Healing Your Relationship with Food: Part I
Understanding Eating Disorders.
Healing your relationship with food means understanding the basics of disordered eating habits. It also means recognizing that society’s conceptualized versions of eating disorders are not accurate, nor are they complete. The diagnostic criteria for these disorders is lacking and exclusive. It’s important to understand that these disorders might not be what you assume of them, and they are far more prevalent than we are led to believe. First let’s try to understand what these disorders look like. Most of us have heard of anorexia nervosa and bulimia nervosa. Some of us have even heard of lesser-known disorders like binge eating disorder or “EDNOS” (eating disorder not otherwise specified, though this title has since been altered in the lasted version of the diagnostic and statistical manual of mental disorders).
Anorexia Nervosa
Anorexia Nervosa effects nearly 1% of individuals. Though this doesn’t seem like much, it’s important to note that eating disorders are one of the most deadly mental illnesses, second to opioid overdose. Additionally, many sufferers will go undiagnosed because they don’t fit within the weight-restrictive parameters of anorexia within the DSM5.
For an anorexia diagnosis, an individual must meet certain criteria outlined in the DSM5. “There are three essential features of Anorexia Nervosa: persistent energy intake restriction; intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain; and a disturbance in self-perceived weight or shape” (1). Persistent energy intake restriction refers to the purposeful restriction of food and drink for the sole purpose of preventing weight gain. Many sufferers will assign calorie intake limits, ranging from over 1000 calories per day to just 100-200 calories per day. Often these individuals suffer from what is known as body dysphoric disorder, which is a drastic disturbance in one’s own view of their physical body. When sufferers look in the mirror, for example, they may see themselves as larger than they truly are. One of the more limiting diagnostic criteria for anorexia is that the individual must maintain a body weight that is “below a minimally normal level for age, sex, developmental trajectory, and physical health,” which relies mostly upon the body mass index (which is calculated using one’s weight and height). the BMI scale has proven to be unreliable in terms of diagnosing anorexia, as one typically needs a BMI of below 17 to be categorized as having significantly low body weight by the world health organization (WHO).
This restrictive criterion takes physical form into account when diagnosing anorexia nervosa, but does not effectively acknowledge the suffering of those who do not fit within this weight requirement. because of this, I often express the statistics of anorexia as based solely on diagnosed cases. The median age of onset for anorexia is roughly 17 or 18 years. Though the disorder mainly effects women, men are also at risk for developing anorexia and are statistically more likely to die of the disorder, because it is much rarer in men. The DSM5 estimates the ratio of female to male diagnoses at 10:1. The dsm5 also notes that some crossover between subtypes of anorexia may exist, specifically noting that some individuals exhibit a binge-purge type of anorexia, wherein they binge eat and purge through self-induced vomiting or the misuse of laxatives, diuretics, or enemas, (though some individuals with this subtype do not binge eat but do regularly purge after the consumption of small amounts of food).
Bulimia Nervosa
Bulimia Nervosa effects roughly 1% of females and 0.1% of males annually, though these numbers are based on diagnosed cases of bulimia. Bulimia is diagnosed based on recurrent episodes of binge-eating and purging, though various subtypes of the disorder exist.
An episode of binge-eating is characterized by both “eating in a discrete period of time (e.g., within any 2-hour period) an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances; a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)” (1). Purging is characterized as any “recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise” (1). The binge eating and purging occur on average at least once per week for 3 months. The DSM5 also notes severity, ranging from mild (1-3 episodes of compensatory behaviors weekly) to severe (an average of 14 or more episodes of compensatory behaviors weekly).
Unlike anorexia nervosa, people with bulimia can fall within the normal range for their weight. But like people with anorexia, they often fear gaining weight, want desperately to lose weight, and are intensely unhappy with their body size and shape. Prevalence is highest among young adults, since the disorder peaks in adolescence and young adulthood. Like anorexia, the DSM5 estimates the ratio of female to male diagnoses at 10:1.
Binge-eating disorder
Though less commonly recognized, Binge-eating disorder is more common than anorexia and bulimia, impacting an estimate 1.6% of women and 0.8% of men in the United States. Although BED is not a new disorder, its new formal recognition in the research community has left noticeable gaps in the data on the incidence and prevalence of BED than for anorexia and bulimia.
