As I mentioned in my post earlier today, it is National Eating Disorder Awareness Week. This is a topic close to my heart AND to Rachel's, which is one of the reasons we started this blog in the first place. Please enjoy her knowledge!
This week is National Eating Disorders Awareness Week! And, as my career passion is the treatment of eating disorders, it's always a time I want to offer resources and information to people. This year, I decided I would do something different and see if people had any questions I could answer, and these are the fantastic questions I got! I'll answer them to the best of my knowledge. Please feel free to ask follow ups! Or brand new questions!
Maybe it's just me, but whenever I hear eating disorder, all I think of is anorexia or bulimia. Are there official names and other disorders? I'm thinking mostly about those that go in the opposite direction from not enough to overeating.
Short answer is YES! There are other disorders. Anorexia and Bulimia are certainly the most researched of eating disorders at this point, and are the most commonly known- but not necessarily the most *common*. In this iteration of the DSM, Binge Eating Disorder (BED) was given it's own diagnostic code and acknowledged as it's own diagnosis. According to the Binge Eating Disorder Association (an organization I trust run by people I admire and trust), BED is the most common eating disorder in the US. One of the stats I find most notable is that it impacts 30-40% of people who seek weight loss treatment- that's right, nearly HALF! Binge Eating Disorder is characterized primarily by out of control eating, and the amount of food that may be in a binge is highly subjective. As with all mental health diagnoses, it's important to remember that the symptoms must cause distress if it's going to be diagnosed. What distress means is also somewhat subjective. BED is also incredibly damaging to health- and NOT because it can result in a higher weight. People with BED are not necessarily overweight or obese, and are often/always malnourished.
One thing that is really important to remember about this and all other eating disorders is that you cannot simply look at someone and diagnose them with an eating disorder. People come in ALL different shapes and sizes, so just because someone is below, at, or above average weight does not mean we can make a health diagnosis.
There are also other eating disorders that are identified. Another newly acknowledged one is Avoidant and Restrictive Food Intake Disorder. This most commonly starts in youth/adolescence, and is not my area of expertise. What I do understand about it, though, is that it's something like highly selective, picky eating that results in nutritional deficits and often significant weight loss. It differs from Anorexia in that the drive for thinness and body shape distress aren't present.
Two other unofficial diagnoses that can cause distress are Orthorexia (obsessive about eating clean or organic or following certain guidelines- may or may not be underweight) and Diabulimia (use of insulin to purge/control weight). Neither are things I know enough about to really talk about, though I have seen more cases of Orthorexia than Diabulimia. Again, these are not official diagnoses.
There are more, but those are the ones I feel I can speak about in an educated way, and they are the major diagnoses.
What do we know about the risk factors for eating disorder development? And while I know that they require treatment, what does treatment entail? And, since I'm asking questions, what are the warning signs that folks should look out for in others and themselves.
First question: What do we know about the risk factors for eating disorder development?
GREAT! Short answer is "Not nearly enough." Much longer answer is "But still a lot, and here it is:"
We know that eating disorders are biologically based illnesses with genetic underpinnings. People are genetically predisposed to them, generally. The common saying is that Biology loads the gun, Environment pulls the trigger. It is *exceptionally* important that this next thing is understood: Biology & genetics do not mean FATE- just because someone is predisposed to the development of an eating disorder does not mean they develop an eating disorder. And "environment" can be large scale (media, social pressures, etc) and can be small scale (family, peer group). Eating disorders are nobody's FAULT and a person does not choose to have one. So, some basic risk factors:
- Family history of an eating disorder. I would also bet that a family history of addictions would merit some closer attention, but I don't know that based on research. More just a gut feeling. :)
- If a child is excessively or unusually focused on his or her weight/shape, commenting on his/her own or other's bodies, wanting to go on a diet, etc, etc. These are the sorts of things that should raise an eyebrow.
- Participation in sports that are particularly appearance focused can also warrant some extra attention. If I was a parent, and my child was participating in cheerleading or dance or ice skating, I would want to know their coach and his/her methods very well, and I would pay extra attention to what my child was eating and saying about food/body image. (Note From Chrys: I would also include any sports that focus highly on weight in this, including gymnastics, wrestling, and distance running. I do not know much about pole vaulting, but I have a feeling that might be included as well. )
- Picky eating can certainly be a warning sign, but also should not be forced. We're learning a lot more in that area of research (that whole "sit there until you clean your plate" method isn't good), but I don't know enough to speak more about it.
