When I open my phone’s newsfeed on any given day, there is no shortage of articles about how to lose weight, which foods to eat or not eat, when to eat to maximize weight loss, which workouts boost weight loss, which supplements promote weight loss, and articles showcasing an individual’s weight loss. These articles are interspersed between celebrity bikini photos (with impossibly smooth foreheads) or celebrity postpartum photos that look like they simply ate a big burrito. When I turn on the TV, there are endless commercials for the latest and greatest (and expensive) fitness equipment. It is no wonder that despite what the initial presenting concerns are with many of my clients—who range from college-aged, young professionals, new parents, middle-aged, recently retired, and individuals adjusting to aging challenges—a preoccupation with eating, weight, and fitness surfaces. The messages that drive these preoccupations are everywhere.
With Eating Disorders Awareness Week coming (February 28th—March 6th), I wanted to bring awareness to these disorders and their subclinical presentations. While treating eating disorders requires extensive training and an interdisciplinary team, we need to be on alert for disordered eating that is interfering with life and has the potential to develop into a diagnosable condition. Let’s first address the most common eating disorders in the Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V):
- Anorexia Nervosa (AN): AN is characterized by restriction of food intake, leading to a problematically low body weight. This is accompanied by an intense fear of gaining weight or becoming fat, and undue influence of body weight or shape on self-evaluation. There are two main subtypes: restricting and binge eating/purging type. The severity is based on how far the individual is below a healthy body mass index (BMI). AN is the deadliest of all the DSM-V diagnoses, across all categories. This is due to the medical complications that arise from self-starvation which can impact every organ in the body. Even if an individual with AN is not significantly underweight, cardiac complications from imbalanced electrolytes and abnormal heart rhythms can cause sudden cardiac deaths. According to the National Eating Disorders Association (NEDA), at any point in time between 0.3-0.4% of young women and 0.1% of young men will suffer from anorexia nervosa.
- Bulimia Nervosa (BN): BN is characterized by recurrent episodes of binge eating (see definition below) and subsequent 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. Like AN, self-evaluation is unduly influenced by body shape and weight. The severity of BN is based on the number of compensatory behaviors in a week. According to NEDA, at any point in time 1.0% of young women and 0.1% of young men will meet diagnostic criteria for BN.
- Binge Eating Disorder (BED): BED is characterized by recurrent episodes of binge eating which involves eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances. There is a lack of a sense of control during these episodes. They also involve three 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 being embarrassed by how much one is eating, and feeling disgusted with oneself, depressed, or very guilty after overeating. The severity is based on the number of binge episodes per week. According to NEDA (based on a study by Hudson et al. 2007), BED is over three times more common than anorexia and bulimia combined, with 3.5% of women and 2.0% of men having binge eating disorder during their lifetime.
- Other Specified Eating or Feeding Disorder (OSFED): OSFED was developed to include individuals who do not meet strict diagnostic criteria for the above disorders but still have a significant eating disorder. OSFED is just as severe as the other eating disorders; the symptoms simply do not fit one specific category, for example, purging without binge eating.
Individuals with eating disorders frequently have additional psychiatric diagnoses, especially depressive and other mood disorders, anxiety disorders, and obsessive-compulsive disorder. Trauma is also correlated with disordered eating as well as problematic relationship patterns.
Moving on From the Stereotypes
While eating disorders have stereotypically been considered a thin, white, and heterosexual female problem, this is not the case. Further, by perpetuating this stereotype, people of color and sexual and gender minority individuals are not receiving help. For example, again from NEDA (from a study by Gordon et al., 2006): “When presented with identical case studies showing disordered eating symptoms in white, Hispanic and African American women, clinicians were asked to identify if the woman’s eating behavior was problematic. 44% identified the white woman’s behavior as problematic; 41% identified the Hispanic woman’s behavior as problematic, and only 17% identified the black woman’s behavior as problematic. The clinicians were also less likely to recommend that the African American woman should receive professional help.” In addition, there are no significant differences between heterosexual women and lesbian and bisexual women in the prevalence of the eating disorders.
In a study of college students by Diemer et al. (2015), self-reported disordered eating and inappropriate compensatory behavior was higher among transgender students than cisgender of heterosexual students. For more information on this topic, CE-Credit currently has a course featuring an article on eating disorders proneness in gay men, lesbian women, and TGNC adults, including which factors contribute to eating disorder proneness in these groups.
