Eating Disorders vs. the Collective Focus on Weight and Food

The cultural views of weight and being fat factor heavily in the clinical approach to treating people with eating disorders. Those with anorexia are often lauded for their weight even when the illness severely limits their lives. Fat people are shamed so much they develop body distortions or eating disorders through endless dieting and even Bariatric surgery. Bulimia is sometimes seen as a necessary evil to manage weight. 

The lens through which many people understand eating disorders is itself distorted by the vilification of fat and glorification of thinness. 

In order to make more sense of eating disorders, the distinction between what these illnesses are and the societal distortions about body size and shape is critical. 

Eating disorders are characterized by abnormal eating behaviors: chronic starvation, binging, purging, excessive exercise, laxative abuse. However, the true nature of an eating disorder is psychological. Obsessive thoughts about weight, food and self-loathing dominate the minds of people with eating disorders. These thoughts make it almost impossible to live a full life. Even those who objectively seem to be living talk in secret of how much mental energy they use for the eating disorder. Their lives are not theirs to live. 

Society’s views about weight reinforce much of these eating disorder thoughts. The endless praise for thinness, pervasiveness of dieting and marketing for diets and exercise all confirm that the underlying basis for the eating disorder appears to be valid. It seems as if everyone is focused on weight and food. 

When people hear about or discuss eating disorders, the difference between our collective focus on food and weight doesn’t seem much different from an eating disorder on the surface. 

People without eating disorders may engage in these thoughts and behaviors, but their lives go on. They can let go of these thoughts, stop a diet or exercising and think nothing of it. Someone with an eating disorder cannot make these changes without the illness consuming their lives. 

Changing the obsession with food and weight is not a short-term solution because the obsession is too ingrained in our national ethos. It’s critical to recognize that eating disorders are true illnesses, many levels more severe and all-consuming than simply altering one’s daily diet. Comparing eating disorders and the general focus on food and weight completely misunderstands how severe and destructive eating disorders really are.

Present and Future of Eating Disorder Treatment

Eating disorders have complex and multifactorial causes. With our still limited knowledge of brain function, genetics, environment, behaviors and brain pathways all are part of what leads to an eating disorder. Dieting and food restriction may be the number one risk factor, but the still basic understanding of our brains leaves medicine with only a cursory sense of why and how a diet causes anorexia in one person, bulimia in another and only a few days of hunger in a third.

Since there is no standard approach to treating any eating disorder, clinicians or researchers tend to recommend treatment based on their own personal bent rather than overall knowledge about these illnesses. Some treatment is primarily pharmacological, some psychoanalytic and others behavioral or relational. The fact that clinicians have so many approaches reflects the difficulty finding adequate and successful treatment.

Some approaches seem to have benefit: high doses of Prozac for severe Bulimia or binge eating, cognitive behavioral therapy for bulimia, family based therapy for some adolescents with anorexia. However, there are no treatments known to work broadly based on repeated research studies.

These facts can be demoralizing for patients, especially those who don’t get better quickly after the first series of treatment. As they emerge from the initial shock and preliminary steps into treatment, families and patients can get bogged down in the difficulty finding the best treatment pathway, assessing the hodgepodge of residential treatment programs and combing through the informal training process for clinicians who treat eating disorders.

There is some research on the horizon that is promising. One direction is starting to delineate the hormones that modulate hunger, fullness and the gastrointestinal system. It is interesting and useful but not yet enough to lead to effective medications on the market. Perhaps these medications can open doors to at least moderating the strength of some eating disorder symptoms and improving outcomes.

In addition research into the experience of appetite and fullness in the brain is also present in academic circles, yet these neural pathways are complex and just starting to be understood.

For now, the most effective treatment aims to circumvent and weaken behavioral pathways for all eating disorders. By figuring out how to help people identify the repetitive eating disorder thoughts and behaviors and change them accordingly may be an involved and long process, but it’s one that works long-term and is effective. This therapy does the work medications may help do more quickly in the future.

The truth is that effective treatment is out there for everyone. It may be hard to find or take a long time, but it is important to keep trying and know that recovery is possible.

Why is it so Hard to Find Competent Treatment for Eating Disorders

It is notoriously difficult for people with eating disorders or for their families to find competent help in the mental health field. Despite the increasing incidence of eating disorders, the most frequent complaint I hear is how difficult it is to navigate the eating disorder treatment world.

People frequently say they have seen treatment providers who purport they know how to treat eating disorders and then turn out to have minimal experience. Over and over again, they report the ignorant things professionals have said about eating disorders. This frustration often leads to giving up and a sense that there is no real help to be found.

Even when I cannot see someone, I will try to provide connections to the eating disorder treatment world in New York. Similarly, people contact me from all over the country, and even in other countries, with the same complaint seeking any kind of guidance.

It’s confusing how a set of disorders so prevalent have such limited infrastructure in the mental health community.

There are a number of reasons for this discrepancy. First, the training programs to teach clinicians how to treat people with eating disorders are very limited and completely unregulated. The programs vary from analytic programs, short-term certificates and informal training at residential programs. All these training areas focus on their own way of treating eating disorders but don’t coordinate to teach an overview of treatment and basic knowledge about these illnesses.

Accordingly, there is no formal accreditation for clinicians to attain and advertise. Instead, any experience helping with eating disorders will do, and clinicians can say they have experience treating people with eating disorders even if that’s not true.

Similarly, most academic medical centers have limited treatment and knowledge of eating disorders as well. Instead, the mainstay of treatment is residential centers which are for profit private companies and have no motive to consider treatment and wellness as their ultimate goal. Although these programs can be beneficial, they don’t help codify a basic knowledge for clinicians in the community and don’t encourage research into best practices.

Three more social components of eating disorders make them very different from other illnesses in psychiatry. First, eating disorders are relatively new and there is a short track record for understanding and treating them. Second, treatment is difficult and frequently long-lasting, something anathema to the current mental health world. Third, these illnesses have a central medical component typically not part of psychiatric treatment. These three differences appear to have made it less desirable for the medical community to prioritize treatment for these illnesses.

The lack of formal training for and complex social aspects of eating disorders have created a void in competent eating disorder treatment. The real question is how to recognize this public health crisis (outlined in the last post) and begin to change the treatment landscape to make good treatment easier to find.

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.