Eating disorders are not about food: what is really underneath

“I do eat. I just … can’t stop thinking about it.”

I have heard that sentence in my room so many times that it stopped sounding like a confession and started sounding like the description of something much larger. The person in front of me was not talking about a meal. They were talking about a mechanism that stays switched on in their head and refuses to go off — and about food being simply the place where that mechanism is most visible.

Eating disorders have an odd fate in public conversation. Everyone knows their names, almost nobody knows what they are about. They look like a problem with eating, so the solution seems to lie with eating. And because it looks that simple, the people around get pulled into the wrong conversation: what would be good to eat, how much, when. That conversation almost never helps and often harms, because it pushes the person deeper into the very axis along which the disorder developed in the first place.

Why distress leans on food at all

Food is something very particular for human beings. It is the one thing we do every day, several times a day, from birth to death, and it is at once deeply bodily and deeply social. It is tied to care, to home, to a mother, to family, to celebration, to comfort and to belonging. When a person is looking for something that gives them the feeling of a hand on the wheel, food is right there — always, free, requiring nobody’s agreement.

That is why eating disorders often develop in people who, at some point in life, lost their sense of influence. A move, parents separating, illness in the family, a change of school, a competitive environment, a loss, violence. The areas of life that are uncontrollable then remain uncontrollable. But the relationship with food suddenly becomes the only field where something can be decided and carried through. The sense of mastery this brings is short, but it is very convincing — and the trap is precisely in how convincing it is.

Something else tends to be overlooked: the disorder almost never appears on empty ground. Usually the person has already had years of experience of being answerable for their body in front of others — the object of comments, comparisons, assessment at training, at the family table, in a changing room. That experience does not by itself cause a disorder, but it prepares the ground on which the new rules feel logical. So with this topic I always want to keep two things apart: cultural pressure is the environment in which the disorder grows, but it is not its engine. The engine is internal.

Feelings there were never words for

In people with eating disorders I often notice what the field calls difficulty recognising and naming emotions. It is not that the feelings are absent. It is that they arrive as an indistinct bodily wave — something is squeezing, something is boiling, something is too tight — with no label to say whether this is anger, fear, loneliness or hurt.

A nameless wave is unbearable, because nothing can be done with it. Handling food gives it a shape. Suddenly the inner state has an outer expression, something measurable that comes to an end. Researchers who have studied emotion regulation in anorexia describe exactly this: the symptom does not serve appearance, it manages states the person otherwise cannot tolerate.

This is where eating disorders meet everything I write about elsewhere on this blog — self-compassion, the inner critic, and the idea that a symptom is saying something, even when it looks senseless.

Control that promises calm

People often describe that in the period when it began, something was completely clear to them for the first time in their life. The rules were precise, the boundaries sharp, success and failure unambiguous. For someone who grew up in an environment where it was never clear what was expected, or where the atmosphere at home turned unpredictably, that kind of clarity is an enormous relief.

The problem is that control of this kind is not stable. It demands more and more, because the sense of safety it gives deflates faster each time. And as the rules escalate, life shrinks around them — planning the day, avoiding company, dodging occasions where eating happens in front of others. In the end the person controls nothing. They are controlled by the system they built in order to feel safe.

What undernutrition does on its own

Something everyone with a person like this beside them should know: a large part of what looks like character is the consequence of a biological state. This has been well documented since Ancel Keys’s study in the middle of the last century, where volunteers who had been mentally healthy beforehand developed preoccupation with food, irritability, social withdrawal, poor concentration and rigid thinking under prolonged undernutrition.

That means two things. First, it is not fair to hold against someone behaviour that is largely driven by a starved brain. Second, no psychotherapy can really work until the body is in a state that allows the mind any flexibility at all. This is why establishing nutritional stability comes first in treatment — not because the disorder is “about food”, but because without it there is no raw material for change.