The diagnostic criterion for BED is similar to that of bulimia nervosa, though those suffering from BED often do not utilize compensatory behaviors after a binge episode.
A diagnosis for binge-eating disorder is characterized by “eating in a discrete period of time (e.g., within any 2-hour period) an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances; a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)” (1).
Additionally, binge-eating episodes are associated with three (or more) of the following: eating much more rapidly than normal; eating until feeling uncomfortably full; eating large amounts of food when not feeling physically hungry; eating alone because of feelings of embarrassment regarding how much one is eating; feeling disgusted with oneself, depressed, or very guilty afterward. There is also a marked distress regarding the binge eating, and it occurs, on average, at least once a week for three months. similarly to bulimia nervosa, severity ranges from mild (1-3 binge-eating episodes per week) to extreme (14 or more binge-eating episodes per week).
Though not entirely correlated, people with binge-eating disorder often are overweight or obese. BED occurs in normal-weight individuals, as well as overweight and obese individuals, but binge-eating disorder is distinct from obesity. Most obese individuals do not engage in recurrent binge eating.
Other Specified Feeding and Eating Disorder (OSFED)
When discussing eating disorders, particularly anorexia nervosa, I often note that a sizable number of sufferers are diagnosed with OSFED as opposed to anorexia because they do not meet the underweight diagnostic requirements of anorexia nervosa. OSFED encompasses atypical eating disorders, including the following:
Atypical anorexia nervosa: All of the criteria for anorexia nervosa are met, except that despite significant weight loss, the individual’s weight is within or above the normal range.
Bulimia nervosa (of low frequency and/or limited duration): All of the criteria for bulimia nervosa are met, except that the binge eating and inappropriate compensatory behaviors occur, on average, less than once per week and/or for fewer than three months.
Binge-eating disorder (of low frequency and/or limited duration): All of the criteria for binge-eating disorder are met, except that the binge eating occurs, on average, less than once per week and/or for fewer than three months.
Purging disorder: Recurrent purging behavior to influence weight or shape (e.g., self-induced vomiting; misuse of laxatives, diuretics, or other medications) in the absence of binge eating.
Night eating syndrome: Recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal. There is awareness of recall of the eating. The night eating is not better explained by external influences such as changes in the individual’s sleep-wake cycle or by local social norms. The night eating causes significant distress and/or impairment in functioning. The disordered pattern of eating is not better explained by binge-eating disorder and or another mental disorder, including substance use, and is not attributable to another medical disorder or to an effect of medication.
The best-known environmental contributor to the development of eating disorders is the sociocultural idealization of thinness. “By age 6, girls especially start to express concerns about their own weight or shape. 40-60% of elementary school girls (ages 6-12) are concerned about their weight or about becoming too fat.” (2). Of American elementary school girls who read magazines, 69% say that the pictures influence their concept of the ideal body shape. 47% say the pictures make them want to lose weight (3). Up to 40% of overweight girls and 37% of overweight boys are teased about their weight by peers or family members. Weight teasing predicts weight gain, binge eating, and extreme weight control measures (3).
Those who suffer with eating disorders are also more likely to suffer from other mental health issues, and vice versa. Two-thirds of people with anorexia also showed signs of an anxiety disorder several years before the start of their eating disorder; approximately one in four people with an eating disorder has symptoms of Post-traumatic Stress Disorder (PTSD); a 2009 study in the International Journal of Eating Disorders found that one in five women seeking treatment for an eating disorder had six or more signs of Attention-deficit Hyperactivity Disorder (ADHD) (3); personality disorders also commonly occur in individuals with eating disorders; depression and other mood disorders co-occur with eating disorders quite frequently; 48-51% of people with anorexia nervosa, 54-81% of people with bulimia nervosa, and 55-65% of people with binge eating disorder are also diagnosed with Anxiety Disorder; 32-39% of people with anorexia nervosa, 36-50% of people with bulimia nervosa, and 33% of people with binge eating disorder are also diagnosed with Major Depressive Disorder; there is a markedly elevated risk for Obsessive-Compulsive Disorder among those with eating disorders, and up to 69% of patients with anorexia nervosa and 33% of patients with bulimia nervosa have a coexisting diagnosis of OCD (3).
