A Dietitian’s Review of Netflix Movie ‘To the Bone’

I was curious to watch this movie as there was quite a lot of hype leading up to it’s release and part of my current job includes working with young people with eating disorders.


 

‘To the Bone’ tells the story of a young woman named Ellen (played by Lily Collins), who changes her name to Eli during the movie. Eli is struggling with anorexia nervosa and ends up in a specialist eating disorder recovery centre.

The movie has a slightly cringey ‘teen movie’ feel, especially the romantic storyline, but what I was really concerned about was the portrayal of eating disorders. I was hopeful that this would be an accurate depiction as it was written and directed by Marti Noxon who has suffered with anorexia herself. However, I found this to be quite a mixed bag so I have split this review into four main points: raising awareness, potential to trigger eating disorders, medical treatment style and lack of dietetic input.

 

Raising Awareness

This movie does raise awareness about some of the signs and symptoms of eating disorders such as:

  • An obsession with calorie counting
  • Excessive exercising
  • Risk of self-harm
  • Fasting and food avoidance
  • The extreme distress associated with weight gain and eating – even touching chocolate is difficult for Eli and she catastrophizes that it feels like “the world’s going to fall apart” if she eats
  • Black and white thinking – Eli is afraid that if she starts eating she won’t be able to stop and will become obese
  • Behaviours such as cutting food into tiny pieces, cutting the breading off a piece of chicken and chewing and spitting food out rather than swallowing
  • Body checking – Eli is obsessed with checking her upper arm circumference using her thumb and index finger
  • Social isolation – Eli is often withdrawn and had to drop out of College
  • Masking behaviours like fluid loading to make it seem like Eli has gained weight
  • Wanting to become desexualised as a motivation for weight loss
  • Purging behaviour such as vomiting and using laxatives after eating

 

It also raises awareness about some of the physical side effects of anorexia nervosa such as:

  • Emaciation
  • Loss of period (amenorrhea) and infertility
  • Excess soft fine hair growth as the body attempts to insulate itself as body fat drops (lanugo)
  • Spinal bruising from excessive sit-ups
  • Dizziness
  • Irritability
  • Unable to sleep
  • Loss of muscle and organ tissue

I think that this movie did quite a good job in depicting the massive strain on Eli’s family while she is struggling with the eating disorder. They feel shocked, confused and frustrated as they can see a clear solution but don’t understand why Eli can’t overcome this and just start eating. In an emotional family counselling scene Eli’s half-sister Kelly tells the group that she feels angry because “it’s my life too, I don’t get to have a sister”. It also shows how eating disorders can thrive in unstable environments, as Eli has a volatile family life and the surrounding drama doesn’t help with her recovery.

 

Potential to Trigger Eating Disorders

It is worrying that Lily Collins had to lose weight to play the role of Eli, despite having previously suffered from an eating disorder herself as this could be a massive triggering factor for a relapse.

The movie acknowledges that images and messages related to food and weight can result in “fetishizing anorexia”. However, images of emaciation and strategies to promote extreme weight loss are present throughout which could be a triggering factor for viewers who are predisposed to disordered eating. I think it is important to be aware of this before making a decision about whether to watch the movie; however it would be difficult to avoid some element of this in any movie covering this topic. ‘To the Bone’ does begin with a disclaimer which warns that it contains “realistic depictions [of eating disorders] which may be challenging for some viewers”.

 

Medical Treatment Style

One of my main issues with this movie was the strange treatment style used by Dr Beckham (played by Keanu Reeves). He started off well by highlighting to Eli’s family that anorexia never has one simple cause or solution but then he displays a number of unconventional and potentially harmful treatment methods.

Dr Beckham seems to have a bit of a God Complex, rather than referring to evidence based treatments he makes all-knowing statements like “for Eli [hitting rock bottom] is critical”. In one scene Dr Beckham turns against Eli’s family by saying that a family counselling session was a “shit show”; this seems bizarre as family based therapy (FBT) is one of the most well established treatments for young people with eating disorders. This type of ‘splitting’ behaviour causes the perfect environment for an eating disorder to thrive rather than creating a stable and consistent support structure.

At one point in the movie Dr Beckham acknowledges the ‘voice of anorexia’ as he tells Eli to tell that voice in her head to “fuck off”. But in other parts of the movie he tells her that “you’re on your own” and seems to put the onus on her rather than externalising the eating disorder. This seems to be reflected in the way Eli feels defined by anorexia, as she says that she feels like “a problem not a person”. Dr Beckham encourages patients to “become more resilient” rather than treating nutritional deficiencies and using distractions techniques (although Eli tends to draw of her own accord) and although weight is monitored there is also no blood pressure monitoring and no mention of mental health assessments or sectioning.

 

Lack of Dietetic Input

Another big issue with this movie is of course the complete lack of dietetic input, despite Eli’s malnourished condition!

Patients in the treatment facility don’t have meal plans, they aren’t required to eat anything at meal times and there are no rules limiting exercise. It suggests that it is empowering them to make sensible decision for themselves, but when people are severely malnourished they are unable to make rational decisions as their body is prioritising keeping their vital organs functioning rather than supporting higher functions like decision making.

I’m glad this movie showed that some people need naso-gastric (NG) feeding tubes if they aren’t making progress with their recovery, but again there is no sign of a dietitian to support with this. It seems unsafe and unrealistic that there are no build up meal plans to follow, patients can eat or not eat whatever they want, but if they don’t gain weight they automatically get a 1500 calorie feed through a tube.

 

Conclusion

I personally find eating disorders to be a challenging but rewarding area to work in as I have seen the importance of dietetic input as part of the overall multidisciplinary team in this context; so it was disappointing that dietetic input, or any type of dietary guidance, was completed omitted from this movie.  Although ‘To the Bone’ does raise awareness about some of the signs, symptoms and consequences of eating disorders, it is very concerning that the main message seems to be that if you starve yourself enough you will hit rock bottom, then have an epiphany and decide to get better. I really hope that nobody who is effected by an eating disorder sees this movie as sharing sensible advice on recovery! 

 


For more information about eating disorders you can read this post about Recognising the Signs of an Eating Disorder.

If you or anybody you know is affected by an eating disorder then please seek support from friends and family, your GP or trusted websites for information such as:

Beat – The UK’s Eating Disorder Charity

NHS Choices

NHS support for parents

National Eating Disorders Association

National Eating Disorders Collaboration

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