The reasons why eating disorder patients drink

RESEARCH ARTICLE

The Reasons Why Eating Disorder Patients Drinky

Susan Hart1,5,6*, Suzanne Abraham1,6, Richard C. Franklin2,3 & Janice Russell4,5,6

1
Department of Obstetrics and Gynaecology, Royal North Shore Hospital, University of Sydney, NSW, Australia
2Royal Life Saving Society Australia, Broadway NSW, Australia

3Department of Paediatrics and Child Health, University of Queensland, Australia

4Discipline of Psychiatry, University of Sydney, Australia

5Royal Prince Alfred Hospital, Camperdown, Australia

6The Northside Clinic, Greenwich, Australia

Abstract

Objective: To explore the reasons why eating disorder patients consume non-alcoholic fluids and to examine

variables associated with poor and excessive drinking.

Methods: A sample of 115 patients admitted for inpatient treatment to a specialist eating disorder facility completed

a semi-standardised retrospective fluid intake history of type and amount of fluid and of reasons for drinking.

ANOVA, chi-square and factor analysis were performed.

Results: The main reasons for consuming fluids were for fullness and appetite suppression; for feelings of control

including feeling empty; to assist with purging; and for physiological reasons such as drinking when thirsty, after

exercising and to increase energy levels via caffeine ingestion.

Discussion:An eating disorder needs to be considered a disorder of fluid intake, as much as a disorder of food intake.

Factors affecting the fluid intake of eating disorder patients are related to the presence of eating disorder behaviours.

Copyright # 2010 John Wiley & Sons, Ltd and Eating Disorders Association.

Keywords

anorexia nervosa, fluid intake, appetite, drinking, caffeine

*Correspondence

Susan Hart, BSc, MNutrDiet, Level 2, Missenden Psychiatric Unit, John Hopkins Drive, Royal Prince Alfred Hospital, Camperdown, NSW

2060, Australia. Tel: 0061 2 9400 9695.

Email: [email protected]

Published online 8 October 2010 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.1051

Do patients with eating disorders also have drinking

disorders? It has been shown that patients with eating

disorders have disordered fluid intake on admission to

a specialist eating disorder treatment facility (Hart,

Abraham, Luscombe, & Russell, 2005) and few patients

drink the recommended amount of fluid (35–45mL/kg)

yThis article was published online on 8 October 2010. An error was

subsequently identified. This notice is included in the online and

print versions to indicate that both have been corrected [13October

2010].

Eur. Eat. Disorders Rev. 19 (2011) 121–128 � 2010 John Wiley & Sons, Ltd and

(Passmore and Eastwood, 1986). This study showed that

54% of patients drank excessively, somemore than 6 L of

fluid/day and 28% of patients drank restrictively,

particularly younger patients. Drinks of choice were

low calorie non-alcoholic beverages, such as water, diet

cola, tea and coffee. A relationship between weight and

fluid intake was demonstrated, with lower weight

patients, and older patients having a significantly higher

fluid intake (Hart et al., 2005).

Fluid intake has been associated with eating disorder

behaviours, such as binge eating, purging and exercise

rather than personality, temperament, mood and

Eating Disorders Association. 121

Eating Disorder Patients and Fluid S. Hart et al.

diagnosis (Abraham, Hart, Luscombe, & Russell, 2006).

Reasons suggested for drinking in eating disorder

patients include to: aid vomiting (Gendall, Sullivan,

Joyce, Carter, & Bulik, 1997); facilitate post-vomiting

irrigation, as a calorie-free alternative to food, related to

attempts at self-control, as a response to thirst arising

from dehydration, to have with a binge, increase weight

prior to weighing (i.e. to falsify weight), to feel good,

replace fluid lost while running, because it is

recommended in slimming magazines (Salkovskis,

Jones, & Kucyj, 1987); to help weight loss (Kornreich,

Dan, Verbanck, Fontaine, & Pelc, 1998); to attempt to

purify the body and eliminate toxins and calories via

urine (Santonastaso, Sala, & Favaro, 1998).

It has also been reported that patients with binge

eating and purging behaviours drink excessive

quantities of caffeinated beverages (Fahy & Treasure,

1991; Sours, 1983) to: suppress appetite (Fahy &

Treasure, 1991; Rock & Yager, 1987; Salkovskis et al.,

1987); boost energy levels without consuming calories

(Sours, 1983); restore energy, eliminate hunger and

relieve fatigue (Salkovskis et al., 1987); control weight,

increase effects of laxatives, increase metabolic rate and

for its diuretic effect (Fahy & Treasure, 1991).

