Eating Disorders: Guide to Savouring A Bigger Slice of the Pie

What is an Eating Disorder?

Eating Disorders (ED) are defined as “psychological disorders involving gross abnormalities in eating” (Crowther et. al, 2013). It is of my opinion that an ED is "any dysfunctional relationship with food that ultimately interferes with a person’s quality of life". Coming from a warped self-image, it is a psychological issue with not-so-delicious physical manifestations - which is my motivation for this post!


Have you ever wondered if you have an eating disorder? Why would someone have one? How does it feel?

ED involves many risk factors and can take many forms. I wanted share my personal experiences and to address:

For TL;DR humans, hop through the post by clicking the links above!



Types of Eating Disorders

Some eating disorders are more common than others, let’s explore four today. These include:

  1. Orthorexia Nervosa

  2. Anorexia Nervosa

  3. Binge Eating

  4. Bulimia Nervosa


1. Orthorexia Nervosa (ON), aka The Clean Eater.

In Greek, “Orthos” and “Orexia” translate to“Straight/ Proper Appetite”.

People with ON are clean eaters - they shun anything “unhealthy”, “unclean' or “non nutritional”', and are obsessively focussed on only consuming “healthy”, “clean” and “quality” foods” (Strahler et. al, 2018). Their diets are shrouded by unbending rules of which violations would elicit exaggerated emotional distress (Cena et al, 2018).


Often motivated by health and weight improvement, these eaters spend a marked amount of time preparing similar foods to eat at similar timings everyday (Håman et. al, 2015). The preoccupation with biologically pure foods ends up excluding them from social relationships and causes emotional dissatisfaction (Strahler et. al, 2018).


2. Anorexia Nervosa, aka The Fearer.


Anorexia Nervosa (AN) is driven by a refusal to maintain a body weight at its minimally normal range due to an intense fat phobia.

There are two types of Anorexia: (1) Restricting (through Diet/ Fasting, Excessive exercise) and (2) Binge-eating/ purging (Induced vomiting, Misuse of substances like laxatives) (Harrington et. al, 2015).

Victims have a disturbed self-image, deny both the state and seriousness of being underweight, and experience secondary amenorrhea (missed periods for more than three months) (Garner, 1993).


3. Bulimia Nervosa aka The Compensator.


Bulimia Nervosa (BN) is marked by inappropriate compensatory behaviours following recurrent episodes of binge eating.


Binge eating is characterised as:

  1. Eating abnormally large amounts of food in a discrete period of time.

  2. A lack of control over eating during the episode.


To prevent weight gain, victims of BN engage compensatory behaviours such as:

  • Self-induced vomiting.

  • Misuse of laxatives, diuretics, or other medications.

  • Fasting.

  • Excessive exercise.


Unduly influenced by body weight, these episodes occur on average at least once a week for three months (Harrington et. al, 2015).


4. Binge Eating Disorder aka The Helpless.


Binge Eating Disorder (BED) is largely similar to BN in patterns of recurrent binge eating (Average once a week over three months). However, unlike BN, there is no regular use of inappropriate compensatory weight control methods.


Binge eaters face a similar lack of control over their episodes. Eating is typically:

  • Much more rapidly than normal.

  • To an uncomfortably full extent.

  • Occurring even when not physically hungry.


Episodes are followed by profound levels of distress such as feeling extreme embarrassment, depression, disgust and guilt at the self (Wilson, 2011).



What Causes Eating Disorders?

Sociocultural Factors (External Environment: Society and Family)

As much as we wish to be original, to be individualistic, to be “ourselves”, the fact is that we are all functioning within the same dizzying society. Oftentimes, our thoughts are naked to the same social narratives, and our actions clothe the same body of social norms.


Society

The way we perceive and relate to our body is something we learn within the framework of society. What defines good and bad? You don’t have to scroll Instagram, switch on the television or flip a magazine to understand this: A fit body represents health and good living, while an obese body is stigmatized with laziness, weakness and unattractiveness (Crawford, 1980). The norms of leanness and diet rigidity exist within most of our psyches, although more exaggerated within certain subcultures such as among athletes, fashion, yoga and dance communities (Valera et. al, 2014). Structuring bodies around the “correct” weight and shape is commonly a response to socialized moral obligations, and an instrument for social and self acceptance.