According to ANAD (National Association of Anorexia Nervosa and Associated Disorders), eating disorders as a whole affect at least 9% of the population worldwide. More than 28 million americans will have an eating disorder in their lifetimes, though fewer than 6% of people are medically diagnosed as “underweight.” There is also a genetic aspect to developing an eating disorder, and an estimated 28-74% of risk for inheriting an eating disorder. Unfortunately, there is also a disproportionate rate at which bipoc are diagnosed and treated for eating disorders; bipoc are significantly less likely than white people to have been asked by a doctor about eating disorder symptoms, and those with eating disorders are half as likely to be diagnosed or to receive treatment. “Black people are less likely to be diagnosed with anorexia than white people but may experience the condition for a longer period of time. Black teenagers are 50% more likely than white teenagers to exhibit bulimic behavior, such as binge-eating and purging. Hispanic people are significantly more likely to suffer from bulimia nervosa than their non-hispanic peers, and asian american college students report higher rates of restriction compared with their white peers and higher rates of purging, muscle building, and cognitive restraint than their white or non-asian, bipoc peers. Asian american college students report higher levels of body dissatisfaction and negative attitudes toward obesity than their non-asian, bipoc peers.” (4).
“Gay men are seven times more likely to report binge-eating and twelve times more likely to report purging than heterosexual men. Gay and bisexual boys are significantly more likely to fast, vomit, or take laxatives or diet pills to control their weight. Transgender college students report experiencing disordered eating at approximately four times the rate of their cisgender classmates. 32% of transgender people report using their eating disorder to modify their body without hormones. 56% of transgender people with eating disorders believe their disorder is not related to their physical body. Gender dysphoria and body dissatisfaction in transgender people is often cited as a key link to eating disorders. Non-binary people may restrict their eating to appear thin, consistent with the common stereotype of androgynous people in popular culture.” (4).
Individuals who are obese or overweight are also at risk for developing eating disorders, though they are generally disproportionately diagnosed compared to individuals at a “normal” weight, according to the BMI scale. Athletes and veterans are also at a unique risk for developing eating disorders, particularly due to the physical standards each category is expected to uphold. Athletes are more likely to abuse overexercising as a form of purging, though athletes are also less likely to seek help for their eating disorders as compared to non-athletes.
Another risk-factor for athletes is a disorder referred to as Orthorexia, which is an eating disorder in which sufferers have an obsession with healthy eating. What classifies eating habits as disordered under this category is the obsession with the quality of the food one eats, rather than the quantity. Those with orthorexia are often not concerned with losing weight (5). Orthorexia is not explicitly recognized in the DSM5 as a feeding and eating disorder, but it is gaining social notoriety. Though not everyone will face the struggles of an eating disorder in their life, it is important to understand the fundamentals of eating disorders. Struggling with a poor relationship with food puts you at a higher risk of developing an eating disorder somewhere down the line, especially if you struggle with poor body image.
Societal expectations of weight and body type have changed drastically since the turn of the century, but those expectations still exist. They put a heavy burden on the shoulders of both women and men to look a certain way, sometimes regardless of the methods used to achieve that “ideal” look. Working with a health coach to really tackle whatever hurdles you face in healing your relationship with food is one of the fundamental goals of a coaching program. If you’re looking to lose weight but also emotionally rely on food as a coping mechanism, you might be more likely to suffer from binge eating, which can deter your progress and make you feel hopeless. If you are looking to add more vegetables to your diet but have a “picky” palate, you might find it harder to willingly add new foods to your intake without also struggling.
So how does one acknowledge these things?
If you’ve never taken the time to address your relationship with food, how can you find and resolve any potential problems? Stay tuned for the next part in this series, where we will address common ways in which you can rebuild your own relationship with food. If you’d like to book a free health history consultation with me, please contact me. If you or someone you know is struggling with disordered eating, please seek help in any way you can. Eating disorders are dangerous and deadly. For resources available in your area, click here, here, or here.
sources not directly linked:
1: American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
2: Smolak, L. (2011). Body Image Development in Childhood. T. F. Cash & L. Smolak (EDS.), Body Image: A Handbook of Science, Practice, and Prevention (2nd ed.). New York: Guilford.