Physiological mechanisms for abnormal fluid balance

have been described in anorexia nervosa (AN) patients,

such as impaired osmo-regulation (Evrard, da Cunha,

Lambert, & Devuyst, 2004), abnormal secretion of anti-

diuretic hormone (Gold, Kaye, Robertson, & Ebert,

1983) and a reduction in glomerular filtration rate

(Boag, Weerakoon, Ginsburg, Havard, & Dandona,

1985; Russell & Bruce, 1966) causing excretion of large

amounts of dilute urine.

Reasons for severe fluid restriction in seven young

eating disorder patients was because it contained

calories, drinking made them feel full and they felt

more in control when they restricted fluid as well as

food (Lowinger, Griffiths, Beumont, Scicluna, & Touyz,

1999). Many papers describe fluid excess rather than

restriction as described by Lowinger et al., 1999.

Young, healthy, normal-weight adults regulate intake

based on the internal physiological state and needs of

the body (de Castro, 1993). Apart from a dry mouth

and thirst, which has been shown to stimulate drinking

in fluid-restricted adults (Brunstrom, Tribbeck, &

MacRae, 2000), a range of psycho social reasons have

been shown to affect intake such as: the timing and

energy content of meals; preferences (i.e. taste, flavour,

colour, packaging, appeal and temperature); avail-

122 Eur. Eat. Disorders Rev. 19 (2011)

ability; knowledge of proper hydration; societal norms

and habits, and the presence of others who are drinking

(Kenney & Chiu, 2001). Both eating disorder (Hart

et al., 2005) and normal individuals have variable fluid

requirements and intake (Maughan & Griffin, 2003).

There is a wide distribution around average levels of

fluid consumption with complex factors affecting fluid

intake in normal people (Grandjean, Reimers, &

Buyckx, 2003).

To date there has been no study that has assessed

eating disorder patients’ motivation to drink, so analysis

was undertaken in patients who provided a self-reported

fluid intake history and survey of reasons for drinking.

The aim of this paper was to explore reasons why patients

with current eating disorders chose to drink non-

alcoholic beverages, and whether drinking behaviours

are significant in patient management.

Methods

A sample of 115 patients was surveyed on admission to

a specialist eating disorder inpatient facility in Sydney,

Australia. Patients were prompted to recall and describe

the frequency, type and amount of all fluids consumed

in the seven days prior to admission, including energy-

containing drinks (e.g. juice), energy-free drinks (e.g.

water and diet drinks) and caffeine-containing drinks

(e.g. coffee) (Hart et al., 2005).

Questions asked during the standard fluid history

included how many days and how many times each day

in the last seven days did the patient have this drink, and

if this was representative of average drinking behaviour.

Patients were asked to describe their fluid intake by

comparison to standard samples of cups and glasses

used at the clinic, and standard serving sizes for cans

(375mL) and bottles (300, 500 or 600mL) commonly

available.

Total fluid intake was calculated in total millilitres/

day (mL/day), and per kilogram of body weight/day

(mL/kg), as was total volume of caffeinated beverages in

mL/kg. Caffeine intake from fluid was also calculated as

milligram/day (mg/day). Patients were defined as

consuming an excessive amount of caffeinated bev-

erages (coffee, tea, diet cola and energy drinks) if they

were ingesting 300mg/day or greater of caffeine

(Nawrot, Jordan, Eastwood, Rotstein, Hugenholtz, &

Feeley, 2003) from fluid intake.

A self-report 32-item survey was developed from the

authors’ clinical experience of why they perceived

121–128 � 2010 John Wiley & Sons, Ltd and Eating Disorders Association.

Table 1 Survey of reasons for drinking. In the week before admission to hospital did you increase or decrease your fluid in order to

[Correction made here after initial online publication]

