malnourishment.

Orthorexia thrives in a society in which we're urged to count calories and "eat clean", to avoid artificial additives and preservatives, to beware plastic packaging and hidden toxins and, above all, never to get fat. Dr Steven Bratman, who coined the label in 1997, describes his own experience of orthorexia: "I pursued wellness through healthy eating for years, but gradually I began to sense that something was going wrong... My ability to carry on normal conversations was hindered by intrusive thoughts of food. The need to obtain meals free of meat, fat, and artificial chemicals had put nearly all social forms of eating beyond my reach. I was lonely and obsessed ... I found it terribly difficult to free myself. I had been seduced by righteous eating..." Many of us will recognise this experience, or know people like this.

While orthorexia is not officially recognised in DSM-V (the Diagnostic and Statistical Manual), it resembles other eating disorders in the rigidity and guilt of the mind-set: while anorexics or bulimics obsess about calories and weight, orthorexics obsess about the purity and quality of everything which passes their lips. Many specialists believe that orthorexia is an eating disorder in disguise – more respectable, but no less restrictive. Yet another subset of these sanctioned, even fashionable, disorders is the growth of dietary intolerances, allergies or avoidance of entire food groups.

And it's spreading. More than one in five Brits currently claims to have a food allergy or intolerance, an increase of 400% in the past 20 years. The European Academy of Allergy and Clinical Immunology estimates that approximately 17 million Europeans suffer from food allergies, with the number of cases among children apparently doubling over the past 10 years. Another source, the Allergen Bureau, estimates that despite 30% of adult Europeans claiming to experience adverse food reactions, only 3-5% of Europeans have been diagnosed as suffering from a genuine food allergy.

This is a worldwide phenomenon, with figures by the Australian Bureau of Statistics revealing that almost four million people in Australia reported avoiding a food type because of allergy or intolerance. The perception of allergy or intolerance among consumers is consistently far higher than actual recorded cases: countless studies have concluded that true food allergy occurs on average in about 1-2% of the adult population (with a slightly higher prevalence among young children of 3-7%).

In other words, millions of people have decided, or been persuaded, that they are "allergic" to certain foods, the most commonly cited culprit being wheat. Whole aisles in supermarkets are now dedicated to gluten-free products – even though, when questioned, most consumers don't know what gluten is or what it does.

For diagnosed eating disorders, the statistics could be considered equally misleading. According to the National Institute for Health and Clinical Excellence, 1.6 million people in the UK are affected by an eating disorder. But that figure is what the NHS calls "hospital episode statistics" and vastly underestimates the true number.

Anorexics and bulimics and over-eaters and many others, obese or skinny, whatever their weight, have this in common: intense shame about their appetite, a sense of being out of control around food, feeling guilty, anxious or embarrassed about eating. None of these people appear in that official figure of 1.6 million because they're not hospital patients or in counselling. They're "normal" on the outside.

Black water

Then there's the exercise. Disordered eating invariably goes hand in hand with excessive levels of physical activity. It's logical enough, when you're restricting the amount of calories going in, to try and maximise the amount going out. We've all seen frail women in the gym, or out pounding the pavements, who are clearly pushing themselves too hard. Every one of the women interviewed for this article combined restrictive eating with high intensity exercise, working out six or seven times a week. Sophy opts for "kickboxing, spinning or circuits, as hard as possible. I never take a rest day, I'd feel so lazy." They all felt "guilty" if they missed a session through illness, work or family commitments; Fran even went running on Christmas Day.

As a sufferer of anorexia throughout my teenage years and twenties, it's this relentless self-punishment that I remember most vividly. It's inexplicable to the outsider, but for a while, not eating makes you feel superhuman. You don't rely on food like everyone else, you're light and maniacally hungry. And it's dangerous: when Fran recently shattered her hip from a simple fall, her doctors told her she has the bones of a 90-year-old. Low bone density is an invisible but growing problem among young women, many of whom avoid calcium-rich dairy products like milk and cheese. Teens and twenties are a crucial life-stage for building bone mass – shockingly, up to 90% of anorexics show some degree of bone loss.

Brutal physical training regimes are surging in popularity among the beautiful people, the rich and famous and the affluent urbanites, along with the notion that everyone should attain peak athletic performance. US military-style exercise classes are popular in the UK, catering for this new hardcore mindset. Workouts aimed at women that claim to "kick your ass" are de rigueur, such as Barry's Bootcamp or the Skinny Bitch Collective, exclusive temples of fitness for ultra-svelte women, models and celebrities, combining weightlifting, high-intensity cardio, deadlifting and circuit training. Classes are held at 6am or 7am, allowing devotees to "feel the burn" before most people are even awake.

Trying out an early-morning spinning class in central London, a dark basement studio filled with flashing strobe lights and pounding dance music, I am left figuratively in the dust (the bikes are stationary) astonished at the sheer intensity of the discipline. Devotees lift hand weights and execute push-ups on the handlebars while pedalling in time to the deafening beats. The classes have a tribal feel, with "ripped" instructors (mostly dancers and athletes) who enjoy cult-leader-like status.

