Can You Try Too Hard to Eat Healthy?

By Jessica Setnick, MS, RD, CEDRD-S

Messages about food can be so complex! They intermingle dimensions of health, “fitness,” nutritional content, size, shape, and physical appearance… misusing scientific terms to make a food seem better or worse than others… and blatant marketing tactics like labeling cherries “gluten-free.”

I’m a dietitian and I’m not immune. I find it impossible to avoid food messages, even as I am cursing them silently in my mind. They are right here in my home, I see them as I drive down the highway, and they’re almost everywhere in stores and in the media. They are very “sticky” since many of them are intended to cause an emotional response. It’s not a coincidence that magazines have delicious foods on the cover and weight loss articles on the inside.

You may be the kind of person who can ignore food messages – you choose, purchase, and eat foods based on your personal preferences, occasionally branching out to try something new. Or, you may be someone who tries to keep up with food news when you can, replacing outdated information with newer thinking, opting for ‘Meatless Monday’ or ‘Taco Tuesday’ to spice up your routine, trying to feed yourself and your loved ones to the best of your abilities while maintaining balance in other aspects of life.

There is a third group among us, and you may be or may know someone like this… This person sticks to a certain way of eating no matter what, does not want to be flexible or try something new, and believes so strongly in a certain way of eating that they miss out on other parts of life due to this dedication.

There are many reasons you may eat so strictly. It may have developed over time as a response to confusing food messages, a sort of protective group of foods that are unequivocally nutritious and safe. It may be a response to a health scare, either your own or a loved one’s, facing the fact that eating is one of the few aspects of health that we can control. Or, it may have been prescribed by a doctor, such as foods to avoid or eliminate due to an allergy, medical diagnosis, or preventative measure.

Some of us are able to adhere to a specific diet on a lifelong basis, happy and healthy, and balanced. And others of us become consumed by the demands of eating and limiting and avoiding and controlling, continuously shortening the list of foods that are acceptable to eat, and ultimately the quest for “eating healthy” morphs into an archenemy of the original goal. This enemy is orthorexia.

Orthorexia nervosa was coined and first used by Dr. Steven Bratman in 1997 to describe an “obsession with healthy eating” that he observed among his family practice patients. The obsession was actually impairing their ability to eat normally or appropriately, due to a fear of doing something wrong.

Dietitians often notice this type of obsession and restriction among our clients, even those who do not meet criteria for eating disorders. Individuals who come to us for help with their chronic illness, sports nutrition, or just to “eat right” can associate eating certain foods with guilt and shame, disease, anxiety, fear, and death.

They are often surprised when we tell them that the excessive focus they are putting on food is actually the problem, not the individual foods they are eating. Some clients refuse to further meet because they feel we don’t understand proper nutrition, or we have an ulterior motive to get them to violate their rules.

These feelings are understandable in the context of orthorexia. Anyone who wants, asks, or expects you to change your eating against your will can be viewed as your enemy. It is wise to be suspicious of anyone who tells you his or her food or product will cure disease, save your life, or make you a good person. But what about the voice inside your mind telling you the same things?

• Do you feel bad about yourself depending on what or how you eat? Do you ever punish yourself after eating something you shouldn’t have?
• Do you eat differently when you are alone as opposed to when there are other people around?
• How much of your day do you spend on food planning and preparation? Is this enjoyable or does it feel pressured and stressful?
• What happens when you are at a social function and you aren’t able to control what is served? Can you manage or do you feel nervous or guilty?

Honestly answering these questions might clue you in to something you might not want to know, something you might be hiding from yourself. Look at the chart describing Positive and Pathological Nutrition. If your quest for health through eating has become pathological, it’s time to get back in control of your eating instead of allowing eating to control you.

There’s no shame involved in how you eat. It doesn’t make you bad or good or anything else. You are a good person already; the way you eat reflects that when you are following a combination of your internal senses, your wealth of personal experience, and your knowledge of food and nutrition.

If you have become detached from listening to these cues, an eating disorder specialist can help you return to your roots. If you feel that you were raised with food in an unhealthy manner, that same person can help you craft a new, personal way of eating now.

