Earlier this year, thirty-seven year old anorexia nervosa patient Rachael Farrokh shared an emotional plea on YouTube to raise money for the only specialised treatment program that would accept her as a patient due to her life-threateningly low weight. Many of the reactions were prefaced with the obligatory 'no offence, but' and ended with 'can’t she just eat a hamburger?' What surprised me most was the unwillingness of the public to understand the long-term impact that starvation has on the body and mind, and how the 'food-mood connection' means that, as a psychiatric disorder, it is very difficult to prevent anorexia nervosa from recurring.

The saying ‘you are what you eat’ is a double-edged sword in the development and persistence of anorexia nervosa. Cognitive functions are distorted in eating disorders. Food habits, mood, and anorexia nervosa related brain damage directly influence what, when, and how much we eat. Consequently, food intake directly affects the brain in both the short and long term. Both cognitive and emotional functioning become compromised, thereby further consolidating anorexia nervosa in a vicious cycle.

Most of us were told as children to have a decent breakfast or we wouldn’t be able to concentrate in school. And apart from the smiling ladies in advertisements, no one has ever looked happy from restrictive food intake. The short-term effects of this type of diet amounts to difficulties with cognition, mood and motivation. This is because they operate directly via the amount of glucose available to the brain, or via neurotransmitters such as serotonin, dopamine, and norepinephrine. Serotonin, the ‘happiness’ neurotransmitter (also a vital source for antidepressants, SSRIs - selective serotonin reuptake inhibitors) is biochemically derived from tryptophan. The body is in fact not capable of synthesising this compound on its own and relies on supplementary provisions through diet. Food containing high levels of tryptophan include nuts, seeds, cheese, soya food, chicken and turkey, red meat, tuna, and eggs – in other words: healthy proteins. Dopamine, the ‘reward’ neurotransmitter, and norepinephrine, involved in the stress response and derived from dopamine, are closely related to each other and are released through tyrosine. Tyrosine is a non-essential amino acid and is found in high-protein foods such as dairy products, meat, pumpkin seeds and sesame seeds, and almonds. Given that psychiatric disorders are characterized by biochemical imbalances in hormones and neurotransmitters, it is no surprise that our diet supplementing us with the necessary building blocks for these neurotransmitters plays a crucial role in psychological functioning: the food-mood connection.

The cumulative long-term effects of starvation include cardiovascular, endocrinal and gastrointestinal abnormalities and severe electrolyte dysfunction. Electrolytes such as potassium, calcium, sodium, magnesium and chloride are found in blood and bodily fluids and are essential for basic functioning of cells in every inch of our body. Starvation and obsessive exercise (i.e. sweating out electrolytes), common symptoms of those suffering from anorexia nervosa, paves the way for severe organ failure, heart attack and-life threatening conditions for patients. Once more an example of how nutrients influence the cells in our brain. Zooming outwards to more structural brain changes, anorexia nervosa is linked to decreased grey and white matter in the brain, and an increase in cerebrospinal fluid – causing structural alterations in brain structures involved in memory, motivation, mood, and cognition further affecting food-intake.

Such is the way the cookie crumbles with anorexia nervosa. Malnutrition affects the brain in such a way that it further induces restrictive-dieting and prohibit recovery. Anorexia nervosa is the psychiatric disease with the highest mortality rate. Due to cardiovascular problems, organ failure, and suicide, up to 20 per cent of people suffering from anorexia nervosa will die prematurely as a consequence of the disease. So why don’t those suffering from this condition simply break the vicious cycle and increase their calorie intake? Anorexia nervosa isn’t a simple disease with a simple solution. Body dysmorphia, pathological fear of gaining weight and continued starvation have disrupted the regular neural function which would allow that kind of decision making. Dr. Nora Volkow, director of the National Institute of Drug Abuse (Maryland, USA), compared addiction to a disease of free will: “The person who is addicted does not choose to be addicted; it’s no longer a choice to take the drug." Similarly, we can view anorexia nervosa as a disease of free will. Making the decision to eat, or not to eat – a decision we take for granted – is no longer in the hands of those suffering from eating disorders. Anorexia nervosa is not just about losing weight and wanting to lose more weight: it is defined by compulsive thoughts and behaviour taking away the ability to make a rational choice.

Too often the public perception of anorexia nervosa is based on the view that people suffering from anorexia nervosa want to be thin, and make the choice to live unhealthily.  However, a shift in our perception of eating disorders should take into account the complexity of the disease. Just as Dr. Volkow says, anorexia nervosa is a disease of free will, characterised by the way in which the food-mood connection takes away rational choice in dietary behaviour.