Monday, April 06, 2015

Eating Disorders: Replacing Myths with Realities

Last week I attended a lecture at the local medical school by eating disorder expert, figure skater, mother, traveller and general overachiever, Dr Cynthia Bulik. The title of the evening was "Eating Disorders: Replacing Myths with Realities".

The structure of the evening was a systematic debunking of nine common myths surrounding eating disorders. 

What are the nine myths?

1. You can tell by looking at someone that they have an eating disorder
2. Families are to blame
3. Mothers are to blame
4. Eating disorders are a choice
5. Eating disorders are a disease of white, upper-middle class teenage girls
6. Eating disorders are benign
7. Society alone is to blame
8. Genes are destiny
9. Eating disorders are for life

If you have an hour to spare, the entire lecture content is on the NIH website here, in handy sections. In this post, I'm going to organise my own lecture notes. Obviously, these are the parts that were particularly fascinating to me. I only ever jot down things that really matter, and every time I do, I wish I'd learned shorthand in school. :-/

The first thing that got me thinking was the absolute falsity of what we might say is the sterotypical eating disordered person.  Think 'eating disorder'. What comes to mind?  A businessman? (no?), A grandmother? (no?), a mature single lady artist? (no?), a happily married woman with grown children? (no?). What about a thin white female from a dysfunctional family? (yes, that's more like it).

Dr. Bulik pointed out that the way we think about, diagnose, assess and treat eating disorders has helped perpetuate this prototype, which in fact does not exist. For a start, not all eating disordered (ED) people are thin, however it is difficult to get diagnosed with an ED if you look normal, or are overweight. A GP may miss critical signs, no matter how many hints a patient drops. She emphasised the seriousness of this impression that being too thin is the main risk of ED's. I didn't realise it, but in terms of psychiatric and medical comorbidities, binge-eating disorder (the most missed disorder) is just as serious as anorexia nervosa.

Further, despite the 'anorexic overachiever with alcoholic mother' image, many people with ED's have normal families. However, it is common for the ED to 'take over' and trigger problems and family friction that may not have been there before. An inexperienced therapist may only see that family once the ED is running the household. ED's are also not a purely female thing, but men are far less likely to seek treatment early in the disease process. Dr. Bulik noted that the stigma of an ED can be greater for a man, due to the 'feminisation' of the illusory prototype and because a major DSM criteria of bulimia and binge-eating disorder is feeling 'a loss of control' over ones eating behaviour. What man wants to tick that box on a questionnaire? There is also some perception that a man with an ED may be effeminate or assumed gay.

The lecture segment which I found particularly interesting was the discussion around prevalence of ED's in mature women. In her years as a Clinical Psychologist, Dr. Bulik has seen the average age of ED patients creep upward, with more than half now being over 35 years old. That blew my mind, particularly once the medical seriousness of a long term ED was clarified. ED's are not benign. As well as the psychological strain, there are increased risks of cardiovascular disease, gastro-intestinal problems, musculoskeletal disorders, dental issues, and suicide. Statistics taken from the 'Gender and Body Image' GABI study were particularly sobering, and some drew gasps from the audience. I also noticed a few whispered conversations as people recognised their own behaviour. In the GABI study (n=1800 women over 50 years of age):

41% of participants 'body checked' daily. That is, they did things like pinch their waist, critically examine themselves in the mirror, weigh, measure or some other form of body self-analysis.

62% felt that their weight or shape negatively impacted their life (!!)

and this is the most important part:

64% thought about their weight every single day.

The room went silent, and Dr. Bulik exclaimed 'isn't that a waste . of . life?!'  Yes, actually, it is. The worst thing was, I'd just whispered to my friend Bee 'I do that'. Then, along with many others in the room, I sat pondering if what I have embraced as normal is actually some form of subclinical eating disorder. Going a day without thinking about my weight or feeling my flab? Strange concept.

We then discussed the many ways that it has become oh-so-normal to spend considerable time and energy thinking about our bodies, food and exercise. Even when we are relaxing, say on Facebook (or, ahem, blogging...), we are still talking about bodies, food and exercise in various groups and forums. We dissect diet plans, are invited to join this group, buy this e-book, try this plan and we are bombarded with videos showing us what aging can look like if we just work hard enough. We are never told 'enough, think about something else, now go play the piano'.  The constant barrage makes us critical, not just of ourselves, but of each other. 

Does your Grandma look like this?  OMG, she should try harder....

There was a good amount of discussion about what must be done to stem the tide of eating disorders and create a society that truly is body positive (without this becoming an obsession to equal the current 'body negative' theme). Dr. Bulik emphasised that ED's are treatable and that most people fully recover, just as from any other illness. If you think you have an ED, you probably do. Seek treatment. In terms of stopping an ED from developing, she talked about developing an understanding of the interaction between genes and environment. It seems that with a genetic predisposition to an ED, a trigger (for example teasing, or starting one's first diet) may trigger the disorder. The direction that the disorder then takes may also have a genetic influence, for example, the brain of an anorexic reacts euphorically to calorie deprivation, whereas in a binge eater the reaction may be so negative as to drive a reactive eating binge.

The counterpoint to triggers are protective factors. Here, Dr. Bulik mentioned such things as positive role models and making eating a positive experience (family meals). She mentioned the particular 'role-modelling' input of sports coaches and PE teachers, whom should be taught to focus on performance, not aesthetics. This bought to mind a particular riding coach I once had that used to mention my 'meaty thighs' and how I had to arrange them properly in order to look elegant. Thanks for the body image issues, pony club. 

Of course, that 'health affirming' role also extents to doctors, PT's, Nutritionists, Dietitians and any other professional that offers health advice. As a Nutritionist, I've learned that ED's are something we must be very aware of. Not only is there the possibility that the client in front of you already has one (and may need help outside of our scope), but there is the scary possibility that the wrong advice may trigger one. Lectures like this remind me not to get complacent.

Lastly, Dr. Bulik also spoke a little more about her genomics project, ANGI - the Anorexia Nervosa Genetics Initiative. The mission of that is to identify the genetic markers which predispose an individual toward developing anorexia. This project is a grand step toward destigmatising eating disorders by proving they are not purely psychological/behavioural in origin. Dr. Bulik expressed the hope that one day it may be as socially acceptable to say you once had binge-eating disorder as to say you once had pneumonia. It was nice to hear a few individuals either in treatment or recovered piping up during the q&a without embarrassment.  I've been to many ED lectures and it's the first time I've experienced that type of openness. Perhaps a sign that the times are changing? Here's hoping.

I hope this has been as interesting to read as it was to write. I'd love to hear your thoughts and if anyone has attended this lecture and has something to add, please comment. 


  1. Good advice to focus on achievements, not aesthetics in the young ones. I've read that praise is better focused on what a child did rather than what they are. Similar...

  2. Very Inspiring blog. It's a very motivating article that will encourage people to recover from their eating disorders. Thanks for writing this. I had a great time reading it. Visiting this blog is worthwhile.


I love to hear from you! Tell me what's in your brain, your heart or your dinner plate :D.