Ultimately your goal is to find the sweet spot of healthy eating that balances good nutrition and a good attitude. It may take time, but it’s worth it to invest in your health and your future. You already know that, you just need someone to help you find the right direction. If that person is a dietitian, you can find one in your area or someone to meet with virtually at www.IFEDD.com/treatment-finder. And if you are concerned about someone in your life, a consultation with an eating disorder specialist can help you find ways to approach that person and support them in recovery.

Binge Eating and Impulsivity

By Dr. Cari Pearson Carter

Binge eating, which involves consuming an unambiguously large amount of food while feeling a sense of loss of control (American Psychiatric Association, APA, 2013), occurs across eating disorders, including in anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). In fact, in the general population, between 8-12% of 11-12 year old girls report engaging in binge eating behavior (Combs et al., 2012). This percentage seems to increase in late adolescence (up to about 24%) and then decline into adulthood, with about 5-8% of adult women endorsing regular binge eating behavior in mid-adulthood (Keel et al., 2007; Stice, 2001; Tanofsky-Kraff et al., 2007), though these numbers appear to be increasing as more research focuses on adult obesity. Unfortunately, binge eating behavior tends to be chronic and many individuals continue to struggle despite treatment. This is particularly striking when considering the fact that binge eating is associated with several psychiatric and medical problems, including obesity, Type 2 diabetes, high blood pressure, high cholesterol, heart problems, depression, relationship problems, and substance use problems (APA, 2013).

Given the profound negative consequences and the chronicity of binge eating, a crucial question for eating disorder researchers is: What risk factors make one vulnerable to initially engage in binge eating behavior? One such important risk factor appears to be impulsivity.

A useful way to understand the development of eating disorders is that initial binge eating is typically considered an impulsive or rash act. Indeed, initial engagement in many potentially harmful behaviors is often described as impulsive. Early binge eating episodes, consumption of large amounts of alcohol, decisions to have sex with someone one has just met, or betting far more money than intended are all thought to involve acting on an impulse or acting rashly. Engaging in such behaviors appears to be characterized by a focus on meeting one’s immediate need, or acting on an immediate urge, without due consideration of the possible negative consequences of the act with respect to one’s long-term interests, goals, or health. One way to describe impulsive or rash acts is in terms of failures of, or ongoing deficits in, self-control. When a girl engages in her first binge eating episode, she may do so to address her immediate need or urge (e.g., relieving a negative mood), even though doing so has potential negative effects (e.g., feeling ashamed and physically uncomfortable) and is almost certainly not in line with her long-term interests (e.g., weight gain).

Though there are many different personality traits that relate to impulsive behavior, the one that has proven important in predicting binge eating behavior is the trait of negative urgency, which refers to the tendency to act rashly or impulsively when distressed (Cyders & Smith, 2007, 2008a; Whiteside & Lynam, 2001). Negative urgency predicts the onset of binge eating behavior among early adolescents and college women (Pearson et al., 2012; Anestis et al., 2007; Fischers et al., 2013). Interestingly, it also predicts engagement in other risky behaviors, such as heavy drinking, smoking, risky sex, drug use, and gambling. Thus, negative urgency may explain why some individuals who binge eat also engage in a host of other dangerous behaviors, and even why sometimes when individuals are able to stop binge eating, another behavior seems to “pop” up and replace it.

Individuals who are high on negative urgency likely experience distress more frequently and/or intensely and have difficulty sitting with that negative emotion; it likely feels incredibly uncomfortable. As a result, without thinking about the consequences, they are prone to quickly seek a rash behavior (e.g., binge eating) that may distract them from or alleviate that negative emotion. Indeed, binge eating appears to temporarily decrease negative emotions (Smyth et al., 2007), thereby making it more likely that when individuals experience negative emotions again, they turn to binge eating to cope, making the behavior to become more and more likely in the future. Over time, it appears that the behavior may transition from impulsive in nature (e.g., engaging in the behavior without knowing or thinking about its consequences) to compulsive in nature (e.g., engaging in the behavior despite knowing and thinking about its consequences: Pearson et al., 2015).

