Dangerous diets

When Lynn Grefe, president of the National Eating Disorders Association, was at a conference about eating disorders last year, a woman broke down crying in front of her.

The woman, said Grefe, was upset because the sessions had dealt with the well-defined eating disorders: anorexia, bulimia and binge eating. “‘You talk about anorexia and bulimia, and you never talk about me,’” Grefe said the woman told her. The woman went on to explain that she was consumed with thoughts of food and her weight, but that she didn’t fit the definition of any one disorder.

Even at a conference of experts, her issues went unrecognized.

She’s not alone. Though anorexia, bulimia and increasingly binge eating disorder are the most talked about, there are likely millions of women and men who don’t fit the classic definitions of a clinical eating disorder but who nevertheless have problems related to body image and food.

“What you have,” said Grefe, “is a whole lot of people that aren’t recognized in any major way as people that are truly, truly taking huge risks with their health.”

Though there are few reliable estimates of the number of people who suffer from disordered eating patterns, their numbers almost surely dwarf the numbers of people with clinical eating disorders.

According to the Diagnostic and Statistical Manual of Mental Disorders, a listing of recognized mental disorders published by the American Psychiatric Association, 0.5 percent of the population develops anorexia, defined as a restriction of food that causes a person to dip below 85 percent of his or her normal body weight. Between 1 percent and 3 percent of the population develops bulimia, defined as binging on food and then using inappropriate methods – vomiting, laxatives, even excessive exercise – to prevent weight gain. Binge eating disorder, binging without compensatory purging, occurs in up to 4 percent of the population.

Estimates of the percentage of the population with disordered eating patterns that don’t reach a clinical level are scarce, but range from 10 percent to 65 percent of the population. In some places, such as sororities, as many as 80 percent of women may have some form of disordered eating.

Disordered eating patterns do not always turn into full-blown clinical eating disorders, but they can still cause major distress, disrupt people’s lives and lead to psychological issues. Perhaps most dangerous, the patterns can go unchecked for years because the symptoms may never reach a level of severity that triggers professional or family attention.

Many people — especially women, who are much more likely to have disordered eating patterns than men — suffer for years as the problem damages both their psychological and physical health.

“I worry a lot about those people who fly beneath the diagnostic criteria,” said Cynthia Bulik, director of the eating disorders program at the University of North Carolina at Chapel Hill. They often cannot get insurance coverage to get treatment, Bulik said, and if the pattern continues, the behavior “might be the first step on a slippery slope.”

The person, she said, could quickly go from a disordered eating pattern to a full-blown clinical eating disorder.

But insurers, she said, are not the only institutions that do not recognize disordered eating patterns. She and other researchers said it is difficult to get money for research on behavior that doesn’t meet the diagnostic criteria for an eating disorder. “If I put a grant into the NIH (National Institutes of Health) for sub-threshold conditions, they would say, ‘Look at threshold conditions,’” she said.

Without funding, little research is done, and without research, very little is known about how many have disordered eating patterns, how to identify them or how to treat them.

Healthy or disordered?

Disordered eating patterns fall into several primary categories: restriction of diet, compulsion to exercise, use of purging behaviors or products, and use of food as a coping mechanism. For any given individual, the behaviors can be different, and many people have a mix of many different types of disordered eating patterns.

One person might cut an entire food group, such as carbohydrates or dairy products, from her diet. Another might keep a daily tally of exactly how many calories she has consumed. Still another might feel so guilty for skipping exercise that he works out even through sickness or injury. Some may get up in the middle of the night and, unbeknown to the rest of the house, eat an entire pizza.

The common thread, experts say, is what is going on in the mind. “It’s not how many hours you work out. It’s not how much food you eat or don’t eat,” said Nancy Curfman, a therapist in Bend who specializes in eating disorders. “It’s how compulsive is your mind.”

When she is counseling people, Curfman said, she asks questions such as how often they think about food, whether there are foods they are fearful of eating, and what they eat.

Those who restrict their food, she said, “take orders from the head” rather than listening to the body. They often set up rules, she said, that are unrealistic or overly harsh: “I have to exercise for an hour and a half because I ate this much yesterday.”

Curfman said she also sees people who become consumed by the need to exercise. This, she said, can be a form of bulimia because it is done to “purge” calories from the body. “There’s nothing wrong with a more fit body, but the difference is how to keep that in perspective with how to keep a healthier life,” she said. “Exercise can still be fun and social and playful.”

When either exercise or eating stops feeling good or being social, that’s when experts say a problem could be developing. People who have disordered eating and exercise patterns become consumed by them, and other things get put to the wayside. Work, family and friends sometimes become less important.