Reason Total sample AN restrict AN binge–purge Bulimia nervosa EDNOS

To feel full inside 65 26 5 18 16

To feel empty inside 16 9 2 3 2

To decrease appetite 53 22 3 14 14

Increase caffeine to boost metabolism 48 16 3 17 12

To weigh more when weighed 10 8 0 1 1

To feel in control 26 10 2 6 8

To weigh less when weighed 16 6 2 2 6

To eat less 63 24 6 16 17

To eat more 3 3 0 0 0

To smoke less 5 1 0 3 1

To aid vomiting 40 9 5 21 5

To prevent vomiting 6 1 0 5 0

To replace fluid lost purging 29 7 4 14 4

To aid gut transit of food 18 10 1 4 3

To slow gut transit of food 0 0 0 0 0

To prevent abdominal bloating 17 10 2 2 3

To slow absorption of food 2 1 0 0 1

To increase absorption of food 1 0 0 1 0

To stop feeling thirsty 88 36 4 22 26

To feel thirsty 10 5 1 2 2

To have something to do 53 19 4 13 17

To increase activity 11 4 1 4 2

To punish self 9 3 0 3 3

To keep body functioning 46 19 1 13 13

To replace what’s lost in exercise 37 12 2 13 10

To be able to exercise 28 13 2 11 2

To stop constant feelings of thirst 22 6 1 8 7

To improve blood test results 6 4 1 0 1

Increase caffeine intake to boost energy 22 7 2 8 5

To increase alcohol intake 3 1 0 1 1

To decrease alcohol intake 4 0 0 2 2

With spicy food 36 17 2 9 8

S. Hart et al. Eating Disorder Patients and Fluid

eating disorder patients may or may not drink

(Table 1). Patients were asked to mark ‘‘yes’’ or ‘‘no’’

to each item on the survey as to whether it influenced

their drinking in the seven days prior to admission.

A factor analysis was performed using a principal

component analysis as an extraction method. The

rotation method used was varimax with Kaiser

normalisation. Items where less than 10% of the

sample responded to the item were excluded from the

factor analysis [i.e. to increase activity (9.6%), weigh

more when weighed (8.7%), to punish self (7.8%), to

prevent vomiting (5.2%), to improve blood test results

(5.2%), to smoke less (4.3%), to decrease alcohol

intake (3.5%), to increase alcohol intake (2.6%), to eat

more (2.6%), to slow absorption of food (1.7%), to

increase absorption of food (0.9%) and to slow gut

transit of food (0%)].

Eur. Eat. Disorders Rev. 19 (2011) 121–128 � 2010 John Wiley & Sons, Ltd and Eating Disorders Association. 123

:

Once the factor groups were extracted from the

factor analysis, they were named by the authors

(Table 2) to describe the items from the self-report

survey i.e. to ‘aid vomiting’ and to ‘replace fluid lost

purging’ related to purging behaviour, therefore this

became the name of Factor 4. The sub heading of

each factor relates to the underlying mechanism, for

example, conscious behaviours that increase or

decrease fluid intake, physiological factors that may

increase or stimulate drinking behaviour as shown

in non-eating disordered samples, i.e. exercise

(Grandjean et al., 2003; Weinheimer, Martin, Weaver,

Welch, & Campbell, 2008) and in response to thirst

(Brunstrom et al., 2000).

Diagnoses were made by the Medical Director of the

program using Diagnostic Statistical Manual, version

IV (APA, 1994). Categories of behaviours (vomiting,

Table 2 Rotated component matrix for reasons for drinking

Item Factor 1

(fullness)

Factor 2

(control/

emptiness)

Factor 3

(exercise)

Factor 4

(purging)

Factor 5

(thirst)

Factor 6

(caffeine)

Factor 7

(gastrointestina

function)