Interventions for binge eating that target negative urgency are likely to be particularly helpful for those who are more impulsive. That is, interventions with an emphasis on: (a) enhancing emotional awareness and emotion regulation through describing and labeling emotions; (b) identifying cues for emotional experiences; (c) learning how to tolerate distress in the moment; and (d) learning alternative means of coping that do not harm oneself. The hope is that individuals will learn alternative strategies for responding when they experience intense negative emotions, but in order to do so, they must be able to recognize and tolerate the emotional experience. Current binge eating treatments (e.g., dialectical behavior therapy, DBT; Linehan, 2014) are beginning to incorporate these type of strategies, increasing hope for recovery and full remission.

Is More Aggressive Refeeding Safe for Severely Malnourished Inpatients?

Vol. 28 / No. 2 — Eating Disorders Review

More evidence on this controversial question.

Recently there has been increased interest in the rate of refeeding people with AN. A new article from University of California, San Diego researchers suggests that more aggressive refeeding may be appropriate in selected young patients hospitalized with restricting eating disorders, including AN,  avoidant/restrictive food intake disorder (ARFID), or other specified eating disorders (J Eat Disord. 2017; 5:1, published online before print). The study group of 87 patients 8 to 20 years of age included a subgroup of severely malnourished patients who presented at less than 75% of expected body weight (%EBW).

On admission, most patients were started on an oral nutritional rehabilitation diet, and the initial caloric level was based on the patient’s recent dietary history. Typically the patients received from 1500 to 1800 kcal/day, but lower-calorie diets (such as 1200 kcal/day) were used if the patient had been using extreme dietary restriction, for example, fewer than 500 kcal/day over several weeks. Daily caloric intake was titrated to achieve 2 kg weight gain per week. If the daily target weight wasn’t achieved for 2 days in a row, the caloric intake was increased; this was also the case for those with persistent or severe cardiac complications, such as bradycardia overnight, symptomatic postural changes in heart rate or blood pressure, or arrhythmias.

Nasogastric or nasojejunal tubes were used if needed until the patient could consume 100% of daily nutritional and fluid needs by mouth for at least 24 hours. Intravenous fluids were reserved for dehydrated patients unable to tolerate oral fluids.

On admission, all patients were screened with complete blood counts and complete metabolic panels, urinalysis, and electrocardiograms. Refeeding laboratory findings were assessed daily, concentrating on serum magnesium and phosphorus levels, and urinalysis. Continuous cardiac monitoring was used throughout the patient’s entire hospital stay.

According to Dr. R. Tamara Maginot and colleagues, %EBW was determined through evaluation of several clinical factors. Although the conventional approach uses the 50th percentile body mass index (BMI, or kg/m2) to calculate expected body weight for children and adolescents, the San Diego researchers customized %EBW to return each child or teen to the growth trajectory in which he or she was healthy. For example, if the patient’s premorbid BMI was greater than the 85th percentile, and the patient was otherwise healthy, the initial %EBW was selected to restore the patient to a BMI at the 75th percentile level. If the premorbid growth patterns were unknown, the authors used the conventional 50th percentile for sex and age.

Most of the study group had been diagnosed with AN-restrictive subtype (66.7%), while 16.1% had diagnoses of AN-binge-purge subtype, 5.7% were diagnosed with Other Specified Eating Disorders, and 11.5% were diagnosed with ARFID. Fifteen patients required the use of nasogastric/nasojejunal feeding tubes during hospitalization. About 75% of patients were assigned to a higher-calorie diet on admission (66 patients; range: 1500 to 3000 kcal/ day). The lower-calorie group (21 patients) was given a mean of 1185 kcal/day, and had significantly longer hospital stays than other patients (38.3 days versus 31.9 days, respectively).