- And then there are physical warning signs. Extreme weight loss or gain. Yellowing teeth, scabs on hands. Person being always cold, dressing in lots of layers constantly. Things like that can be a sign that someone may be struggling with an eating disorder.
Next: what does treatment entail?
It can entail a lot of different things. I'll go through the levels of care as laid out by the APA:
- Acute inpatient hospitalization: This is for someone who needs constant medical monitoring, may be on some sort of life preserving or life saving technology, very medically unstable.
- Inpatient hospitalization: This is for someone who is not quite as unstable as the previous, but still needs access to 24/7 medical care, needs frequent labwork, may need tube feeding. Suicidal ideation (active, with plan & intent) is often seen at this level of care.
- Residential Treatment: This is what I do! =D Residential treatment (RTC) is 24/7, but the patient is stable enough that they don't need frequent labs. Some RTC will accommodate tube feeding and do more frequent labs (Renfrew did when I worked there, for instance). Others (such as Carolina House) require more stability than that and do not do tube feeding, and generally speaking don't draw labs often. This is for a medically stable patient that is behaviorally in need of 24/7 supervision and intervention in order to do things like weight restore, stop binging, stop purging, stop compulsively/excessively exercising. It's a very therapeutic environment, ideally.
- Partial Hospitalization: This is a partial day of treatment. It's kind of like a job- you go in during the day, and stay at home at night (generally- all treatment facilities I know of that offer both RTC & PHP have a hybrid of the two, where a patient's insurance company pays for PHP, but they pay a room and board rate to still get 24/7 care). Their day is filled with therapy, groups, nutrition and medical appointments, and, of course, meals/snacks.
- Intensive Outpatient: This is even less of a day than PHP. IOP can mean a variety of different things, but usually means at least 3 days/week, at least 3-4 hours/day. It can mean more; I have not really known it to be less. A patient may also get therapy and nutrition counseling at an IOP program, or they might have outpatient therapy/nutrition services they use in conjunction with the IOP and just use it for groups and 1-2 meals/snacks.
- Comprehensive Outpatient: This is what people will often do if an IOP is not available. This would be a full treatment team of therapist, nutritionist, psychiatrist, medical doctor that they saw 1+ times/week, and there would also usually be an outpatient group or 2 in there, as well. Meals aren't often included in this unless one of the providers does meal support therapy.
- Outpatient: Now, this is something that can go on for years. This is probably what most people traditionally envision if they think of going to therapy. Seeing a therapist 1-2x/week, having a nutrition appointment once/week to start with, and medical and psychiatry appointments as needed. Sometimes there are groups. The amount of OP you do would depend on the level of need- it may be that you start out at basically a comprehensive OP plan, and then move on to less and less as recovery gets stronger. For best prognosis, someone will engage in some level of care for about 5 years.
People start at lots of different places. Starting at the least restrictive level necessary is definitely considered best practice. Now, "necessary" seems to mean something different to providers than it does to payers, but that's probably to be expected. ;-)
Finally, what are the warning signs that folks should look out for in others and themselves?
I pretty much covered this accidentally in the first question! :) OOPS! If you find yourself, or your friend, excessively focusing on weight/shape/food/etc, if you see someone restricting their food intake (naked salads, never eating when you get together, etc), if you notice that every time you eat with a friend, they get up and go to the bathroom immediately, if you notice that whenever you see them/eat with them, they get multiple large servings or eat very fast... these are all things that could indicate a problem. If they are constantly at the gym or out exercising (and it's not necessarily in accordance with, say, a training plan for an athlete)... those are also potential hazard signs.
What's your take on the whole gluten free/organic/dairy free/restricted eating? For the record, I know some people have allergies and such, but it seems like some of it is more choice. Just curious.
I have 2-3 initial thoughts. First and foremost is that if someone feels they have a physical need for a restriction in their diet, or have a problem that needs further exploration, then they should absolutely get a full work up, not just from a PCP, but from specialists, such as endocrinologists. There are real needs for these restrictions, and missing those needs can have horribly detrimental effects.
Second is that the diet & weight loss industry (A TERRIBLE BEAST) saw something that was a genuine problem for a small subset of people and realized that they could use our weight/thinness obsessed society and profit from that problem by turning the phrase "Gluten free" into a diet catch phrase. And, because the diet industry is very good at playing into people's fears and insecurities, it worked wonderfully. Every new diet craze probably started similarly - a real medical need for some people co-opted to make money for the diet industry.