To decrease appetite 0.804 0.068 0.033 �0.014 �0.001 0.156 0.102

To feel full inside 0.779 �0.106 �0.056 0.218 �0.201 0.014 0.097

To have something to do 0.675 0.063 0.005 0.012 0.182 0.029 �0.159

To eat less 0.648 0.040 0.117 0.220 �0.289 0.231 �0.203

To feel in control 0.117 0.818 0.062 �0.054 0.056 0.038 0.084

To feel empty inside �0.088 0.742 �0.071 0.276 �0.044 �0.050 0.040

To weigh less when weighed 0.018 0.602 0.206 �0.035 �0.511 �0.094 �0.096

To keep body functioning 0.029 �0.067 0.761 0.054 0.000 �0.047 �0.008

To replace what’s lost in exercise �0.067 0.127 0.708 �0.019 0.172 0.101 �0.054

To be able to exercise 0.125 0.283 0.447 0.211 �0.109 0.331 0.160

To aid vomiting 0.125 0.093 �0.023 0.874 �0.018 0.029 �0.002

To replace fluid lost purging 0.150 0.054 0.161 0.746 0.289 0.185 0.112

With spicy food �0.078 0.022 0.060 0.104 0.747 �0.251 0.044

To stop feeling thirsty �0.044 �0.114 0.319 0.112 0.588 0.279 �0.178

Drink caffeine to boost energy 0.329 0.089 �0.126 0.086 �0.028 0.662 �0.187

To stop constant feelings of thirst 0.001 �0.211 0.188 0.129 �0.089 0.654 0.150

Drink caffeine to boost metabolism 0.360 0.366 0.022 �0.116 0.327 0.510 0.284

To prevent abdominal bloating �0.184 0.145 �0.156 0.121 �0.061 0.113 0.772

To aid gut transit of food 0.174 �0.076 0.511 �0.039 0.086 �0.109 0.636

Explained variance (%) 13.26 10.22 9.57 8.53 8.31 8.11 6.94

Factor loadings >0.40 are presented in boldface type.


binge eating and excessive exercise) were assessed at

admission by a computerised eating and exercise

examination, which measures the presence of the

behaviour in the 28 days preceding admission (Abra-

ham & Lovell, 1999). Categorical variables were

analysed using chi square and continuous variables

were analysed using ANOVA using SPSS version 15.0,

Graduate version (Copyright SPSS Inc., 1989-2006).

Ethics approval was given by The Northside Clinic

Ethics Committee.

Results

In the sample of 115 patients, 57 patients met criteria

for AN, six patients with AN binge-purge and 51 with

AN restricting; 26 for bulimia nervosa; and 32 for eating

disorder not otherwise specified (EDNOS; Table 3).

Seventy six patients (66%) were under weight with

BMI< 19.0 kg/m2, while the remaining 39 patients

(34%) had a BMI in the normal range between 19.0 and

24.9 kg/m2.

There were seven factor groupings extracted from

the factor analysis which explained 65% of the

variance in reasons for drinking (Table 2). Mean

124 Eur. Eat. Disorders Rev. 19 (2011) 121–128 � 2010 John Wiley & Sons, Ltd and Eating Disorders Association

l

factor loadings for Factor 1 (fullness) were statistically

significant (df¼ 1, F¼ 17.894, p� .001) in patients

who drank caffeinated beverages excessively, com-

pared to other behavioural categories, i.e. patients

who drank excessive quantities of tea, coffee and

diet coke did so to feel full and suppress appetite.

Patients who drank excessive quantities of caffeine

also had a significant correlation with mean factor

loadings for purging (Factor 4; df¼ 1, F¼ 4.607,

p� .05), thirst (Factor 5; df¼ 1, F¼ 4.196, p� .05)

and caffeine (Factor 6; df¼ 1, F¼ 15.587, p� .001;

Table 4).

Patients who vomited more than seven times in the

previous month (n¼ 41; df¼ 1, F¼ 72.547, p� .001)

and those who had objective binge eating episodes

(n¼ 32; df¼ 1, F¼ 49.087, p� .001) drank fluid to

assist with purging behaviour (Factor 4). Patients who

drank an excessive quantity of fluid >45mL/kg, also

drank for reasons related to control (Factor 2; df¼ 1,

F¼ 15.508, p� .001), and reasons related to purging

(Factor 4; df¼ 1, F¼ 5.753, p� .05). AN patients with

BMI< 17.5 kg/m2 drank to assist with improving

gastrointestinal function (Factor 7; df¼ 1, F¼ 5.463,

p� .05).

.

Table 3 Characteristics, diagnosis, eating disorder and drinking behaviours of patients (n¼ 115). [Correction made here after initial online

publication]

n Mean Range

Descriptives

Age (years) 115 22.0 14–59

Admission weight (kg) 115 48.7 32.6–66.5

Admission BMI (kg/m2) 115 17.7 12.7–23.8

n mL/day mL/day

Drinking behaviour

Mean total fluid intake 115 2826 183–9013

Poor range drinkers (<35mL/kg) 29 994 183–1986

Normal range drinkers (35–45mL/kg) 13 2030 1250–2875

Excessive range drinkers (>45mL/kg) 73 3696 1886–9013

Excessive caffeinated drinks >300mg/day 30 581 300–1360

Diagnosis

Bulimia nervosa 26 4183 375–9013

EDNOS 32 2539 183–4821

Anorexia nervosa restricting 51 2293 250–5050

Anorexia nervosa – binge and purge 6 3005 985–5500

Eating disorder behaviours

Vomiting >7 times/month 41 3540 375–9013

Binge eating >7 times/month 32 3972 375–9013

Excessive exercise 20 2787 375–7339


Poor drinkers (<35mL/kg) reported their reasons

for avoiding drinking were due to control (Factor 2), i.e.

