Our Intentions About Food Matter

People who come to see me for help with their eating disorders often ask me how I eat and how I think about food. Years ago when first asked this question, I was taken aback, but I have thought quite a bit over time as to why this question is so important. Now I try to answer honestly either about what I might have eaten in any given day or how I approach food in general. As a result, I try to look into all the ways I approach food and how my experience might help guide people in recovery.

This question gets to the heart of dealing with food in our world as it is. There is no clear way to think about and approach food. We aren’t equipped to handle the endless array of food at our disposal, as I mentioned in my last post. The media noise about dieting, “healthy” food, irresistible food and weight is extremely loud while the silent whispers of a more balanced way to think about food and body are barely audible.

For the first time ever as humans, the fortunate of us expect to be able to follow hunger and fullness cues and desires to figure out a way to eat without a care of a future without plentiful food at our disposal. Even for those of us who don’t have eating disorders, eating is complicated and laden with many contradictory impulses.

Many if not most people use the messages in the media to eat based on some ambiguous sense of doing the right thing balanced with their own desires. Some people use exercise as a way to justify eating (food as “fuel”) while others focus on the kinds of food they eat (or don’t eat) either as a way to eat ethically or to focus on perceived health benefits.

We all may look for the right way to eat, but more than anything I think we are searching for a structure to help us eat regularly and in a way that feels good physically and emotionally. And more often than not, the media have an enormous impact on how much time and effort we put to our food.

I often answer the question in a few parts. During the week, my food is fairly consistent without too much variation since this way of eating needs less attention so I have more energy to focus on the weekdays. The weekends tend to be a time of more food pleasure either around foods I enjoy, being with others or cooking. The balance between routine, ensuring there is time and attention to meals even on busy days and enjoyment is a pattern that has worked for me and is often a helpful guide for many people to begin to figure out the place of food in their lives.

The Role of Mass Media in Self-Worth

The first and possibly most important step to avoid the pitfalls of how food and body play an outsized role in modern life is actually not related to food. Instead, we all need to focus on the elements of who we are and what we value in order to put food and weight in their proper place.

In many ways, food and body are defaults to represent self-worth and life priorities. There is an abundance of evidence to show that dieting, body focus and eating disorders arose in large part due to the inception of mass marketing. Only through the creative but insidious generation of images that pervaded our culture did these issues emerge. As media continues to grow and spread into every facet of our lives, we all struggle not to embrace food and weight as imperatives for a meaningful life.

I don’t mean to imply that food and weight haven’t had their place throughout human history, but media allows messages and images to spread much more widely and powerfully than ever before, and, as social beings, we are not wired to ignore the messages.

The only way to push back against the powerful societal messages is an active, directed approach. We need to spend time thinking about, considering and engaging with values and morals that are most important to us. We need to make decisions about how we want to eat for our own well being whether it’s based on how we feel, what we enjoy or the role food plays on our lives.

We need to embrace images of all sorts of bodies to counter the pervasive messages around thinness. We need to see the positive in our physical selves, our bodies and our appearance. We need to look for messages from people who think about and view bodies as beautiful in all shapes and sizes.

If we are passive about how we consider ourselves as humans, we remain very susceptible to the idea that our self-worth is based solely on food and body. But we also are very adaptable so making time to create our own sense of selves and our own thoughts about food and body that can counter the effects media has on each and every one of us.

Eating in the Era of Bounty and Thinness

Hunger and fullness cues used to be dictated by accessible resources and life demands. These cues were necessary to function in the world. With access to unlimited food and societal pressures around food and body, many other judgments affect what and when we eat.

Recent decades ushered in an era of plentiful food, more than anyone could have imagined, at least in the richer countries of the world. The food industry brought about a transformation in accessible foods from the transportation of fresh foods, a plethora of frozen foods and access to prepared foods. For those people privileged enough to have money and access, the abundance of food is extraordinary.

In addition, many jobs changed from manual labor to sedentary work in the past few generations. Without regular physical activity at work, people are able to rest and choose what and how they eat each and every day.

