Body Image in Eating Disorders, Part II

The last post focused on the changes in brain processing which affect body image and the perception of one’s own body differently from others. Another equally important aspect of body image distortion is the emotional connection.

The underlying feeling behind body image thoughts is shame. Thoughts about body always revolve around never being enough: not thin enough, not shapely enough, not attractive enough. The list is endless.

Typically, these thoughts about one’s body starts around puberty when bodies change quickly and suddenly. The development of identity and self-perception occurs at the same time and often in lasting ways.

Adolescents, especially girls, still grow up with the message that their changing bodies are a source of deep shame. That shame may begin in how they are perceived with a developing body, how they dress, how they develop curves or fat in typical places for women or in the deep discomfort others, typically family, have during their development. Sometimes, the shame begins at home and other times from school or peers.

Because of the drive for thinness in our society, many children see dieting, food restriction and weight loss as a concrete way to battle against puberty and attempt to halt the changes in their body. The cultural norm of thinness naturally condones this dangerous behavior and assures teenagers that body shame is a critical part of becoming a woman.

As I have written many times in this blog, dieting is the number one risk factor for developing an eating disorder. Whether or not children become ill, for the most part, they learn about the connection between shame and body image. And the constant negative thoughts associated with their own self-image is quickly ingrained in so many girls and young women.

The new trends of body positivity, varied size models and body acceptance are taking hold. Both for the sake of avoiding eating disorders and for avoiding a lifetime of shame, let’s hope these trends make a dent in the cultural norms of the last fifty years.

Body Image in Eating Disorders: a Brain Malfunction, Part I

People with eating disorders struggle more with body image than with any other part of their illness. Even when eating behaviors have normalized, body image distortion often persists for years afterwards before fading.

The first component of body image thoughts manifests as a brain distortion. The visual image of one’s body is transformed in the brain into something very different from reality. At the most extreme, people who are very underweight see a much larger person on the mirror. Others may only see a body that disgusts them no matter its appearance.

As one’s own reflection is associated with such negative thoughts and feelings, it becomes impossible to disconnect the internal reaction from the way their body actually looks.

I have seen many people have an experience that highlights the power of body image distortions. These patients have told me that they will catch the reflection of their silhouette in a store window and not realize they are seeing themselves. In that moment, they describe having a positive feeling about that body and often a jealous reaction that they wish it was their body. Once they realize it actually is their body, the reaction immediately changes to seeing a body they hate which leads to disgust and hatred.

This moment makes clear how body image symptoms can be seen as a brain malfunction. The brain of someone with an eating disorder can process one’s own image very differently depending on the context. The exact same body can be a source of envy or the locus of disgust depending on whose body it is.

The connection of positive or negative feelings with one’s body grows from years of associations with how one feels about oneself. The core of the negative associations starts at a younger age and coalesces around body and body image through the process of childhood and into an eating disorder. The next post will focus on this process.

The Expanding Influence of Bariatric Surgery

As Bariatric surgery widens its reach in diet and weight loss culture, the psychological risks for many patients increase dramatically.

Originally, these surgeries were meant to be last ditch efforts for people with very high weight and clear and evident medical risks. When weight leads to organ failure and shortened life, it makes sense to consider drastic options. But these circumstances are very rare.

Acceding to the lure of financial gain and a completely new surgical speciality, doctors have increased the type of surgeries and the people eligible for them as well. It’s clear that medicine does not have a clear handle on the long-term anatomical and medical risks associated with these procedures. The siren call of permanent weight loss—without any factual basis to the long-term benefit of surgery—is enough to pull in a multitude of desperate patients.

What these surgical centers lack is a thorough psychological screening for their patients. Having performed several of them and reviewed many others, the centers expect a cursory screening at best. Surgeons and hospitals don’t want to know about latent eating disorders or even more obvious ones. They want to check the necessary boxes and perform more surgeries.

Our culture prays upon people unsure of themselves who have determined that they can manage their own personal limitations by losing weight. Since diets never work, people seek out more desperate measures as time goes on. One increasingly common decision is to research Bariatric surgery.

The surgeons don’t seem to realize they are exploiting cultural vulnerabilities for their own professional gain rather than helping people manage their own health and longevity. Bariatric surgery may have its place in very specific situations, but the overall message of a quick surgical fix to a cultural problem only reinforces the cynical nature of our diet culture.