“If it interferes with your life or daily functioning or affects your health,” then it crosses the line into a disorder, said Kimra Hawk, a registered dietitian who works in the eating disorders program at Providence St. Vincent Medical Center in Portland.

As an example, she said many people overeat once in a while or restrict their calories to lose weight. Those with disordered eating patterns, however, tend to obsess about the food. “We’ve all sat down and (eaten) too many cookies because it was a bad day or cookies just came out of the oven, but the difference is we ate too much, we recover and move on,” Hawk said. “The disordered eater would then say, ‘Now I need to run 10 miles or I feel really bad about this.’ They really internalize it.”

Binge eating also involves the loss of control over what a person is eating, said UNC’s Bulik. While many people overeat because they are celebrating or even mourning, “that’s a different phenomenon than eating until you feel guilty or embarrassed.”

Development of disorders

Experts say disordered eating patterns likely develop through the same combination of biological, psychological and environmental factors that can lead to clinical eating disorders.

People with compulsive personalities, anxiety problems or perfectionist tendencies are more likely to develop problems with eating. Experts say these characteristics, though they can be exacerbated by eating disorders, likely predate the disorder, and that people born with these tendencies may be at greater risk for developing an eating disorder.

Recent studies have begun to examine the genetic underpinnings of eating disorders, and some suggest that the genes that regulate the levels of certain brain chemicals that regulate mood could also play a role in the development of eating disorders.

Psychologically, disorders are likely to develop during life transitions or when there is chaos internally or externally, Curfman said. “An eating disorder comes when someone doesn’t have a full sense of self or a lot of crises in their environment.”

The well-documented vulnerability of adolescent girls to eating disorders likely develops because of the confluence of a changing, growing body and major life transition due to graduating from high school, entering the work force or going to college. Stress around those big changes can manifest as a tighter control over diet, with control over food serving as a proxy for the struggle to control one’s life.

Those same issues, Curfman said, can crop up for women when their children leave home. “The question comes up, ‘Who am I? What am I going to do?’” she said. “A lot of women fit this category at the empty nest time or in retirement.”

Culture has a role in the development of eating disorders and may play a particularly big role for those who have disordered eating patterns that don’t develop into a full-blown clinical eating disorder. It’s hard to avoid emotional eating in a culture that promises cookies and milk after a rough day at school, chocolate after a bad breakup and cake for every birthday. “We’re taught to soothe ourselves with food,” Hawk said.

On the other side, thinness is encouraged, particularly for women, through diet books that routinely appear on best-seller lists, actresses who rarely wear above a size 6, and ever-shrinking models. That issue became so serious that the Council of Fashion Designers of America, which hosts New York’s famous Fashion Week, last year held a special session on eating disorders among models and issued guidelines in response to some models who had become, as the council put it, “unhealthily thin.”

Despite the pervasive cultural signals around both weight and food, the development of a clinical eating disorder is rarely talked about, especially among people who have it. “It’s a very, very secretive illness,” said Grefe, of the National Eating Disorders Association. Those who binge almost always do so in secret and, if people are not eating, they often try to hide that fact as well.

People with disordered eating patterns, Grefe said, are even less likely to be diagnosed than those with clinical eating disorders. Their weight may not change dramatically or their unhealthy behaviors might not be prevalent enough to catch the attention of a health professional or family member.

Danger zone

As long as the disordered eating pattern remains private, there is little chance that someone will get help. Experts say that even if the behavior never develops into a full-blown disorder, there are likely physical problems and almost certainly psychological ones.

Physically, the consequences of disordered eating patterns have not been studied, Bulik said. However, if a woman loses enough weight that she stops menstruating, she is at risk for osteoporosis or fertility problems. At the same time, someone who vomits regularly or uses laxatives can damage her digestive system.

Binge eaters, even those who do not meet the diagnostic criteria, are at risk of obesity, which comes with a host of health problems including cardiovascular disease and diabetes.

Just as damaging as the physical problems are the likely psychological issues. Anxiety, compulsiveness and depression are frequent companions to disordered eating patterns, experts say. Curfman ticks off a list of emotional issues she frequently encounters with her patients: unhappiness, anxiety, low self-esteem, social isolation and depression.

“You are constantly stressed and worried,” said Frankie Mauti, a registered dietitian at St. Charles Bend who works with people with eating disorders. She sees people who put so much energy into their eating that they stop doing other things they enjoy.

The psychological issues, however, can get resolved as a person begins to develop normal eating patterns.

“A normal eater listens to their body to determine how much to eat and when to eat,” Mauti said. “It’s not always perfect, but when they want a cookie, they eat a cookie.”