Afterwards I ask a fellow spinner what keeps her coming back. "It's the best ever workout – and it burns around 1,000 calories. I work in finance so I'm sitting down all day – after this I'm on a high for hours." Doesn't she find it an exhausting start? "No way, I'm totally hooked. It's like a massive shot of adrenaline for my body and soul." No surprise that SoulCycle, the ultimate in spinning-and-motivational-psychology from the US, has ambitious plans to conquer London.

In capital cities all over Europe, hordes of women head into offices after classes like these with barely a protein shake to sustain them. In the changing room at my swimming pool in London, I recently heard a middle-aged woman telling her friend about the new "black water: alkaline fulvic trace-mineral-infused" that she is now drinking instead of both breakfast and lunch.

The skinny collective

The epidemic of eating disorders among adult women is occurring at a time of rapid professional, economic, social, sexual and cultural change. There are so many ways adult women can get it wrong, from work to parenting to relationships to appearance and ageing and weight, so much guilt and confusion about the conflicting roles of career woman and mother, and the ubiquitous glossy super-slim image of how we should look, in magazines and advertisements, on television and film. In a climate of insecurity, the pursuit of thinness is one way of finding approval, certainty and order.

What else might explain the desire for extreme leanness that we see around us? This self-denial seems curiously at odds with the explosion of all things foodie: cookery shows on every TV channel, the current crop of delectable young female chefs, food columnists and presenters, and the mania for organic ingredients, artisanal baking, spiralising courgette to eat instead of pasta, fasting and detoxing.

"Deliciously Ella" Woodward, the 23-year-old healthy eating blogging sensation, claims that her recipes have nothing to do with getting thin. "It's really important not to come over as smug and virtuous. I don't make big promises about losing weight or anything like that." Whether they follow Deliciously Ella, Gwyneth Paltrow's blog Goop, the Hemsley girls, or the Chiappa sisters, many women seem gripped by this culinary porn, while simultaneously uninterested in feeding themselves: toying with a salad or grabbing a wheatgrass shot between kickboxing and the next meeting.

The risk is that we become inured to the shock of emaciated women on the pages of glossy magazines, accustomed to the desperate thinness we see around us. As Susie Orbach powerfully put it in her 1986 classic, Hunger Strike, we must not lose sight of the shocking fact: "To encounter an anorexic woman is to encounter a woman who is starving herself."

A report for B-EAT (the leading eating disorders charity) in February 2015 estimated that the total financial and economic cost to the UK could be as high as £15bn (€21bn) per year. There is no known cure for anorexia or bulimia – treatment involves a combination of talking therapies such as Cognitive Behavioural Therapy and medication, both of which have limited success. However, it has been shown that early intervention vastly improves recovery rates: according to the National Eating Disorders Association for example, women who seek help for bulimia within five years of the appearance of symptoms have an 80% chance of recovery, but if symptoms exist for more than 15 years without treatment, the chances of recovery fall to 20%.

Mental health specialists have been warning for years that NHS cutbacks are putting pressure on services, with patients becoming sicker while they wait for admission. It's not only in the UK: in 2014, the American National Institute of Health allocated eight times as much research funding to schizophrenia as it did to all eating disorders combined, even though anorexia alone is twice as deadly as schizophrenia.

In December 2014, the UK government responded by pledging £150m (€210bn) over the next five years for the treatment of eating disorders in children and young people. Deputy Prime Minister Nick Clegg said: "Eating disorders affect hundreds of thousands of people in the UK but many have been left to suffer in silence, with some having to wait more than two years just to get the treatment. This is completely unacceptable." The number of children treated on wards for anorexia and other eating disorders has increased 12% in the past year to 2,965, double the number treated a decade ago. While this extra funding for children's services is crucial, treatment for adult remains desperately under-resourced.

Young and starving

No matter how well mothers may think they are hiding their food neuroses from their children, something is being passed on. Recent studies from Scandinavia found that daughters of women with eating disorders have twice the risk of being diagnosed with one themselves. Further research from the US and the UK supports the evidence that maternal eating behaviours and disordered eating habits are likely to be passed on. Children display psychological problems around food, and well as more general insecurities and attachment difficulties. Whether this happens because girls learn by observing their mothers, or whether there is also a genetic, heritable component, is still not clear. There has been some promising neurological research but this is still in its early stages. More likely, as with most human behaviour, it's a combination of nature and nurture.

It's often thought that young women will grow out of faddy dieting, or body hang-ups; sadly, the opposite is true. Eating disorders are addictive, and self-starvation becomes involuntary. Dr Paul Robinson, research consultant psychiatrist at St Ann's Hospital in north London, explains that, for some, the condition simply proves impossible to overcome. A sizeable minority develop what are known as Severe and Enduring Eating Disorders (SEED): "Of all the girls and women who develop anorexia nervosa around 20% will develop a chronic condition – the group that continue to have the disease in middle age. They may have become so attached to their thin body shape that no persuasion, therapy nor fear of consequences has allowed them to be free of the disease."