to help them feel in control, and to maintain a sense of

emptiness (df¼ 1, F¼ 8.366, p� .01). This group also

had a negative correlation with fullness as a reason for

drinking (Factor 1; df¼ 1, F¼ 8.366, p� .01), i.e. avoid

drinking to avoid feeling full, and with thirst (Factor 1;

df¼ 1, F¼ 6.766, p� .05), i.e. they are either not feeling

thirsty or not responding to the cue of thirst. The reason

‘to punish themselves’ was excluded from the factor

analysis as <10% of the total sample responded,

however poor drinkers selected this significantly more

than normal or excessive drinkers (7 out of 29; df¼ 2,

x2¼ 14.419, p� .001) when all 32 survey items were

considered.

Patients were also asked an open-ended question of

‘other’ reasons they chose to drink. Reponses included:

‘because it’s good for me’, ‘it tastes good’ (usually diet

cola), ‘to stop headache’, ‘when having a dry mouth’,

‘with salty food’, ‘to warm up and when I feel cold

inside’, ‘to stay awake’ and ‘to be social’. Poor drinkers

responded to the open-ended questions with additional

reasons for restricting fluid intake of ‘too busy and a

waste of time’, and ‘I don’t deserve to drink’.

Exercise (Factor 3) was extracted from the factor

analysis as a distinct factor to the other six factors,


however when the mean factor loadings were compared

with patients who were defined as having excessive

exercise (Table 4) there was no significant correlation. It

is possible that this is related to the difficulty in defining

those who exercise excessively versus those who exercise

normally, as currently there is no gold standard for the

definition of excessive exercise.

Figure 1 describes a formulation of the reasons for

drinking obtained from the factor analysis from this

paper combined with previous papers for why patients

drink to form a model of fluid balance in eating

disorder patients (Evrard et al., 2004; Garigan & Ristedt,

1999; Gold et al., 1983; Lowinger et al., 1999; Maughan

& Griffin, 2003; Russell & Bruce, 1966; Santonastaso

et al., 1998; Weinheimer et al., 2008).

Discussion

This paper demonstrates that eating disorder patients

drink for four main reasons: (i) for fullness and appetite

suppression; (ii) for feelings of control including feeling

empty; (iii) as a weight-losing behaviour to assist in

purging and (iv) for physiological reasons, such as

drinking when thirsty, to exercise, to increase energy

levels via caffeine ingestion and to improve gastroin-

testinal function.

Eating Disorders Association. 125

Table 4 Relationship of mean factor loadings with categories of eating disorder behaviours. [Correction made here after initial online

publication]

Eating disorder

category

n Factor 1:

Fullness

(conscious

increase)

Factor 2:

Control

(conscious

decrease)

Factor 3:

Exercise

(physiology)

Factor 4:

Purging

(weight

losing)

Factor 5:

Thirst

(physiology)

Factor 6:

Caffeine

(physiology)

Factor 7:

Gastrointestinal

function

(physiology)

Vomiting 41 0.134 0.161 �0.033 0.836�� 0.012 0.057 �0.134

Objective binge

eating

32 0.168 0.015 0.080 0.882�� 0.079 0.240 �0.180

Poor drinker

<35mL/kg

29 �0.450�� 0.451�� 0.262 �0.215 �0.408� �0.192 �0.030

Excessive drinker

>45mL/kg

73 0.107 �0.265�� 0.121 0.166� 0.105 0.110 0.024

Caffeine excessive

>300mg/kg

30 0.620�� 0.032 �0.125 0.332� �0.317� 0.583�� 0.020

Excessive exercise 21 �0.082 0.010 �0.069 0.250 �0.244 0.304 �0.012

AN 57 �0.050 0.059 �0.103 �0.118 �0.062 �0.190� 0.216�

�� p� .001�� p� .01� p� .05


Patients who have objective binge eating and

purging behaviours, drink to aid their vomiting

behaviour and to replace fluid that is lost during

purging. Patients report that when binge eating they

have large quantities of fluid to make it easier to

regurgitate stomach contents. Caffeinated beverages

appear to be used by eating disorder patients to

feel full and suppress appetite, to aid with purging,

to boost energy levels and to stimulate metabolism.

