It's Time to Treat Eating Disorders as Both Psychological and Physical Diseases

What makes eating disorders unique in the scope of psychiatric illness is the fundamental medical nature of treatment. As such, the complete approach to recovery needs to include a medical sensibility as well as psychological one. 

However, artificially separating the psychological and physical tends to limit the effectiveness of care. The best plan must incorporate and weave together these two parts of eating disorder for truly comprehensive care. 

The clinical world tracks eating disorder providers into specialities: food, therapy and medical. Each provider is a crucial member of the treatment team but usually focuses their specific treatment on only one component of recovery. However, the individual's experience is a cohesive one, and separating out the different aspects of an eating disorder doesn't reflect the reality of having one. 

This problem begs for creativity on the part of the treatment team, something always called for in eating disorder treatment. The wisest clinicians have gleaned enough knowledge and experience to know that blending information from other parts of recovery, even when it's not one's specialty, makes for more complete care and an increased chance for recovery. 

For the therapist, this means referring regularly to the medical complications from an eating disorder and heeding the severity of the illness. For the physician, respecting the power of the eating disorder thought process rather than implying recovery is the same as willpower. For the nutritionist, recognizing food and nutrition education isn't really the cornerstone to treating someone with an eating disorder: the treatment is really food therapy. 

Each clinician may have a specialty; however, the team overall must focus on the psychological and physical components of an eating disorder as well. Each appointment is a way to call into question the dominant eating disorder thoughts and point out the fallacy of continuing the symptoms. A cohesive approach of each member of the team can acknowledge the realities of recovery and help the patient recognize how physical and psychological impairment limits their lives.


The Role of Family and Friends in Recovery

People in recovery from an eating disorder need the kind of help most people would need when healing from a chronic, severe illness. Family members and friends can offer love and care while showing expressing their concern with time and attention. Most loved ones wouldn't interfere with the medical and clinical plan other than to be sure that care is adequate and proficient. 

However, it is hard for families and friends to resist meddling in treatment for eating disorders. In general people have very strong personal opinions and feelings about food and weight. Despite every intention of following clinical care, loved ones have ideas about what recovery ought to look like. 

More often than not, those opinions come from a place of love. Adding seemingly useful advice to a treatment plan can seem helpful and constructive. 

However, the person with the eating disorder almost universally experiences the guidance as intrusive and judgmental. The advice comes across as harshly critical and detrimental and is counterproductive in ways that won't make much sense to the family member or friend. 

Clinical guidelines and meal plans come from an objective caregiver with experience and knowledge about how to approach eating disorder recovery in a caring but non-judgmental way. There is no way for a loved person in the patient's life to express opinions about food that are purely supportive. 

The easiest way to explain this paradox is that for a person with an eating disorder, discussing food and meals is the most  personal, exposing and potentially shameful thing to open up to others. Nothing else compares. For people without eating disorders, food is largely impersonal, but people with eating disorders would discuss anything else first. So offering love and support can help the loved one use her own strength for recovery. Objective opinions about food only leads to a feeling of exposure and shame which only strengthens the eating disorder. 

The basic premise is that support for someone in recovery needs to involve love and care. Advice, like with any other illness, belongs to the clinical treatment team, not with loved ones.


Body Size and Shame in Recovery

The markers of success in our society are fairly clear: money, power and education all rank high on the list. But to a large degree, the people who are successful are most often born into that world. Realistically, movement into and out of that world is very limited. 

The powerlessness of daily life has reinforced a new marker of success: thinness. For people without any indication that life can change, dieting and creating an enviable body has become a way to mark accomplishment and then display it to the world. 

Although the eating disorder epidemic began in a wealthier, more successful class, all indicators show that these illnesses no longer discriminate. The generalization of dieting throughout all first world communities opens the genetic door for all people to develop eating disorders.

One consequence of the drive for thinness, ironically, is the increase in obesity, in part from binge eating disorders. Chronic dieting triggers overeating and binge eating for many people. Being overweight is seen as the antithesis of thinness, not only in terms of body size but as a sign of success or failure. 