Third, the diagnosis of Orthorexia I briefly mentioned in my answer to the first question comes to mind. This particularly type of mindset- the obsession with organic, clean, "healthy" eating and the petrification that can come with the mere idea of BREAKING those eating rules- is very susceptible to these diet crazes, particularly since so many of them ARE based in a medical need for some people. The individuals who struggle with this mindset will often overgeneralize these sorts of rules from "good for a certain subset of people" to "good for everyone and necessary to prevent problems."
Note From Chrys: This is something that I care a lot about, as I know many people, including family members, who genuinely need to have restrictive diets due to some really funky allergies and sensitivities. These include to gluten, soy, certain proteins in milk, fructose, and eggs. They also include diseases such as Arthritis, Rheumatoid Arthritis, and Gastro-Esophogeal Reflux Disease, which can require avoidance of certain foods in order to avoid flare-ups of disease and significant discomfort. I ALSO know many people who have gotten caught up in the low carb diets, the low-fat diets, the gluten free diets, Paleo diets, Atkins diets, the dairy free diets, who avoid soy due to fear of the affect is has on hormones, etc, etc, etc that are, in essence restrictive of certain foods/food groups. I agree wholeheartedly with Rachel that one should seek consultation with a SPECIALIST if they feel they need to be on one of these diets. People need to remember that you can cause sensitivities by cutting out certain food types from your diet, and some discomfort is expected when re-introducing foods to their diets. For example: I was vegetarian for 6 years as a teen/in my early 20s. When I re-introduced meat, especially red meat, my body didn't really know what to do with it at first! After a few months of slowly re-introducing these things, though, my body loves, and sometimes craves, these things and the nutrients that they give me. IF a person is engaging in a restrictive diet of any sort, it is important to look out for a shift towards a "good food, bad food" mentality, as this can be something that precedes the onset of an Eating Disorder. It is also very important to talk to a nutritionist and learn about the nutritive deficits that can be associated with particular restrictions and to replace those in your diet via other foods or via supplements. Whenever you can replace it via food, it is better for your body, more accessible to your body, and, often, cheaper. Supplements can certainly be used, too.
Finally, Amelia asked:
How do you differentiate compulsive exercising from non-pathological training? For instance, it is (mostly) a joke among triathletes that training for an ironman is like getting a second, part time job. And I'm sure the hours they put in would rival some of the time seen in compulsive exercising, but (while I wouldn't call them normal) I would not consider most of the ironmen I know to be ill. Or as my friend Julie put it once, "I'm not exercise addicted, I'm exercise overscheduled."
This is something that is hard for a LOT of folks to understand. The over use and abuse of exercise is one of the absolute most socially reinforced behaviors for people. And, for some people (such as the ironpeople Amelia mentioned), they are exercising in a way that is, for them, acceptable and healthy. Endurance, professional, elite, collegiate athletes- these are all people who are VERY likely to exercise multiple hours a day, often every day.
What sets off "Compulsive" is actually that word- the WHY of the exercise. Are they following a training program so they can achieve a particular goal, and that's the end of it? That's probably not so compulsive. But imagine if an ironperson missed a training day due to an illness or a death in the family or a catastrophe or just being unable to get themselves to do it that day. Hopefully, he or she would not spend significant time feeling guilty or ashamed or like something bad was going to happen. With people for whom exercising is compulsory, they *will not* miss a scheduled day, and often if they absolutely MUST miss a day or session, they will spend time wracked with guilt and fear that "All is lost."
Additionally, compulsive exercise is different from excessive exercise or compensatory exercise. I imagine that the endurance athletes many people know would be more closely associated with excessive exercise rather than compulsive. What defines excessive, for me, is "to the detriment of all else and without adequate nutritional support." Also, excessive would be over and above what a training schedule or program would call for, and outside of what a coach might want. Compensatory exercise is when someone uses exercise as their form of purging- used to compensate for food already eaten or used to justify food yet to come. This is seen and heard ALL THE TIME in our society. Think any time someone eats something and says "I'm going to have to work out extra tomorrow!" or something like that... but, again, taken to unhealthy extremes.
Finally, disordered exercising patterns are most often focused more heavily on changing body weight or shape rather than achieving particular goals related specifically to the activity (i.e., "Finish Ironman, don't die"). They also frequently exist without adequate nutritional support, so that your body is not remotely maintained through this exercise.
I have had a great time answering these questions, and hope those of you who asked the question feel fully answered! If there are any follow up questions, those are very welcome here! I hope those of you who read this stuff feel more informed and knowledgeable about eating disorders, and I would be absolutely happy to continue answering questions all week!