June 2, 2019 is World Eating Disorders Action Day#ShowUsYourPurple. I want to recognize this day because I’ve personally seen the devastation caused by an eating disorder (ED) and have come to understand it as a complex mental illness and not something that is easily controlled.
I will never forget a conversation I had with a former schoolmate – one of the most beautiful young women in our community – who essentially wasted away after high school due to an ED. Fortunately, through the support of her family and a lot of hard work, she recovered. When we met years later I asked her how she couldn’t see how gorgeous she was and she said, “That’s not what I saw when I looked in the mirror.”
Shaleen Jones, the Executive Director of Eating Disorders Nova Scotia, says, “Eating disorders aren’t simply about wanting to be pretty. Our culture is fixated on the false notion that our worth as humans – and especially as females – is contingent on how we look, and that being thin is the only acceptable body size. The voices are so strong – telling you that you aren’t good enough, no one is going to love you, you’re fat or ugly.”
For many, including males, the eating disorder becomes a metaphor for how they want to be treated in society, and where their value comes from.
“People think that the individual who is experiencing an eating disorder should just be able to get over it by eating something. It’s much more complex than that.”
The National Eating Disorders Information Centre(NEDIC) states: “Eating disorders are not choices, but serious, biologically influenced mental illnesses.” It also reports that “Eating disorders affect people of all genders, ages, races, ethnicities, sexual orientations, and socioeconomic statuses” and that, “Eating disorders carry an increased risk for both suicide and physical/mental complications.”
In Canada, almost one million people over the age of 15 currently have an ED (Statistics Canada). Shaleen says it’s probably even higher due to the large number of Canadians who never receive a diagnosis.
So, while there’s clear evidence that this is an important issue we need to talk about, I found it difficult to write about. It’s become personal. My daughter Angela’s immense anxiety in her first two years of university contributed to issues with food and eating, resulting in significant weight loss. I felt helpless being thousands of miles away and not knowing what to do to support her to regain health before it became worse. Fortunately, she was open to talking about it, did reach out for help, and is doing better. It was a wakeup call that it could happen in a family like ours, that I have always thought had healthy relationships with both body image and food.
Understanding the issues
To start the conversation, Shaleen and I met for lunch at a favourite Halifax restaurant. It was an intentional choice as it was where I’d first witnessed my daughter’s distress around food.
When I asked Shaleen what she’d like to see changed in society, she held up her fork, brandishing an impeccable cannoli, and exclaimed, “Make food joyful!” She added, “We have to give up this wish that we can restrict our way to a healthier life. Releasing this belief frees us up to do so much more with our energy.”
The key lies in unpacking the mythology around weight, size and shape in our culture and the deeply held belief that our worth is tied up in how we look at weight. “This is fed (pun intended) by the massive wellness, dieting, detox industry that perpetuates the belief that you’re unhealthy if you’re overweight, when really the underlying goal is to sell you something.”
“The worst thing someone can do for their health is to repeatedly try to lose weight through diet. We know restrictive eating does not result in long term weight loss. It impairs all of our systems.”
Instead, Shaleen says, “Focus on actions to become more active, to gain more energy and to feel better.”
While the new Canada Food Guide does a good job of promoting healthy eating, Shaleen loves the Brazilian Food Guide because it is founded on eating food you enjoy with people you love.
“When we look at eating well, it shouldn’t be about restricting, or what we should and shouldn’t be eating. It should be about enjoying the food, and to stop eating when we’re full.”
“It should be about experiencing a range of foods and eating with people we care about.”
That can be easier said than done, particularly when the usual checks and balances, such as trusting, healthy relationships or positive role models aren’t in place.
Triggers for serious illness
Genetic or biological risk factors – which can include perfectionism, black and white thinking, or more rigid personalities – can have an enormous impact. “If a person is born with these genetic risks and goes through a stressful situation or begins restricting food intake, it can trigger an eating disorder,” Shaleen explains.