Meanwhile, the reality of dieting and overeating is that they are flip sides of the same coin. As I have written many times in this blog, longstanding restriction triggers a very powerful hunger response which often leads to binging. In addition, slowed metabolism from restriction triggers the body to react by storing energy as fat to preserve against future limited food intake. In other words, thinness and being overweight are two of the body's reaction to not feeding oneself properly. The opposite to both of these is normalized eating. 

This thought process confirms a crucial part of recovery from binge eating disorders, eliminating the shame. Society may impose harsh criticisms about weight, and a necessary step in treatment is to quiet those voices. The reality is that one's body will handle the effects of disordered eating to survive, whatever that means about weight.

Facing any source of shame or negative feelings needs to be a cornerstone to therapy while also trying to separate the personal feelings from the societal sense of blame. Inevitably, recovery includes finding a sense of personal peace irrespective of body size. Health and wellness means both normal eating and psychological well being. A strong focus on body size will only reinforce the illness. 


Disorders of Overeating and the Place of Blame

I have written many times about Binge Eating Disorder, compulsive overeating and obesity in this blog, and the central message about these illnesses is that these compulsive behaviors are not a matter of willpower. This false belief perpetuates a feeling of shame and responsibility and a pervasive sense of blame, secrecy and, most sadly, a long delay in seeking help. 

Almost always, eating disorders or disordered eating stems from a combination of a genetic predisposition to the eating symptoms combined with a powerful emotional and chemical response to the behaviors. All disorders comprised primarily of overeating are the exact same way. 

In fact, the symptoms and treatment for people with these illnesses are essentially identical to the treatment for bulimia. The exact expression of the eating disorder symptoms relate mostly to physiology and biological response to eating disorder behaviors, not to a difference in willpower or personal responsibility. 

Not only are eating disorder symptoms an attempt to manage hunger and weight, they also have powerful effects on mood and thought processes. Starving, binging, purging and compulsive overeating all change someone's mood very quickly and decrease anxiety significantly. The positive effect is brief, however, and the long term result inevitably is worsening mood and anxiety. But, like anyone who uses a behavior or substance to change their immediate state of mind, the urge to use that symptom overrides any logical conclusion that it won't work. 

People with eating disorders of overeating have the added societal bias that their behaviors are primarily from a personal flaw and that the world around them judges their symptoms more harshly as failure. In addition, the bias about weight often leads to being overlooked in both personal and professional parts of their lives.

Accordingly, recovery from these disorders needs to incorporate ways to challenge or circumvent this bias, to assert self-confidence and to refute the assumptions around them. Accepting judgment only reinforces the illness and extends the period of being unwell. The next post will address how treatment can focus on this component of recovery.


Doctors and Nutrition

The science behind nutrition, if it can be called that, is extremely limited. Here is what we know: eat a variety of food, more plants and minimal processed food. That's it. 

If you read the unlimited literature on dieting and its supposed link to health, you would be led to believe that nutritional science is incredibly advanced, but the diet industry has a vested interest in propagating this lie. 

What's more surprising is the similarly unlimited diet advice from doctors. It has become commonplace for doctors to blame a substantial number of medical illness on diet and weight, with minimal evidence. On the heels of such a statement, medical professionals often launch into their own beliefs around food and diet, again without any way to substantiate their claims. 

Medical training includes very little nutritional education. Since there is basically no science to review, nutritional guidelines tend to only reference vitamin or mineral deficiencies. Precious else in medical education has merit. 

This fact means doctors' diet advice is based solely on their own opinion. They use their position of authority to trumpet their own personal thoughts about diet, exercise and weight, as if these opinions are fact. In a world where we are inundated by diet and exercise propaganda, mostly to line the pocket of big industries, this component of the machine is disturbing. 

