The Number One Risk Factor for an Eating Disorder: Dieting

The precipitating factor for every eating disorder is a diet. It’s not a coincidence that the number of eating disorders in this country skyrocketed when dieting became a nationwide fad in the late 1960’s and early 1970’s. As dieting continues to be regular practice for people in so many communities, eating disorders have become a larger public health problem.
Dieting over an extended period of time triggers a powerful genetic mechanism in all of us to survive famine. The human species has persevered in part because of our biological ability to adapt to limited availability of food for extended periods and utilize times of abundance wisely. 

Dieting mimics famine for our biological constitution. Thus, what we now describe as a disorder actually reflects a built-in adaptation to the lack of food. For some, prolonged dieting will trigger anorexia: the ability to survive on extremely small amounts of food and simultaneously shift all conscious awareness towards searching for and hoarding food. For others, dieting triggers a version of binging, hoarding food by eating long past the feeling of fullness and storing extra energy in our bodies. And many people diet for a few days or a week and just give up. 

The main difference between eating disorders and famine is that these adaptive measures are triggered by conscious decisions to diet rather than external environmental factors. Nonetheless, the behavioral and psychological symptoms are the activation of programmed survival mechanisms currently triggered by maladaptive means.

The lack of this basic knowledge about eating disorders frequently leads family members, friends and clinicians to blame people for their eating disorders. Rather than understand the medical explanation of an eating disorder, people become frustrated with such irrational, nonsensical behavior and simply implore the person to eat a hamburger or drink a milkshake.

Instead, recovery needs to involve an extended period of normal eating that will reassure one’s body and mind that regular nutrition is on the way: the famine is over. Once that period of eating lasts long enough, the psychological component of the eating disorder will diminish over time, with consistent psychological and emotional support.

However, it’s critical people don’t forget the only clear risk factor for developing an eating disorder: dieting.


The First Attempt to Treat Anorexia

The first appointment for someone with essentially untreated Anorexia Nervosa is a complex and intricate moment. These people are usually young, very trapped and hopeless. They frequently have met clinicians who have weighed them, threatened them, explained the dire consequences of the illness. Ultimately, these clinicians relent after facing the stubborn will of anorexia.
The longer this battle continues between a relatively new case of anorexia and ineffective professional help, the more hardened anorexia becomes and the more unwilling the patient is to be open to any help.

In addition, anorexia completely isolated this person from their lives. Although they can seemingly go to school, have friends and interact with the world, their entire mind is co-opted by obsessive thoughts about food and weight. There is no escape and the illness feels like a permanent prison.

The goal of that first meeting with someone with untreated anorexia is to try to help them feel understood and cared for. The endless string of ineffective attempts to care for them have already backfired. No one seems to understand. Everyone ultimately is the enemy and it feels like life is slipping away from them.

People who feel this way won’t benefit from an attack or a threat. They won’t respond well to a poorly conceived message that stems from fear or frustration.

They are looking somehow and someway for care and understanding, for attention and compassion, for comfort and love.

A clinician needs to understand that there are no magic answers in that first appointment. There is nothing one can say that will immediately break down this wall. That’s not the goal. The only hope is to start to find some way to show a modicum of understanding and care, to see them realistically and to meet them where they are.

The only real measure of success is whether or not there is any connection, any real human moment that transpires. This person may or may not come back again. Often sent to the appointment under duress, they assume they won’t follow up with someone they didn’t choose in the first place.

But maybe that first conversation can open a door and give this person the idea that there is a way out of anorexia. That would be a true success.


A Binge Eating Disorder Treatment Plan

Treatment for BED has some similarities to treatment for other eating disorders. Normalizing eating patterns is still a critical initial step. Thoughts about weight and food remain dominant and interfere with learning other ways to manage daily life. Shame is a central part of the eating disorder and needs to be addressed.
These are underlying aspects of any eating disorder and demand significant attention in successful treatment.

The more obvious differences center around the exact type of behaviors and around weight.

Food restriction and weight loss—focal points of most eating disorders—are lauded behaviors in our society. People with most eating disorders feel like they are engaging in behaviors considered acceptable by society since weight loss and thinness are idealized and viewed as true accomplishments in life. The effect of overvaluing thinness makes it harder to face eating disorder thoughts for many people.