Subclinical Eating Disorders
As with nearly all psychiatric diagnoses eating disordered behaviors fall on a continuum. Although many individuals may not meet criteria for an eating disorder diagnosis, they may display disordered eating behaviors. Some of these behaviors include:
- Excessive dieting
- Excessive exercise or exercising even when injured, sick, or fatigued
- Anxiety about certain food groups
- Limiting food groups
- Hoarding food
- Obsessive meal rituals
- Avoidance of social situations that may involve eating
- Feelings of guilt around eating
These are just a few. In my clientele, I have seen an unhealthy fixation on losing the same few pounds, restrictive meal programs, excessive fasting, canceling activities because of a dissatisfaction with one’s weight, yo-yo dieting, and wearing very oversized clothes to hide one’s weight or perceived bodily flaws.
Orthorexia Nervosa (ON) is not currently a diagnosis in the DSM-V, and there is controversy over whether to include this in future versions or if it is better explained by other psychiatric disorders (Meule and Voderholzer, 2021). ON, as it is currently being researched, is characterized by an obsessive focus on healthy eating. Whether this should be its own diagnosis, the focus on clean eating crosses the line into a subclinical eating disorder symptom when it becomes extreme. In my practice, I have seen the focus on clean eating trickle down to a client’s children, causing friction in relationships when a grandparent, preschool teacher, or other caregiver gives her children processed foods, nonorganic foods, or foods over a specific sugar limit.
Where is the Line, and What Can We Do?
We all may have times in our lives when losing weight and increasing fitness levels are healthy goals, but where is the shift from the pursuit of health to a pursuit of something else disguised as health? Unfortunately, the line is often not clear. As providers we may want to:
- Be alert- In my own clinical experience, conversations about eating and body image do not arise in the first few sessions because of the shame associated with them. Listen for subtle indicators (like starting new fad diets, multiple “cleanses,” etc.), especially if you notice a client is losing or gaining a lot of weight.
- Refer as needed- Of course if a client discusses extensive eating disorder symptomatology and this is not your area of expertise, a referral is in order. For subclinical eating disorders or preoccupation, a referral to a dietician who has experience with disordered eating can be helpful. With the medical complications that can arise with eating disorders, inpatient treatment is often required with a team of professionals to support all aspects of recovery.
- Psychotherapy- Psychotherapy focusing on body image and the emotional triggers to disordered eating can be very helpful. Cognitive Behavior Therapy (CBT) and Interpersonal Therapy (IPT) have strong research support for BN and BED. CE-Credit also has a course featuring an article about the feasibility of emotion-focused therapy in treating BED. The American Psychological Association’s Division 12 is a great resource for up-to-date evidenced-based interventions. In my practice, I find values work to be a helpful supplement to CBT. Intuitive eating, Brene Brown’s work, and Health at Every Size (HAES®) are just a few of the additional resources I use with subclinical eating concerns. One quick intervention from which most of my clients report instant relief is unfollowing all diet and fitness accounts on social media.
There is Hope
The bad news is that diet culture is everywhere. The good news is that awareness of its toxicity is increasing. Eating disorder prevention programs are emerging with success (see NEDA’s website). Many of my own clients have found medical providers who support HAES®. Many have also found a variety of body positive websites and influencers who speak to their struggles. We are understanding that even the pursuit of “health” can go too far. Nearly all my clients who struggle with disordered eating are very aware of the unhealthy, confusing, contradictory, and impossible eating and body image messages all around them. As mental health professionals we are in a powerful role to make a difference, bringing these struggles to light. One client at a time, we can help shift attention away from unhelpful and unhealthy diet culture and move toward what really matters.
Diemer, E. W., Grant, J. D., Munn-Chernoff, M. A., Patterson, D. A., &
Duncan, A. E. (2015). Gender identity, sexual orientation, and eating-related
pathology in a national sample of college students. Journal of Adolescent Health, 57, 144–149.
Gordon, K. H., Brattole, M. M., Wingate, L. R., & Joiner, T. E. (2006). The impact of client race on clinician detection of eating disorders. Behavior Therapy, 37(4), 319-325. https://doi.org/10.1016/j.beth.2005.12.002
Hudson, J.I., Hiripi E., Pope, H.G. Jr, & Kessler, R.C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3), 348-58. https://doi.org/10.1016/j.biopsych.2006.03.040
Meule, A., and Voderholzer, U. (2021). Orthorexia nervosa- It is time to think about abandoning the concept of a distinct diagnosis. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.640401
National Eating Disorders Association. (2022). Statistics and research on eating disorders. https://www.nationaleatingdisorders.org/statistics-research-eating-disorders