Repetitive restricted eating (or dieting) can also be a trigger. In a study of 14–15 year old adolescents, girls who engaged in strict dieting practices were 18 times more likely to develop an eating disorder within six months than non-dieters (Patton, G. 1999).
“The negative energy imbalance is thought to trigger changes in the brain,” says Shaleen. In other cases, like my daughter’s, anxiety can trigger a loss of appetite and subsequent weight loss, and even after the anxiety is dealt with the eating disorder has taken over. Another risk factor is for those who are “othered” in some way, such as sexual orientation, a disability, or race. Trauma can also be a trigger.
Bullying and body shaming around weight and size continues to present a significant risk factor for eating disorders and obesity, along with other tragic outcomes, as we are seeing in the news way too often.
Girls who reported teasing by family members were 1.5 times more likely to engage in binge-eating and extreme weight control behaviours five years later.
Body dissatisfaction and weight change behaviours have been shown to predict later physical and mental health difficulties, including weight gain and obesity on the one hand, and the development of eating disorders on the other.
Knowing when there’s a problem
Shaleen says the tricky part that makes EDs so difficult to understand is that they involve periods of restrictive eating – which triggers binge eating for some and increased restriction for others.
The 2016 Report, Eating Disorders – A Guide to Medical Care the Academy for Eating Disorders (AED) states: “Malnutrition is a serious medical condition that requires urgent attention. It can occur in (people) engaging in disordered eating behaviors, regardless of weight status. Individuals with continued restrictive eating behaviors, binge eating or purging, despite efforts to redirect their behavior, require immediate intervention.
The report also includes the following:
- All EDs are serious disorders with life-threatening physical and psychological complications.
- EDs do not discriminate. They can affect individuals of all ages, genders, ethnicities, socioeconomic backgrounds, and with a variety of body shapes, weights and sizes.
- Weight is not the only clinical marker of an ED. People who are at low, normal or high weights can have an ED and individuals at any weight may be malnourished and/or engaging in unhealthy weight control practices.
- Individuals with an ED may not recognize the seriousness of their illness and/or may be ambivalent about changing their eating or other behaviors.
- All instances of precipitous weight loss or gain in otherwise healthy individuals should be investigated for the possibility of an ED as rapid weight fluctuations can be a potential marker of an ED.
- In children and adolescents, failure to gain expected weight, and/or delayed or interrupted pubertal development, should be investigated for the possibility of an ED.
- All EDs can be associated with serious medical complications affecting every organ system of the body.
- The medical consequences of EDs can go unrecognized, even by an experienced clinician.
AED cautions that a life-threatening ED can occur without obvious symptoms. Some of the top ones to watch for include:
- Marked weight loss, gain, fluctuations or unexplained change in growth curve or body mass index (BMI) percentiles in a child or adolescent who is still growing and developing
- Cold intolerance, weakness, fatigue or lethargy, dizziness, fainting, hot flashes, sweating
- Oral and dental issues, including oral trauma, cavities, and salivary gland enlargement
- Cardiovascular and Gastrointestinal issues
- Irregular menstruation, low sex drive
- Hair loss, scarring from self-induced vomiting, poor wound healing, brittle hair and nail
- Poor concentration, memory loss, insomnia
- Depression/anxiety/compulsive symptoms and behaviours
- Self-harm and suicidal thoughts
Early intervention for full recovery
“One of the challenges is convincing people that they don’t have to live with their ED; that they can get better,” Shaleen says. Another concern is that many people don’t get help until they are very sick.
Schools – elementary, high school and post-secondary – all need to be mindful this is a very serious health condition. “Have a conversation, train staff in what to look for, and don’t wait for people to get really sick before having a process in place to support them,” Shaleen suggests. Policies should include supporting students with eating disorders, and strictly prohibiting weight bullying.
Early intervention and aggressive treatment is the most effective way to treat an eating disorder.