Shame is fuel, not a side effect

Eating disorders live on secrecy. Almost everyone who comes to me tells me very early that they have told nobody, or that they told one person and regretted it. Shame works as a fuse against help: it convinces you that you are not ill enough to deserve treatment, and at the same time too ill for anyone to still want you around.

These double messages are typical of shame that speaks not about a deed but about a person. So in therapy the first real shift is often the moment when something is said out loud and the world does not collapse. It is not a technique. It is a corrective experience: I said the worst of it and I stayed inside the relationship.

What others see and what is happening inside

Between what the people around notice and what the person experiences there is often very little overlap. That gap is exactly why well-meant responses so often miss.

The family is not to blame, but it is the strongest resource

For a long time families were held responsible for eating disorders. That explanation did enormous damage and was not supported by evidence. Today we know something more useful: the family is not the cause, but it is the most powerful tool we have when treating adolescents.

This is why family-based treatment is the recommended first-line approach for adolescents with anorexia — an approach in which parents take an active part in establishing nutritional stability, while the therapist works with the family as a whole. Not because parents need correcting, but because they are the closest and most constant support a young person has. In young people the evidence supports this more consistently than any individual approach.

Where this claim does not hold

Now the part that has to be said, even though it unsettles everything above. The sentence “eating disorders are not about food” is true as a description of meaning, but dangerous as an instruction for action.

First: eating disorders have a strong biological and genetic component. Large genetic studies suggest that anorexia is not only a psychiatric but also a metabolic disorder. Which means that no amount of “understanding the real cause” will by itself remove the illness.

Second: in practice the sentence is often used as an excuse to delay. If the disorder is “not about food”, then it seems we can postpone eating and sort out the feelings first. That is the wrong way round. Without nutritional stability the brain cannot settle enough for therapy to take hold.

Third: plenty of people are not helped by an in-depth exploration of childhood and do not need one. Behavioural approaches that address mainly what maintains the disorder in the present have well-supported effectiveness in adults. Searching for a deep origin is not a precondition for recovery, and sometimes it becomes a form of avoiding change — as long as we are looking for the cause, nothing has to be attempted.

And fourth: the same sentence means different things to different people. For one it brings relief, because they stop blaming themselves for lack of willpower. For another it becomes a weapon that deflects every suggestion that would change anything about eating. So I use it as an explanation, never as a reason to postpone.

When therapy is not the first step

Among mental disorders, eating disorders carry the highest physical risk. So the rule is clear: if fainting, heart rhythm disturbances, marked weakness, loss of menstruation or rapid deterioration in general condition appear, the first address is a doctor, not a therapist. A GP can order basic investigations and judge whether more intensive care is needed.

The same applies when thoughts of self-harm or of not wanting to be alive appear. Psychotherapy stays important then, but it is not the only thing a person needs. I have written more about when it makes sense to begin with a doctor in the piece on when a doctor is the first step, and I map out the routes to help in Slovenia in the piece on referrals and waiting lists.

What we actually do in therapy

We rarely talk about menu plans. Far more often we talk about the moment in the week when the feeling arrived that everything was too much, and what happened just before that. We are looking for a pattern, not a culprit. Gradually a vocabulary is built for states that used to be nothing but pressure in the chest.

We also work on what the disorder does inside relationships: how it guards against closeness, how it expresses anger that was never allowed to show, how it holds a family in a certain balance. And we work on the person slowly acquiring other ways of getting what the disorder has been giving them — calm, a boundary, the sense of managing something. There is no taking away without a replacement. That is the most practical thing I know about eating disorders.

What to remember

Eating disorders play out at food but they are not speaking about it. They speak about regulating states a person has no words for, about control that promises safety, and about shame that makes sure it all stays hidden.

And at the same time: nutritional stability is not something that comes after understanding. It is the condition for it. In adolescents, family-based treatment is the recommended first choice, and where physical health is at risk the first address is always a doctor.

If you recognise yourself or someone of yours in this: you are not too little unwell to ask. Eating disorders respond best early, and the only step that matters more than the right step is the first one.