Doctors tend to be naive about their influence on common societal beliefs. Each doctor lives in a bubble with their patients or cohort and often forgets the power of authority vested by the white coat. Pharmaceutical companies have used that sway for years to drum up business for new drugs. The exercise and diet industry has, perhaps less overtly, used that sway with less than savvy doctors to promote their beliefs and brand.

Without any way to combat the plague of striving for thinness, endless dieting and overvaluing exercise, doctors often support whatever company has the newest and greatest product and are just as suggestible as everyone else. 

The solution is less obvious than the problem. Nutrition education is a start for doctors, but the problem runs deeper. Weight and diet have become such a facile way to explain medical issues. Medical education needs to explain the true place diet has in our lives. The lack of scientific knowledge about food choice translates into a realm doctors need to avoid. Our job is diagnose and treat illness and to promote health. Treading lightly on topics we know very little about is advisable. Stick with medicine instead.


Exercise in Our Lives

Much of our learning about health and exercise has stemmed from large changes in lifestyle since the industrial revolution and especially in the last fifty years. Job opportunities in the first world have become increasingly sedentary. The human experiment of life with minimal movement and exercise has forced the medical world to explore the ways in which moving our bodies improves overall health and well being. 

However, clinical understanding of the health benefits of exercise has lagged behind the powerful food, diet and exercise industries. Capitalizing on the lack of information, big business took advantage of an opening to create a new narrative, and that storyline is much more compelling and powerful. 

Rather than explore how activity can enhance our daily routine in today's world, these for-profit businesses have used another convincing but ultimately cynical tack. The bottom line is a subtle attempt to place blame and responsibility for the lack of exercise on the individual.

Using guilt as the ultimate subtext for a business model has been very successful. Education about the type of useful exercise and the many ways to create opportunities to be active is much less profitable than convincing the public that exercise is essential and that the level of exercise can only be attained in classes or at a gym, in other words by spending money.

The effect of this misinformation is to create a cohort of young adults addicted to exercise and who feel they are not ok, and even cannot eat, without it.

Similarly for those at risk for an eating disorder, exercise has become a gateway to illness. The exercise industry encourages the urge to obsess about body and shape and as a means to justify the intake of any food. More and more, exercise is a cornerstone for young people to develop eating disorders. Instead of exploring the place for activity and movement in our lives, exercise is a personal responsibility and a source of self-assessment, almost always one that leads to negative thoughts about oneself. 

Prior to the sedentary lifestyle of many career choices today, exercise was not an activity but part of daily life. Just the act of standing, walking and taking care of life events helped keep our bodies fit and capable. The goal today is to fit time into our day for that movement, not to create an opening for industry to exploit our own insecurities and fears.


Eating Disorders in the Presidential Campaign

Fat shaming sadly has become a central part of the presidential campaign this week, a place this form of bias clearly doesn't belong. However, the high profile publicity of ridiculing women forces our society to face a hidden and malicious prejudice. 

Just as eye opening as the comment was the presidential candidate's shocking capacity to defend his statement as if it were completely acceptable. Needless to say, some media outlets exposed the callousness of the remarks, but it also became clear that fat shaming is not only an accepted form of attacking women but one accepted by a significant segment of the public. 

Outing this hidden bias exposed a dynamic women must struggle against every day. Just as important, these expectations of thinness, and the general acceptance of shaming women who don't fit into this image, encourages women, including young women and girls, to look into dieting at increasingly younger ages. 

The last few posts make clear the dangers of dieting: it is the most important risk factor for developing an eating disorder. And so the effects of fat shaming run much deeper than a mere insult. 

The overall effect of condoning this kind of behavior is an increased risk and even likelihood that girls and young women will develop eating disorders. Messages about body shape and weight are destructive in their immediate psychological effect and insidious in sustaining the high incidence of eating disorders in our community. 

As harmful as elements of the presidential campaign have been, fat shaming takes the misogyny on display to a new level. Using the largest political platform in the world to indirectly encourage severe, life threatening illnesses is despicable and represents a form of bias that must be fully exposed.