Family

Household conditions and parent-child relationships greatly shape personality traits. Families that emphasize success and external rewards can develop within the child a sensitivity towards prize and punishment. In attempts to attain success, children may turn to the nearest thing they can control: which is most often what they eat and how they look (Harrington et. al, 2015).


Psychological Factors (Internal Environment: Personality)


But in a tidal sea of social norms, what makes someone sink? It appears that individuals struggling with anxiety, insecurity, personality disorders or mental illnesses tend to express more vulnerability towards the development of eating disorders.

A restrictive diet fulfils feelings of complete control, safety, puritanism, identity and even spirituality for some (Kinzl et. al, 2016).

The key personality traits associated strongly with ED include:

  • Perfectionism and a strong desire for control.

Certain personal reasons (eg. insecurity, repression, health problems) can lead someone to seek an irregular level of control in diet. The restriction is further emphasized among perfectionists, who harbour a deep fear of disapproval and anxiety towards inadequacy. Especially pronounced among ON and AN, an accordance to a prohibitive diet is often perceived as a realization of self discipline and control (Koven and Senbonmatsu, 2013).


  • Low self esteem.


Still within the theme of anxiety, individuals with low self-esteem can excessively restrict their diet in a rejection and attempt at change of their body image. These feelings are often layered with negative emotions of which a person may lack effective management for. Diet then becomes a strategy to regulate these emotions, and these restrictions tend to become triggers for binging (Amianto et. al, 2015).


  • Weakness in emotional awareness and control.

A fragility in emotional control and self-monitoring can fixate someone on their diets and thus develop an eating disorder (Koven and Senbonmatsu, 2013).

Alexithymia (a complete incapacity in emotional identification, social attachment, and interpersonal relation) can turn many towards eating as their catharsis, especially among BED (Amianto et. al, 2015).

  • Mental illnesses.


  • OCD AN and OCD can be traced to the same obsessive-compulsive spectrum and share common etiopathogenic roots at the genetic and neurochemical levels (Cavallini et. al, 2000; Barbarich, 2002). Among ON subjects, 30% express considerable obsessive–compulsive symptoms, as compared to 11% in non-ON (Koven and Senbonmatsu, 2013).


  • Depression/ Mood disorders Within the same study, 48% of ON subjects (as compared to 22% in non-ON) could be considered to suffer from at least moderate depression (Koven and Senbonmatsu, 2013). Depressive and negative feelings, disinhibition and anger are also exhibited among BED patients, of which may be linked to severe eating impulsiveness (Amianto et. al, 2015).


  • Other comorbidities of eating disorders Amidst these traits and illnesses, other conditions often observed to co-occur with ED include:

  • High interpersonal problems

  • Personality disorders

  • Substance abuse


Can Eating Disorders be Genetic?


Possibly due to heritable characteristics such as anxiety, depression and body weight that tend to prime an onset of eating disorder, having eating disorders within your family unit can make you seven to twelve times more likely to develop one (Berrettini, 2004).


Prior to puberty, environmental factors were linked to the development of eating disorders, but after puberty, there is a 50% genetic reason for eating disorder emergence (McGuire, 2017). This may be due to the hypothesis that prenatal androgens (male sex hormones) organize genetic disposition of ED which is then prompted by estrogens during puberty (Klump et. al, 2005).


More research would be required to determine the heritability of eating disorders.



Recognising Eating Disorders

How can we recognise an eating disorder? I guess most sufferers do know, but choose to nestle in denial. Likewise, the disorder was something I never wanted to acknowledge until a month or two ago. I had missed my period for five months and was developing chronic Angular Cheilitis. The condition may be even more difficult for outsiders to pick up on. In fact, many people were swept under the false impression that I was admirably “healthy” and “disciplined”.


But there are some quiet signs I personally experienced, which we can all look out for.


Pertaining to diet:

  • Complete elimination of “villainous foods”.