The authors note that just as in previous studies, the incidence of electrolyte abnormalities in their sample was not linked to the rate of caloric increase or initial calorie level. Instead, low phosphorus levels were more common among patients who had a lower %EBW on admission. This suggested that the degree of body depletion may be a more important predictor of electrolyte abnormalities than caloric levels. In this study, with every 1% decrease in %EBW on admission, the odds of hypophosphatemia increased by 6%. However, starting severely malnourished patients at on a higher-calorie regimen was not associated with a higher risk of hypophosphatemia, hypomagnesemia, or hypokalemia.

An important caveat to this study is that refeeding occurred on a medical unit with continuous cardiac monitoring. Although the regimen was well tolerated in this sample, this degree of monitoring would not be available in most ED treatment settings. Future studies of larger patient populations will be needed to help define the safety of administering higher-calorie diets, especially to severely malnourished patients. It is important to define rates that are safe, but also as effective and promptly delivered as possible.

Tracking Recovery from AN and BN over the Long Term

Vol. 28 / No. 2 — Eating Disorders Review

Encouraging results for most, but not all, patients over more than 2 decades.

Gaining weight is a major worry among people with EDs. The Massachusetts General Hospital Longitudinal Study of Anorexia and Bulimia Nervosa has once more provided valuable information about the long-term effects of AN and BN. Dr. Kamryn T. Eddy and colleagues recently reported the results of their 22-year follow-up of women with AN and BN (J Clin Psychiatry. 2017. 78:184). At follow-up, two-thirds of the women had recovered. The Longitudinal Study was begun in 1987 with 246 women, all of who were seeking treatment for AN or BN. As part of the study, the women were interviewed every 6 months for a median time of 9.5 years to assess weekly symptoms, comorbidities, participation in treatment, and psychosocial functioning. Subsequently, 22-year follow-up was completed.

Dr. Eddy and coworkers reported that one of the indictors of long-term recovery was early recovery. At 22-year follow-up, 62.8% of women with AN and 68.2% of those with BN had recovered. This was vastly improved over the 9-year follow-up evaluation, which showed 31.4% of women with AN and 68.2% of those with BN had recovered.

Notably, about half of the women who were still ill at the 9-year point had recovered from their ED by the 22-year point. Recovery happened earlier for the women with BN, while recovery for AN patients was slower and continued over the long term.

A second study shows mortality trends 

An earlier study by Debra L. Franko, PhD, and her coworkers at Massachusetts General Hospital identified risk factors for mortality in people with AN and BN over time (Am J Psychiatry. 2013. 170:917). These researchers found that a long duration of illness, substance abuse, low weight and/or poor social functioning all raised the risk for death from AN. Among the 246 women who participated, 16 deaths (6.5%) were reported; among the 186 women with a lifetime history of AN, 14 (7.5%) died. Four of the deaths were from suicide Among the 60 women with BN and no history of AN, 2 (3.3%) had died. The authors also reported that the majority of women who had been initially diagnosed with AN experienced crossover from AN to BN, while crossover from those with an initial diagnosis of BN to AN was much less common.

A return to normal weights for most in a third study

H.B Murray and colleagues recently published very valuable long-term weight outcome results from a well-described cohort of people with AN and BN (Int J Eat Disord. 2017. Feb 11. doi: 10.1002/eat.22690).

The authors described the results of their 22-year longitudinal study of an original group of 225 patients with AN and BN. Two hundred and twenty-five were followed for 10 years and 177 were still in the study at the 22-year follow-up point. Over the course of this long study, most weight gain occurred within the first 2 years, and this lessened between years 2 and 5. Thereafter, the subjects’ weight remained relatively stable. Body mass index increased most rapidly during the early years of the study for those with lower weights at baseline (i.e., AN) and plateaued over time, settling in the normal range for most. At the 22-year follow-up point, 69% of participants were in the “normal weight range.” Seventeen percent were overweight or obese, and 14% were underweight.

Clinically, it seems as though people with AN or BN have various fears related to weight; these include the fear of ending up overweight or obese, but also the fear of gaining any weight. These results will be helpful for addressing the former fear.

As the longitudinal study continues, we will undoubtedly learn much more, and there is always the hope that recovery rates will move upward.