People with BED experience the opposite. The pervasiveness of fatphobia means that these patients suffer from bias and prejudice in all aspects of their lives. Not only do they struggle to get well, but they also face the constant message that they are weak and incapable people.

The eating disorder symptoms are signs of their lack of worth, an erroneous fact validated by the world around them. Even eating disorder treatment can view binging from a negative standpoint rather than as a symptom of an illness.

Similarly, programs tend to focus on weight stabilization as a key to recovery, largely driven by the lure of the illusion of concrete steps towards wellness and by the number-oriented insurance companies. However, it’s hypocritical to harp on weight for people who restrict and ignore the inherent complications for people with BED in our society.

A well-conceived treatment plan for BED needs to address these two differences head on. Programs must face the complicated world we live in that includes fatphobia and body image in order to begin to create an adequate treatment plan for these patients. Similarly, clinicians need to consider how to talk about weight in different ways for people with BED and to consider any plan individually rather than use a one-size-fits-all policy, no matter the eating disorder.

The treatment for BED is often as or even more successful than for other eating disorders. The key to success is considering the true nature of this illness and create a treatment plan aimed at recovery from this specific eating disorder.


Binge Eating Disorder: the Neglected Stepchild of Eating Disorders

Binge eating disorder (BED) finally received the recognition as a true eating disorder diagnosis in the DSM in 2014 yet still seems to be the neglected stepchild of the eating disorder treatment world.
The clinical community remains transfixed by the immovable fortress that Anorexia Nervosa presents in so many patients. And the relative success of cognitive behavioral therapy for Bulimia Nervosa makes for some positive affirmation in treating these difficult illnesses.

However, BED taps into several prejudices both in the medical establishment and in our culture that sideline interest in the disorder and undermine any movement towards improved care.

First, both overeating and larger people immediately trigger the fatphobia ingrained in our culture. Eating more and being larger invoke an automatic response of weakness, inferiority and worthlessness. The kindness, compassion and understanding that are the cornerstones of eating disorder treatment often don’t break through the raw prejudices in our society.

In addition, the eating disorder treatment protocols and insurance company standards for care all revolve around weight gain. Eating a nutritious meal plan and maintaining supposedly adequate body weight are erroneously deemed the overall goal of treatment. However, this entire philosophy is not relevant for someone with BED, and there is no similar approach to helping people with this disorder.

Time and again, people with BED who enter treatment programs note that they don’t belong, aren’t truly accepted and don’t see any value in treatment not geared towards their illness.

These patients frequently remark that they cannot find an outpatient program or group designed to help them and populated with people like them. However, these patients with BED are a significant and prevalent part of the population who have eating disorders. Just in my practice alone, easily one third of my patients with eating disorders have BED.

The next post will outline the goals of treatment and what adjustments in clinical goals can help people specifically struggling with BED.


The Plight of an Eating Disorder Born before the Emergence of Treatment

People with chronic eating disorders who are age mid-40’s or older have had a very different course of their illness. Without access to treatment or even knowledgeable professionals when they were younger, they had to navigate their personal struggle on their own and find any way they could to survive.
The term eating disorder was only coined in 1973, and the first fledgling treatment modalities first appeared in the early 1980’s. However, more widespread diagnosis and treatment did not emerge until the late 80’s or early
90’s and even then only in certain urban pockets of the country.

Before then, the medical literature reports only a handful of perplexing cases largely attributed to profound neurotic complexes. The concept of a genetic or biological illness called an eating disorder was unimaginable. So the people with eating disorder flew under the radar: undiagnosed and untreated. 

People who developed eating disorders prior to the advent of eating disorder treatment found ways to cope and survive. Rather than learn about their illness start recovery, people rightly assumed this illness was their lot in life. In order to move forward, they coped the best they could and endured.

Now, later in life, some of those people have taken advantage of treatment programs but with little success. Residential treatment is aimed at young, newly diagnosed women and struggles to accommodate people with different backgrounds and courses of their illness. 

Even in outpatient treatment, these women need a different approach. Once an eating disorder has been fully incorporated into one’s identity and psyche, it isn’t easy to extricate it at all. Instead, treatment needs to adapt to the psychological reality of these women.