For a long time I sustained only on fruits, vegetables and nuts. The idea of having sugar, salt, refined oils, or anything that was not “whole” or natural in my body distressed me. Even on “fun” drinking nights, I would staunchly refuse any mixers.


  • Starving at times.

One of my most painful experiences was piercing hunger pangs on the bus home from school. I had enough courage to only nibble at a piece of raisin-walnut bread I had kept and I didn’t know why I felt this way.



Pertaining to emotions:

  • Extreme distress and guilt at consuming “blacklisted” foods.

  • Anxiety towards certain foods (I truly believe, even until today, that eating a bowl of rice would severely and irreparably inflate my body size).

  • Marked fear of looking at photographs others have taken of me.

  • Daily self-surveillance in the mirror and perplexity towards the reflection.


Pertaining to disturbing actions:

  • Rejecting social events in knowledge of having to consume any foods outside of my diet. (A few unavoidable times when people offered me food I would chew it, pretend to wipe my mouth, then secretly spit it out and attempt to hide it).

  • “Punishing” myself through extreme exercising or attempts at purging when I consumed something against my self-imposed rules.



How to manage Eating Disorders.

Eating disorders are deeply personal issues. It is often individual life experience that distorts one’s perception of food and the self. To overcome it, one has to: (1) Acknowledge the issue, and (2) Gradually and sensibly recalibrate the mental outlook.

I want to share some effective strategies I’m practising.


For victims:


1. Socialise and surround yourself with positive energy.


This was tremendously helpful for me. In the past, I briefly opened up about this to certain people. But because they were either partiers or people I was not that close with, it was natural that they didn’t really know how to respond or involve themselves. So go out, immerse in good company and friendships, and communicate about it if you want. I have never shared the full story or extent of my disorder to people in my life, but I realised just articulating bits of it and writing about it made me feel better! TIP: If social media makes you feel negatively, it’s not positive energy!

2. Diet revision.


Moderate foods. Eat the things you love in moderate amounts. God knows I love granola, bread and frozen yogurt to death. Abolishing them in my life low-key frustrated me and triggered distressing binges. Though I still hold a deep anxiety towards bread, I’m trying to de-categorise foods and accept that my body will not balloon from half a piece of sourdough. Having a bit of everything breaks the cycle of starving then binging.


3. Eat in nutritional terms - not all calories are equal.


Protein is a complex substance composed of amino acids and plays a vital role in cellular activities and binding (Lambert et. al, 2004). Shown to be effective in weight and fat mass reduction, it also preserves lean mass due to its modulation of energy metabolism, intake and appetite (Leidy et. al, 2015).

I have reintroduced foods like fish and eggs into my veg-fruits-nuts-only diet, which honestly makes me feel healthier, fuller, and more balanced. Along with this, I’ve also been suggested to observe my body composition instead of weight itself. I realised even though I am heavier, I have increased muscle mass and lowered body fat percentage. This helped to remove a bit of uneasiness I had towards weight and foods.

4. Exercise.

When I exercise, I eat more without feeling stressed. Building more muscle is also good for weight loss!

5. A food journal.


How does a food make you feel, independent of its calories and nutritional content? This question elucidated the raw emotional relationship I shared with a food before I concealed it with all my self-imposed qualities (eg. “Unclean”). Then I realised, purple sweet potatoes actually make me profoundly happy!



6. Form an identity independent of your body.


Probably because for more than half my life I could never wear skinny jeans or sleeveless tops with pride, I was engulfed in excitement about wearing them the moment I lost weight. Wearing them day and night, I fell deeply in love with the aesthetic and the attention. The allure of this image started getting stronger and stronger. If I didn’t have slim arms and waist, I was back to the mediocre and unimpressive person that I was. So I got more and more critical towards myself and I had to abide by this image through diet control.

Spiralling around I’ve finally arrived at this point: Don’t prove yourself through appearance - confidence is stronger when established from within. Realise and cultivate your unique passions and interests!



7. Being kind to yourself.


This is the ultimate step! Draw boundaries and keep that safe place. With crayons of determination I’m scribbling lines between my bad thoughts and me. When I look at the mirror in the morning, even if I have a tummy, I promise my mind I won’t be violent towards her today.