Gastrointestinal Effects of Eating Disorders Revisited

Eating disorders are primarily psychiatric disorders. The obsessive thoughts about food and weight combined with the shame associated with body image and negative self-esteem are the heart of these illnesses.

However, all eating disorder symptoms have medical consequences. The effects of chronic under and/or over-eating, purging, laxative/diuretic/appetite suppressant use all wreak havoc on overall health. Chronic medical illness is very rarely a motivating factor in recovery since the underlying thoughts are not logical but obsessive in nature. Through the recovery process, it’s critical to manage and maintain health as much as possible.

The worst and most common medical conditions caused by eating disorders are gastrointestinal. A few of these problems are the most common and also intractable.

Long-standing food restriction slows down the entire gastrointestinal system. This system is one long tube. Muscle contractions starting with swallowing then lead to a long contraction through the entire tube. That’s how food moves through our bodies. Food restriction slows this down considerably and leads to what is called motility dysfunction, namely gastroparesis (slowed digestion in the stomach) and colonic inertia (food getting stuck in the colon). These illnesses lead to chronic fullness and bloating which makes it hard to eat regularly, even if someone wants to try to get well. There is treatment for both, but since the primary issue is the lack of food, nothing heals motility issues more than eating regularly again—a catch 22 for people with eating disorders.

The other most common gastrointestinal problem stems from laxative abuse. These medications stimulate the colon to expel stool and excess water and achieve temporary weight loss by dehydration but does not lead to sustained weight loss. However, chronic use leads to long term damage by weakening colon function to the point where, at its worst, normal bowel function is no longer possible. Instead, the damaged colon causes chronic, painful diarrhea. Often stopping laxative use will lead to significant recovery, even after long-standing use, but permanent damage is possible too.

Although these are the most common and severe gastrointestinal effects of eating disorders, there are other less common ones. Even more so, some simple eating disorder tricks cause significant distress. Bloating and gas are common and often result from overeating vegetables or fiber or chewing gum throughout the day. Various artificial sweeteners can act as a laxative when eaten to excess. Drinking too much coffee or soda frequently leads to bloating and nausea due to the caffeine and/or bubbles.

As recovery progresses, it’s important to pay attention to and manage all medical problems causes by an eating disorder but especially the gastrointestinal ones. Being sure a person’s body functions well helps recovery go forward and also enables that person to fully engage with life as they get better.

Gender Difference in Eating Disorders

One question I have been asked several times is why most people with eating disorders are women. The answer has two parts, the first relates to the role our society plays in eating disorders and the second biology.

The obsession with thinness in our culture has been all consuming for decades. Despite increased interest in the sexualization of men’s bodies in recent years, all the focus has been and remains on girls and women.

The media has idealized thinness and has equated it with success for girls and women for decades. The endless array of photos of girls and women all focus on body size and shape and the privilege accorded to those women. Women’s clothes are often extremely revealing, and status is clearly awarded to those who meet the cultural expectation. The diet culture is aimed squarely at women, and a large majority of women struggle to see any other success as more important then body image and weight.

The result of the onslaught on girls’ and women’s self image and body consciousness is an enormous pressure to diet. As I have written extensively in this blog, the number one trigger for an eating disorder is dieting.

Food restriction kicks off a powerful starvation response first rooted in our biology: our bodies are programmed to adapt to a famine by minimizing energy expenditure and slowing metabolism to survive. Long-standing food restriction triggers a more powerful genetic adaptation to prolonged famine: obsession with food, preoccupation with finding and hoarding food, more permanent metabolic changes and sacrificing less necessary body functions.

Some people respond quickly by developing an eating disorder. Others discard the diet quickly and resume normal life. The decision isn’t conscious but based on how our bodies are designed.

The interesting caveat is that men would develop more eating disorders if the pressure for thinness and dieting was stronger for men because these biological adaptations are the same for men and women.

Instead, the societal pressure on women that have led to the rapid rise in the incidence of eating disorders appears to be a cultural means to force women to expend an enormous amount of energy on the meaningless task of weight loss at a time when their plate is already full: ambitious career goals while still managing other roles always burdened on women. 

It is difficult not to wonder if the increasing pressures that have led to eating disorders reflect a relatively new way to overload women in the current societal climate. The way to change this blight clearly is decreasing the pressure for thinness—a possible but difficult task for a goal so ingrained in our culture.