Our bodies, however, developed a metabolism to survive very different settings. We feel hunger much more acutely than fullness and expect to exist mostly in need of food, not around an endless bounty.

As a result, we spend an enormous amount of time thinking about what to eat, when to eat it and how we are supposed to eat. Combine these circumstances with the societal values about body weight and size and it’s a wonder we are able to do anything other than obsess about food and weight.

Honestly, many people, even those without eating disorders, do spend much of their mental energy on food and weight.

The incidence of eating disorders has skyrocketed under these circumstances. The lockdown during the pandemic revealed that with more empty time in our lives, eating disorders continue to rise.

The situation that led to so much focus on food and accordingly eating disorders isn’t about to change. And the way our metabolism functions won’t change either. We are left with a simple question: how to manage hunger and food in this world?

I’m going to use the next few posts to address this question.

Ozempic in Eating Disorder Treatment

Eventually Ozempic and similar medications will not be the cultural phenomenon they are currently. The immediate craze and urgency to try them will pass. Some people will benefit greatly from them. Some people won’t be able to tolerate them. Others may have some negative consequences. This pattern of patient reactions tracks will all new medications. The only difference will be that so many more people try these medications.

However, all doctors have a responsibility to learn about, prescribe and work on figuring out the appropriate usage of new treatment options for their patients. Despite my initial misgivings about this class of medications, my professional obligation is no different.

In the eating disorder clinical world, there is no guideline currently about how these medications may be effective, but there are some initial thoughts and trends.

First, these medications may be very effective for treating intractable cases of Binge Eating Disorder. For those who have not had much benefit from CBT or other medications, Ozempic can curb binge urges and allow a patient to normalize eating habits and meal planning. Committing to Ozempic would be a long term decision and one not to take lightly, but the potential benefit can be significant for someone in this case.

Another possible use is to stabilize metabolism for a patient with damaged metabolism after long-standing Anorexia Nervosa. It’s unclear if Ozempic may just keep weight down rather than heal metabolism and also whether or not a patient would be able to stop Ozempic. So this use of the medication is still in question.

A third option is for people who have normalized eating patterns but continue to have extreme compulsive thoughts about food. For some people, Ozempic decreases “food noise,” a relatively new term meant to indicate persistent, obsessive thoughts about food. For most patients, these thoughts ease after months or even a year of stabilized eating. For some the thoughts don’t seem to abate. There is some potential benefit using Ozempic at micro doses to curb these thoughts.

Use of Ozempic and this family of medications in eating disorder treatment remains new and untested. Potential long-term risks, difficulty stopping the medications and even sustained benefits are all still unknown. However, the eating disorder community needs to consider all options for treatment to help patients in recovery.

The Mystery of Binge Eating Disorder

The information available about eating disorders is widespread and available across many platforms. National organizations link people to diagnoses and basic understanding of these illnesses. Social media shows a plethora of individuals speaking about their own experiences. Journal articles give more clinical information and research discussions. And the DSM-V, the psychiatric bible, offers the criteria used to make the diagnoses.

Despite the multitude of ways to learn about eating disorders, Binge Eating Disorder (BED) remains a mystery to so many people, even those suffering for many years.

It’s not uncommon for me to see people who have suffered with BED for many years only learn about their own diagnosis at a first appointment.

There are several reasons for this anomaly and also some consequences.

The most common eating disorder symptoms people know about are restricting food, binging and purging. When most people think about eating disorders, these symptoms are typically the ones widely known.

Widespread fat phobia and fat shaming in our culture promote the idea that being fat is a result of personal weakness and shame. Thus, most people with BED believe they are flawed and ought to bury their heads and feel awful about themselves. They often don’t consider they may have an illness.

The medical field knows about Anorexia and Bulimia but are so focused on the faulty association between weight and health that they almost never screen for BED and instead only reinforce the fat shaming in our society.

The end result is that people with BED hide from doctors, feel trapped by shame and often don’t learn about their illness until much later in life, often well into adulthood.