8. Cognitive Behaviour Therapy (CBT).

If the troubles of an eating disorder shroud your life and mind and none of the methods work for you, consider CBT. Based on guided self-help, it is the first-line treatment option for most victims with high eating disorder psychopathology as it eliminates both core features of ED as well as their comorbid psychological problems (Wilson et. al, 2010). Furthermore, it may reduce relapse risk for adults, making it a viable treatment option (Berkman et. al, 2006).



Things to do for victims


1. Be there.

Especially for adolescents and young adults, family therapy or a strong familial support system can effectively treat ED (Le Grange et. al, 2009). While the structure of involvement would vary among individuals, availing yourself to victims can potentially aid in their restoration of diets and health.


2. Don't force them to eat.

Anorexia patients used to be force fed through the mouth, tube or rectum in attempts to regularly and frequently reintroduce foods into their diet (Garner and Garfinkel, 1997). However, such well-intended pressures can potentially irritate and create counter effects. Personally, I felt more compelled to rebel and resist whenever someone tried to coerce me into consuming something against my will.


3. Don’t shame them.

A reason I lacked the boldness to share my struggle was the fear of judgment, as well as the worry of coming off as an attention seeker. Communication was more fruitful when someone asked me why I felt these ways, instead of dismissive responses such as “Omg stop it, you’re not fat” - because that’s not how I see me.


4. Don't reinforce their diets.

This one is a little bit of a tough nut, for it could go both ways. Receiving praises or marvels at a diet may positively encourage one to continue. But it gave me a sense of acceptance and approval which I only felt more obliged to keep up with, even with its afflictions.



Ready for Order?



Beauty, sensuality, health and femininity. We don’t imagine these bound to muffin tops or double chins. And we should not - for obesity and its comorbidities cut into our longevity. My candid observation is that being overweight even affected my life chances: I was teased and referred to with words like “Pui” (“Chubby” in Hokkien), I had scarce opportunity in romance, and in any conflicts my size was always the first to be shot down on.

These experiences internalized a form of self-shame within and probably drove my development of ED, although it’s agreeably entangled with most of the other causes listed here as well.


I don’t believe that beauty ideals would deviate from the “thinness-culture” in my lifetime. To rethink the norms within myself is already a challenge, just how long would it take the world? So when the environment is unyielding, my logic sees me to channel efforts towards my own psyche instead.

To me, overcoming ED is an internal labour: you have to rework habitualised cognitive patterns and relearn the experience of your own body.

Even if you never had the protective factors that protect most people from the expression of eating disorders, it doesn’t mean that you can never put your life back in order. The world is like a big restaurant - you learn how to taste, you learn how to appreciate, how to scorn. But at the end of the day, from all these you’ll have to create and enjoy the dish that is uninterruptedly yours. And that discovery would truly make up the biggest slice of the pie for you to enjoy!


Namaste.


 

References


Amianto, F., Ottone, L., Abbate Daga, G., & Fassino, S. (2015). Binge-eating disorder diagnosis and treatment: A recap in front of dsm-5. BMC Psychiatry, 15(1). doi:10.1186/s12888-015-0445-6

Barbarich, N. (2002). Is there a common mechanism of serotonin dysregulation in anorexia nervosa and obsessive compulsive disorder? Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity, 7(3), 221-231. doi:10.1007/bf03327460

Berkman, N. D., Bulik, C. M., Brownley, K. A., Lohr, K. N., Sedway, J. A., Rooks, A., & Gartlehner, G. (2006). Management of eating disorders. Evidence Report/technology Assessment, (135), 1-166.

Berrettini, W. (2004). Genetic influences on eating and the eating disorders. The Genetics of Eating Disorders, 1(3), 18-25.