Tracing the Path of Disordered Eating Over Time

Vol. 28 / No. 2 — Eating Disorders Review

Four risk factors emerged in a community sample followed over 10 years. 

Little is known about how disordered eating behaviors and symptoms that appear in early adolescence may change over time. Results of a recent study gives us new information about this trajectory over time, including the fact that there is a 75% chance that those who had disordered eating would continue to have symptoms a decade later.

Carolyn M. Pearson, PhD, and collaborators at the University of Minnesota and Columbia University studied a community sample of teens over 10 years to see how risks of ED change throughout young adulthood (Int J Eat Disord. 2017. doi: 10:1002/eat.22692, published online before print). The team studied data from 2,287 participants in Project EAT, a valuable longitudinal study that has assessed eating-related, anthropomorphic, and psychological factors using surveys of male and female middle and high schools students, who are now young adults living in and around Minneapolis/St. Paul, MN. The EAT I survey analyzed teens 11 to 18 years of age and then revisited them as young adults 10 years later (EAT III).

Stability and transitions

The researchers found that those who had no symptoms in EAT I tended to remain in the same group 10 years later. For those identified in the dieting group in EAT I, dieting usually persisted. There was a 75% that chance that those with disordered eating symptoms during adolescence would continue to have disordered eating or to transition to the dieting group over the 10-year follow-up period.

Lower self-esteem, depressive symptoms, and substance use were important predictors of transition to disordered eating, and female respondents had greater odds than males of transitioning to increased symptoms a decade later. Family weight teasing also increased the odds of a teen transitioning to disordered eating; this was nearly statistically significant, and was a more powerful element than peer teasing.

Two factors were protective: higher self-esteem and family communication/caring. Some positive findings also emerged. One was that most teens who were asymptomatic at the first survey had not developed disordered eating behaviors by the 10-year follow-up. And, 1 in 4 of those with ED behaviors at the first survey was asymptomatic at the 10-year follow-up point. This suggested that some young adolescents with disordered eating do get better over time.

Screening for and intercepting risk factors early on

The study underscores the value of early detection and intervention for teens with disordered eating. Screening for psychological and socio-environmental risk factors, particularly low self-esteem, depressive symptoms, substance use, and poor family communication/caring, especially among adolescent girls, may help interrupt transition to EDs in young adulthood.

Transcranial Direct Stimulation for Bulimia Nervosa: Early Encouraging Results

Vol. 28 / No. 2 — Eating Disorders Review

A new treatment shows benefits over electroconvulsive therapy.

Neuromodulation is currently an area of great interest in the field of mental health treatment. One example of a neuromodulation technique is transcranial direct current stimulation (tDCS). Like electroconvulsive therapy (ECT), this method involves application of current to the scalp, but tDCS is quite different from ECT. In tDCS, patients are awake, there are few side effects, a very low level of current is supplied to the scalp, and no seizures follow the application of the currents. In most studies, the targeted site has been the dorsolateral prefrontal cortex (DLPFC). This region is part of the dorsal cognitive frontostriatal circuitry and is the major neural structure involved in executive functions, including self-regulatory control. It is also implicated in reward processing.

tDCS affects behavior in many different domains when applied precisely to the correct area of the scalp. In fact, previous evidence has shown some changes in eating behavior after even a single session of tDCS (Biol Psychiatry. 2010. 67:793). To further evaluate the potential of tDCS in eating disorder treatment, Dr. Maria Kekic and colleagues at Kings College, London recently conducted a study of tDCS in 39 patients (37 females and 2 males) with bulimia nervosa (PLoS One. 2017. 12: e0167606).

In this study, the subjects received either tDCS or sham application of tDCS in a double-blind fashion for 3 sessions. The results showed when a particular scalp electrode configuration was used (with the anode on the right and the cathode on the left), eating disorder cognitions were diminished, and mood was improved.

It seems likely that tDCS could ultimately be used as an eating disorder treatment that augments other treatments, rather than as a single modality. The authors are correct that this work is encouraging, and further study of tDCS is definitely needed.