“With early intervention and treatment, you can get the eating disorder into remission quite quickly,” Shaleen says. She shares real-life examples where individuals’ cries for help were ignored by doctors and the system in general because they weren’t seriously underweight.
Pathways to recovery
If you have an eating disorder or suspect a family member does, first and foremost, is making an appointment with a physician. The Eating Disorder Support Network of Alberta (EDSNA) provides an excellent guide to help you and your family members prepare for the visit. You can download the guide (See under Working with your Doctor) at https://edsna.ca/eating-disorder-facts/
You may also wish to access the services of a psychologist or community resources, many of which can be found at http://nedic.ca/providers/search. Dieticians can also be helpful but Shaleen emphasizes the importance of seeing one who encourages health at every size because again, “Low weight does not equal seriousness of the illness.” She also advises to look for a community based eating disorders organization in your area for additional support and assistance navigating the health care system.
NEDIC states: “Given the complex nature of eating disorders and the many factors that play a role in their development and perpetuation, treatment must address a variety of issues. It is accepted that a two-track approach is necessary for the treatment of eating disorders. They are:
- Issues concerning eating, weight, and physical condition
- Issues concerning the underlying psychological conditions.
Treatment will focus more on the physiological issues in the early phases of therapy, with the view to establishing some degree of normalcy with eating and weight. This enables the individual to benefit from the therapy to address psychological issues.”
NEDIC emphasizes that it’s critical that treatment focus on both physical and psychological tracks to support full and lasting recovery. It’s also important that the treating professional have a thorough understanding of EDs.
Having compassion for ourselves and others
Shaleen says that it’s not necessarily a sign of a problem if we turn to food when we’re distressed. “If we find ourselves binge eating or comfort food eating, we want to look at what’s happening through a lens of self-compassion.” She adds, “The behavior of stress eating is a tool that you have used to get through some troubling times. Good for you if you’ve found something that works!” She says that if it isn’t working for you anymore, that’s when you can look at other things that might help you to cope during difficult times.
“Listen to your hunger, eat when you’re hungry, stop when you’re full.”
She also admonishes that the Body Mass Index (BMI) that, while a guide, doesn’t necessarily take into account all the “data” of our lives. It’s the same with the fact that we may look at a person who appears overweight and feel we have enough evidence to judge whether they are healthy or not.
“We don’t have all the data about their health, and it’s none of our damn business,” Shaleen says.
“People are going to be healthier and happier if they aren’t constantly berated by society and the people around them.”
In additionto the links included above:
Eating Disorders Nova Scotia offers free online peer support as a safe, pro-recovery space for folks with eating disorders to connect, learn, and grow.
The Eating Disorder Support Network of Alberta provides a thorough description of the current diagnostic categories from the “Feeding and Eating Disorders” section, as outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM) – 5, a publication of the American Psychiatric Association.
Most Prevalent Eating Disorders
- Persistent restriction of energy intake leading to significantly low body weight
- Either an intense fear of gaining weight, or persistent behaviour that interferes with weight gain
- Recurrent episodes of binge eating and sense of lack of control over eating during the episode
- Recurrent inappropriate compensatory behaviour (for example, purging)
- Despite significant weight loss, the individual’s weight is within or above the normal range
Binge Eating Disorder
- Recurring episodes of binge eating
- Marked distress regarding binge eating is present
- Binge eating is associated with the recurrent use of inappropriate compensatory behaviours
Adapted from DSM5.
Neumark-Sztainer, D. R., Wall, M. M., Haines, J. I., Story, M. T., Sherwood, N. E., van den Berg, P. A. (2007). Shared Risk and Protective Factors for Overweight and Disordered Eating in Adolescents. American Journal of Preventative Medicine, 33(5), 359-369.
Field et al., 2003; Neumark-Sztainer et al., 2006.
Le Grange & Loeb, 2007)
*Stock photos courtesy of Unsplash