Cavallini, M. C., Bertelli, S., Chiapparino, D., Riboldi, S., & Bellodi, L. (2000). Complex segregation analysis of obsessive-compulsive disorder in 141 families of eating DISORDER PROBANDS, with and WITHOUT obsessive-compulsive disorder. American Journal of Medical Genetics, 96(3), 384-391. doi:10.1002/1096-8628(20000612)96:33.0.co;2-p

Cena, H., Barthels, F., Cuzzolaro, M., Bratman, S., Brytek-Matera, A., Dunn, T., . . . Donini, L. M. (2018). Definition and diagnostic criteria for orthorexia nervosa: A narrative review of the literature. Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity, 24(2), 209-246. doi:10.1007/s40519-018-0606-y

Crawford, R. (1980). Healthism and the medicalization of everyday life. International Journal of Health Services, 10(3), 365-388. doi:10.2190/3h2h-3xjn-3kay-g9ny

Crowther, J. H. (1992). Etiology of bulimia nervosa: The individual and familial context: 2nd Meeting: Papers. Hemisphere Pub., U.S.

Garfinkel, P. E., & Garner, D. M. (1997). Handbook of treatment for eating disorders. New York: Guilford Press.

GARNER, D. (1993). Pathogenesis of anorexia nervosa. The Lancet, 341(8861), 1631-1635. doi:10.1016/0140-6736(93)90768-c

Harrington, B. C., Jimerson, M., Haxton, C., & Jimerson, D. C. (2015). Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosaBrian C. Harrington. Am Fam Physician, 91(1), 46-52.

Herranz Valera, J., Acuña Ruiz, P., Romero Valdespino, B., & Visioli, F. (2014). Prevalence of orthorexia nervosa among ashtanga yoga practitioners: A pilot study. Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity, 19(4), 469-472. doi:10.1007/s40519-014-0131-6

Håman, L., Barker-Ruchti, N., Patriksson, G., & Lindgren, E. (2015). Orthorexia nervosa: An integrative literature review of a lifestyle syndrome. International Journal of Qualitative Studies on Health and Well-being, 10(1), 26799. doi:10.3402/qhw.v10.26799

Kinzl, J. F., Hauer, K., Traweger, C., & Kiefer, I. (2006). Orthorexia nervosa in dieticians. Psychotherapy and Psychosomatics, 75(6), 395-396. doi:10.1159/000095447

KLUMP, K. L., GOBROGGE, K. L., PERKINS, P. S., THORNE, D., SISK, C. L., & BREEDLOVE, S. M. (2005). Preliminary evidence that gonadal hormones organize and activate disordered eating. Psychological Medicine, 36(4), 539-546. doi:10.1017/s0033291705006653

Koven, N. S., & Senbonmatsu, R. (2013). A neuropsychological evaluation of orthorexia nervosa. Open Journal of Psychiatry, 03(02), 214-222. doi:10.4236/ojpsych.2013.32019

Lambert, C. P., Frank, L. L., & Evans, W. J. (2004). Macronutrient considerations for the sport of bodybuilding. Sports Medicine, 34(5), 317-327. doi:10.2165/00007256-200434050-00004

Le Grange, D., Lock, J., Loeb, K., & Nicholls, D. (2009). Academy for eating disorders position paper: The role of the family in eating disorders. International Journal of Eating Disorders. doi:10.1002/eat.20751

Leidy, H. J., Clifton, P. M., Astrup, A., Wycherley, T. P., Westerterp-Plantenga, M. S., Luscombe-Marsh, N. D., . . . Mattes, R. D. (2015). The role of protein in weight loss and maintenance. The American Journal of Clinical Nutrition, 101(6). doi:10.3945/ajcn.114.084038

McGuire, J., & McGuire, J. (2017, October 09). Genetic factors behind eating disorders. Retrieved May 03, 2021, from https://www.eatingdisorderhope.com/blog/genetic-factors-eating-disorders

Strahler, J., Hermann, A., Walter, B., & Stark, R. (2018). Orthorexia nervosa: A behavioral complex or a psychological condition? Journal of Behavioral Addictions, 7(4), 1143-1156. doi:10.1556/2006.7.2018.129

Wilson, G. T. (2011). Treatment of binge eating disorder. Psychiatric Clinics of North America, 34(4), 773-783. doi:10.1016/j.psc.2011.08.011

Wilson, G. T., Wilfley, D. E., Agras, W. S., & Bryson, S. W. (2010). Psychological treatments of binge eating disorder. Archives of General Psychiatry, 67(1), 94. doi:10.1001/archgenpsychiatry.2009.170