They have survived the all-consuming existence of an eating disorder without any prospect of help. Now, with the possibility of knowledgeable support, a clinician needs to table the idea of recovery and instead embrace the prospect of exposing the secret world of this illness in therapy. Just the step towards releasing the secrecy and sharing the details of this private world can be immensely helpful.

The goal in these instances is not the supposed panacea of recovery. Instead, treatment aims at debunking the myth that an eating disorder is a lifelong burden. Therapy can open the door to see an eating disorder as an illness that can improve with real support and help.


Positive Signs for People with Chronic Eating Disorders

People with chronic eating disorders often feel trapped and hopeless without any sense that recovery is still an option. They look into literature and treatment programs and find everything aimed at people who have just been diagnosed, not geared towards them. The path to to recovery looks very murky. It becomes very hard to imagine life without the illness.
In my work with people who are not new to treatment, I look for certain keys that point towards a likelihood of success. 

First and foremost is the existence of a life outside the eating disorder. That may entail a career, friends, a passion or close family ties. When a person has found something meaningful outside the eating disorder, movement in recovery can lead her to further engage this part of her life. She has a place to put that new energy and to escape the eating disorder.

Time of wellness during the eating disorder also is meaningful. It’s important for the person with a chronic illness to have known a period of semi-adequate nutrition, decreased behaviors and to know what it feels like to be better, even if that time is brief. This more recent memory connects them with the idea of wellness so that recovery doesn’t seem so farfetched.

Third is the ability to make emotional connections with people. Sometimes people with chronic eating disorders lose the ability to tolerate personal closeness and the development of emotional bonds. The closeness to the eating disorder replaces real relationships. Knowing that actual relationships are within the person’s grasp makes it possible to be more present in the world, a necessity in recovery.

Last, the patient has to feel able to engage in meaningful work around the food behaviors. If the thoughts and behaviors remain hidden, if that person cannot find a way to communicate and expose the eating disorder, the illness will hold into its most powerful weapon: secrecy. Openness and the ability to tolerate exposure is a critical sign that recovery is possible.

These four signs all point to the possibility of real progress to treat chronic eating disorders. This is a general idea of what parameters make recovery possible although it is not absolute: some people without any of these four strengths can get better too. However, the more a person can engage in these activities, the more hopeful the possibility of recovery.


Individualized Treatment for Eating Disorders

Treatment ultimately needs to become individualized in order for more people with eating disorders to fully recover.
As financial companies have purchased smaller eating disorder programs, profit has become the driving force for treatment. Programs have leverage, connections to insurance companies and marketing strategies that easily overrun the small programs and clinicians in the community.

The result of this sea change in eating disorder treatment is a reflexive reaction by clinicians to immediately refer patients to a treatment program. If that patient does not benefit from a program, it’s too easy to blame the patient for being intractable than to begin to create a specific program that could help this patient.

Programs provide a very specific program that entails absolute compliance with the meal program, rigid structure for daily groups and goals, adherence to weight management plans and an ability to quickly ignore eating disorder thoughts. Accordingly, people who do well at programs have eating disorder symptoms that match the overall philosophy of a program.

People with more chronic eating disorders, stronger eating disorder thoughts, binge eating disorder or more complex psychological and emotional causes for their illness often do not get much help.

There are many forms of outpatient treatment that can be more flexible. Some people cannot gain weight rapidly without immediate relapse. Others need to do more work on emotional resilience before they can tolerate substantial changes in their food. Some need to manage traumatic reactions in new ways before being ready to move forward in recovery. Sometimes it just takes longer to quiet the eating disorder thoughts.

During this transition period for patients, it remains crucial for clinicians to manage medical consequences of the eating disorder and to maintain focus on confronting eating patterns while still making changes in the meal plan. The worst slips into eating disorder symptoms might be treated medically or with short-term stays in hospitals or residential programs.

Individualized treatment always involves taking risks for patients. It means tolerating difficult stretches of worsening symptoms while trying to ensure safety and leave open a path to recovery.

Residential treatment is always a viable option. But the caring clinician needs to consider all routes to recovery to give everyone the best chance to get well.