The relationship between caffeine intake and

eating disorder behaviours needs to be further

examined. There is evidence that caffeine may boost

energy levels (Maridakis, Herring, & O’Connor,

Figure 1 Model of fluid balance in patients with eating disorders

126 Eur. Eat. Disorders Rev. 19 (2011)

2009), suppress appetite (Jessen, Buemann, Toubro,

Skovgaard, & Astrup, 2005) and effect metabolism

(Westerterp-Plantenga, Diepvens, Joosen, Berube-

Parent, & Tremblay, 2006); however, it is unclear

whether excessive caffeine intake is clinically signifi-

cant in preventing or suppressing weight gain in

inpatients.

Reasons for restricting fluid intake in poor drinkers

contrast with other groups, such as those who drink

excessively or who binged and vomited. Poor drinkers

were younger (Hart et al., 2005), so perhaps more likely

to live with other family members where they may

have less control over their environment, therefore

121–128 � 2010 John Wiley & Sons, Ltd and Eating Disorders Association
.


expressing their need to be in control through fluid

restriction, not just control of food intake.

Meals play an important role in helping stimulate the

thirst response in normal healthy adults (Maughan,

Leiper, & Shirreffs, 1996) and as food is decreased so is

ad libitum fluid intake (Kenney & Chiu, 2001).

However, in this sample, patients’ show a contrasting

result to normal adults; that is, as total food is restricted

fluid intake appears to increase. This association of

eating and drinking described in normal adults is lost in

eating disorder patients’ as fluid becomes a conscious

weight control method, as a replacement for food, and

to aid weight-losing behaviours.

Physiological reasons for drinking such as when

thirsty (Brunstrom et al., 2000) and ad libitum intake

when exercising (Grandjean et al., 2003; Weinheimer

et al., 2008) are well-documented to affect fluid intake

in normal healthy people and are consistent with

popular health messages regarding motivation to avoid

dehydration and heat stress when exercising (Garigan

& Ristedt, 1999). These physiological reasons for

drinking also appear to influence eating disorder

patients drinking behaviour.

AN patients were more likely to drink to ‘prevent

abdominal bloating’ and ‘aid gut transit of food’ than

other diagnostic groups. This motivation to drink may

be associated with refeeding, due to delayed gastric

emptying prior to re-nutrition (Rigaud, Bedig,

Merrouche, Vulpillat, Bonfils, & Apfelbaum, 1988).

One patient stated their motivation for drinking

was ‘with salty food’ and four said they drank ‘to

warm up and when I feel cold inside’. These

were reported by patients as a response to ‘other

reasons’ for drinking and unfortunately were not

presented to the whole sample as part of the survey

but it is possible that both these reasons may

contribute to the reasons low weight patients drink

and should be explored further. A drop in core body

temperature at a low weight (Miller, Grinspoon,


Ciampa, Hier, Herzog, & Klibanski, 2005) and

extreme use of salt has been described in AN (Morgan

& Lacey, 1998).

An eating disorder needs to be considered a disorder

of fluid intake as well as of food intake. A nutritional

assessment of the appropriate quantity for each

individual plus discussion of drinking behaviours and

motivation for drinking should be an essential part of

assessment of eating disorder patients. Psycho education

should be provided on: not drinking as a method of

reducing appetite; avoiding drinking when hungry as

an alternative to eating or ‘to have something to do’;

and how eating disorder behaviours may affect fluid

requirements. Clinicians should be aware that patients

who are poor drinkers may be doing this to feel in

control, which will need to be addressed as part of

therapy, and patients who have excessive caffeine intake

may be likely to be engaging in binge eating and vomiting.

Due to the lack of information on drinking habits,

the authors had little to guide survey design and

initiated the study for clinical reasons rather than as a

research protocol therefore the survey may be biased

towards the author’s beliefs about why patients might

drink and towards methods of control of food and

weight. Further work is required to ensure a drinking

that survey is appropriate for both clinical use and

community surveys and as such would ideally have

more questions, and be validated in non-eating

disordered and eating disorder people of the same

age. It is possible that normal young women without

eating disorders may drink for weight control reasons,

as a large percentage of normal women diet (Spear,

2006) and the belief that drinking large amounts of

purified water is good for health is heavily promoted in

the popular press.

In conclusion, this study found that patients with

an eating disorder may also have a disorder of fluid

intake and as such both need to be managed during

treatment.

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The reasons why eating disorder patients drink