Dr Robinson describes a study of an anorexic mother in her thirties with two sons. "They were found to have stunted growth at age five and seven. When the mother was admitted to hospital they started to grow normally, and when she came home their growth ceased." However, he warns: "We are not certain that anorexia passes from mother to daughter."

Less common are those women who develop an eating disorder for the first time as adults: one study found that only 2% developed anorexia after the age of 25 – in other words, most sufferers will have had an earlier experience, either in a milder form, and either relapsed or simply never recovered. The triggers in a woman's thirties or forties may be different to younger women: as a response to pregnancy, the menopause, weight gain, redundancy, divorce, or the increased media expectations to look "fabulous" well into their fifth or sixth decade.

Janet Treasure, Professor of Psychiatry at King's College London, explains how easily disordered eating can become entrenched into a way of life: "Eating disorders have a protracted trajectory, lasting seven years on average for anorexia and 12 years for bulimia. Over 50% of cases develop a severe enduring stage of illness. Thus the illness has its effect in the second and third decade of life, a time of profound change and maturation."

The damage may start even before birth. I ask Dr Nadia Micali, senior lecturer and honorary consultant psychiatrist at University College London's Institute of Child Health, about conception and pregnancy when underweight. "Having a premature baby and baby of low birth-weight are recognised risks," she says. "Studies show that low birth weight and poor growth in utero lead to psychiatric disorders, developmental delays, and metabolic disorders in later life." Binge-eating and obesity also cause problems, including diabetes: "Studies for a long time focused on women with full-blown anorexia and bulimia, who are really a minority of all women who have eating disorder symptoms in the population. We lack good studies that focus on the many women with other and partial eating disorders."'

Too late for babies

Not all women with eating disorders need worry about harming their children: the ultimate cost of anorexia is infertility. The Chicago-based fertility specialist Richard Sherbahn made headlines in 2011 with the findings that women who are underweight have even less success conceiving through IVF treatment than those who are slightly overweight

The oldest member of the group, 76-year-old Valerie, tells me that anorexia robbed her of everything, including children:

"Looking back on the last five decades I don't remember eating a single mouthful without feeling guilty," she says. "It was 1958 when I started to lose weight, aged 22. I had always wanted a family, so I was desperate to gain weight in order to conceive. I carried on hoping and trying throughout my thirties and forties, but every effort ended in failure ... At the age of 70, I finally found a psychologist who explained that the anorexia was to blame, not me, and promised to help me overcome it. For six years we have worked together, and he's got me involved in this group. Now, unbelievably, I am starting to eat normally. Too late for periods, too late for babies, I am grateful I can enjoy food again. But I still feel a great sadness when I think about the children – and the grandchildren – I might have had, if only ..."

It seems tragic to start recovering from anorexia aged 76, and Valerie is well aware of the life she has wasted. In the future we'll see more cases, like Valerie or Fran, of women in their middle and later years with anorexia, bulimia and other eating disorders, and their health consequences. With the proliferation of websites devoted to what's called "thin-spiration", the vogue for instagrammed selfies of teenage "thigh gaps", we'll also see more children and young people following in their mothers' troubled footsteps. We may need to address the obesity problem, but we mustn't forget the other end of the weight spectrum. Eating disorders come in many shapes and sizes but they all take a terrible physical and mental toll.

Ultimately, these conditions are not just about weight or food, but about learning to live in a world of abundance, excess, deprivation; how to work out what we need and where to stop. It's still not easy – for many women, underweight, normal weight and overweight – to say the words out loud: "I need food. I'm hungry."

What's cash got to do with it?

Quite a lot, it might seem. Unlike other mental health conditions such as depression, anxiety, and drug or alcohol addictions, eating disorders do appear to be more prevalent among the middle class. In some ways this is unsurprising: anorexia thrives in the ambitious, perfectionist mindset seen in so many private schools and top-ranking universities. Whether it's vanity, wealth, or simply anxiety or control issues, anorexia does appear to be a disease of the affluent – a dangerous embodiment of the old saying that you can never be too rich or too thin.

But it's a tricky subject. Just as hard as to have a rational discussion about the growing problem of obesity among those of lower socio-economic status is the problem of eating disorders among the well-off. There is no doubt that food and weight are laden with social connotations: organic, biodynamic ingredients carry a hefty price tag, cooking from fresh can be time-consuming, and "eating clean" doesn't come cheap.

It's no wonder that the actress Gwyneth Paltrow lasted barely four days on the New York Food Bank Challenge, in which participants were challenged to survive on the weekly welfare budget of $29 (€27), admitting on her website, Goop, that she broke on day four. Paltrow (oft-ridiculed for the gluten-free, sugar-free, grain-free lifestyle she espouses) included seven limes, black beans, avocado, coriander and kale in her list of "essential ingredients" for the week.