The most unfortunate result is that people with BED, in my experience the most easily treated of a difficult set of illnesses, don’t receive treatment until the eating disorder has had a profound effect on their adult lives. Once starting CBT, as discussed in the last post, these patients start to see benefit within a few months, if not sooner.

A comprehensive screening of primary care patients can make a big difference in diagnosing these patients earlier. People with anorexia and bulimia have signs doctors can see more easily: low weight, missing their period, low bone density for anorexia or electrolyte abnormalities, excessive tooth decay or swollen eyes and face for Bulimia.

To screen for BED, primary care providers need to ask a few simple questions about dietary patterns and specifically if someone ever eats an amount of food significantly larger than a typical meal at any time. One question may open the door for diagnosis, education and treatment. Earlier diagnosis of BED can truly change the course of someone’s life.

The Changing Face of Eating Disorder Treatment in Recent Years

In many ways eating disorder treatment has improved over the last 15-20 years. Despite the concerns I often express here in this blog, it’s important to recognize the progress.

First and foremost, the most significant change is increased access to care. Fifteen years ago one ever present problem was available options for higher levels of care. There were very few hospital and residential programs. Waitlists were long. The best treatment often involved travel across the country. Insurance didn’t cover most care. Accordingly, most people could not even consider more intensive treatment and had very limited options. Now there are many more programs, many of which accept insurance, and major metropolitan areas often have many treatment options. Rural areas are still limited, but virtual treatment is starting to fill in that gap too.

More comprehensive care opens the door to treating people with eating disorders through the day and in their homes. Traditional mental health care involved a handful of appointments per week to address the eating disorder. Since thoughts and behaviors are pervasive, outpatient treatment ignored the need for ongoing care through the week at home. Eating disorder coaches, meal support and virtual programs and groups fill in the gaps of support throughout the day for people in recovery. These new options create an environment at home much more able to promote recovery.

Last many more clinicians have experience treating people with eating disorder. Because there are more treatment programs, there also are more opportunities to train younger providers to learn how to help people with eating disorders. Over time there also is increased availability of these providers in the community—a significant change from a few decades ago.

The one element of treatment that is not prevalent enough is the kind of treatment known to be most beneficial. Cognitive behavioral therapy is the most studied treatment modality for people with eating disorders, yet this approach is neither used nor taught regularly. Addressing eating disorder thoughts and behaviors in a systematic way using CBT provides structure and direction for therapy that is invaluable. Let’s hope that using this approach becomes more recognized, taught and used by the growing eating disorder clinical community.

Inclusivity in Eating Disorder Treatment

Eating disorder treatment began in the late 1970’s and early 1980’s as an affliction only for girls and women. Some of the original causes for these illnesses related to pressures on women and body shape, and these issues exist to this day.

However, the idealization of thinness has expanded past just girls and women to include everyone else. Medical, aesthetic or personal issues around body shape all are the root of many eating disorders. Moreover, the media and social media coverage for eating disorders creates an environment ripe for breeding these illnesses.

Treatment has been slow to adapt to the changing population who have eating disorders. Many treatment programs only accept women with just a few starting to treat others as well. Much of the rhetoric around eating disorder treatment, body image thoughts and meal plans are geared to women and need updating to include the entire population with these illnesses.

Inclusivity needs to broaden to all people suffering with eating disorders: women, men and non-binary people, all of whom need specific attention to their own individual eating disorder and recovery process. As clinicians, we need to consider a much broader sense of recovery and open the door to all people suffering rather than exclude people who don’t fit our own assumptions about what people with eating disorders look like.

Many of the fundamental issues remain the same. Setting a meal plan and following it remain difficult initial steps. Body image is a very challenging and often long lasting part of recovery. Inclusivity of all people with eating disorders will broaden the understanding of recovery while also giving hope to everyone that they can get better.

Older eating disorder treatment were built from feminist theories and originated at a time when eating disorders grew from an unspoken cultural message to disempower women. Although this pressure is still very present, eating disorders are now an epidemic that affects all sorts of people for other reasons as well. Individual providers and treatment programs can include all people by recognizing the current population and alter treatment for everyone’s needs.