Fear of Weight Gain and Dieting Affect Many Women throughout Life

Vol. 28 / No. 2 — Eating Disorders Review

A large Dutch study highlights distinctly different attitudes between men and women. 

Dieting and fear of gaining weight are common all across the lifespan for women, while a much smaller but still sizable number of men also have the same fears. These were a few findings from a recent study conducted in the Netherlands (Int J Public Health. 2017; published online February 20 before print). Dr. Margarita C. T. Slof-Op ‘t Landt and colleagues in Leiden and Amsterdam wanted to explore factors that might lead to the fear of weight gain throughout life, including gender, exercise habits, education, and lifestyle. This study is noteworthy in that it describes dieting and fear of weight gain in both men and women from adolescence to older age.

The researchers evaluated data from the Young or Adult Netherlands Twin Register, two national registers that compile information on health, lifestyle, personality and/or behavioral problems in twins and their family members. Each survey covers a 2- to 3-year period. In the youth-oriented register, twins and infants from multiple births (such as triplets) are registered at birth by their parents, and surveys are then repeated at fixed ages. At 14, 16, and 18 years of age, twins, triplets, and additional siblings complete self-report surveys with their parents’ consent. For those who completed several surveys, the most recent assessment was used. The adult cohort is made up of adult twins and multiple-birth adults born between 1909 and 1996, as well as their parents, non-twin siblings, spouses, and offspring. The authors invited 47,122 subjects to participate in their study, and data were available for 31,636 participants.

Women had the greatest weight-related concerns

Across all ages, the distribution of fear of weight gain was significantly different between men and women. Most men (up to 74%) reported not being afraid of gaining weight or of becoming “fat”; in contrast, up to 46% of women had no such concerns. Most women who responded had been on a diet at some point in their lives. A fear of gaining weight or becoming fat peaked among women between 16 and 25 years of age, and these concerns continued throughout their lives. A particularly troubling finding was that many women in the 16- to 25-year age group were very or extremely afraid of weight gain despite the fact that only 12% to 14% were actually overweight.

Most respondents were female (60.2%) and twins (61.9%). More than a third of the participants lived in densely populated areas; men and women 25 to 35 years of age were most likely to live in urban settings. More than half of the study participants reported having a high education level. Underweight or normal weight was most common among 13- to 16-year-olds. Overweight was most common among men between 55 and 65 years of age and in women older than 65. The level of exercise (determined by metabolic equivalents, or METs) was highest in 13- to 16-year old females and 16- to 18-year old males, and the lowest METs scores were found in men and women over 65 years of age

The study did have a few limitations: twin samples may differ from non-twins in various ways, including the fact that 62% of birth weights are usually lower in twins than in single births, and these body mass index differences continue into adulthood (Twin Res. 2001. 4:464). Still, the results stress that weight and diet concerns continue across the lifespan.

Some Good News for Eating Disorders Patients Concerned About Weight Gain

A return to normal weights for most in a long-term study.

Gaining weight is a major worry among people with eating disorders. H.B Murray and colleagues recently published very valuable long-term weight outcome results from a well-described cohort of people with anorexia nervosa (AN) and bulimia nervosa (BN) (Int J Eat Disord. 2017. Feb 11. doi: 10.1002/eat.22690).

The authors described their 22-year longitudinal study of an original group of 225 patients with AN and BN. Two hundred and twenty-five were followed for 10 years and 177 were still in the study at the 22-year follow-up point. Over the course of this long study, most weight gain occurred in the first 2 years, and this lessened between years 2 and 5. Thereafter, the subjects’ weight remained relatively stable. Body mass index increased most rapidly during the early years of the study for those with lower weights at baseline (i.e., AN) and plateaued over time, settling in the normal range for most. At the 22-year follow-up point, 69% of participants were in the “normal weight range.” Seventeen percent were overweight or obese, and 14% were underweight.

These results will certainly be useful in helping to address and help reduce some of the fears about weight gain that people with anorexia and bulimia have. Clinically, it seems as though people with AN or BN have various fears related to weight; these include the fear of ending up overweight or obese, but also the fear of gaining any weight. These results will be helpful for addressing the former fear.