My mornings start with two cups of coffee sitting at my kitchen table hunched over a laptop and my days end slogging out chart notes and reaching out to therapists and physicians to coordinate care for my patients with eating disorders. In-between, I try to take care of myself.
Like so many things I wish to be different after we recover from this pandemic, I wish for the conversation about eating disorders to be different too. Many of my existing patients are experiencing setbacks or struggling to move forward and new patients without eating disorders are coming to see me with increased concerns about their bodies and eating habits.
The level of worry expressed online about not being able to work out right now or gaining 15 pounds is palpable and the volume of posts reveals something beyond a desire for general self-care. Obsessing about appearance or weight, making comments about food choices, and worrying excessively about staying fit are not innocuous behaviors, now or ever.
How many times have you heard someone say, ”I shouldn’t have eaten that,” or “I’m such a loser for not exercising,” or “This is my cheat day, so it’s ok,” or “Ugh, I look so disgusting right now!” How many times have you said these things? These kinds of disparaging comments are just one example of how disordered thinking has become a mainstay of daily life. In a 2014 article published in the journal Eating Behaviors, author Elizabeth Fallon describes a series of surveys conducted between 1972 and 1997 that revealed a significant increase in dissatisfaction in physical appearance over the 25-year time span.
By 1997, the level of body dissatisfaction was three times greater for men and two times greater for women than when the survey began. Fallon’s 2014 survey results showed that levels of dissatisfaction have plateaued, but the conclusion remains unchanged — dissatisfaction with appearance is now the norm that many researchers have called an epidemic of body dissatisfaction.
This chronic dissatisfaction with our appearance is completely unnecessary but upheld by a culture of believers in the thin and fit ideal. It’s a culture that may not cause eating disorders, but it absolutely sets the stage. My wish is for a complete paradigm shift in the way we approach health and fitness in this country, in the way we treat and care for ourselves and others, and in the way we talk about these issues.
Eating disorders are complex biological, psychological, and socio-cultural disorders that affect people across the globe from all genders, all ethnicities, all ages, and all social backgrounds. While some groups are at greater risk, no one is immune. According to the Academy of Eating Disorders, eating disorders affect approximately 1–3% of the U.S. population or about 30 million Americans. This is roughly equal to that of breast cancer, prostate cancer, non-melanoma skin cancer, and colon cancer, the four highest cancer rates for men and women in America combined according to the Institute for Health Metrics and Evaluation Global Burden of Disease Study in 2017.
Not just a woman’s problem, eating disorders appear to be increasing in men. In a 2012 study published in the Eating Disorders Journal of Treatment & Prevention, lead author Eric Strother writes that more men are either seeking help or are being identified in treatment each year causing him to doubt current estimates of prevalence in the U.S. that suggest .1% or about 1 in 10 people with an eating disorder are male.
The natural history of eating disorders includes predisposing, precipitating, and perpetuating factors, says Dr. Robin Boudette, a psychologist with 30 years of experience treating eating disorders and co-founder of the Princeton Center for Eating Disorders at Princeton Medical Center in Princeton, NJ. Predisposing factors are strongly linked to genetic and neurobiological drivers that include family history and individual personality traits. Generally, they are things we cannot change.
Precipitating factors like the beliefs we hold about food and our body, traumatic experiences, the development of anxiety or depression, or the demands of a sport can all contribute to the onset of an eating disorder, like a spark. Perpetuating factors are things that maintain the eating disorder like the relief from emotional pain the behaviors provide, or the seemingly harmless affirmations people give for losing weight.
Everyone exists somewhere along a continuum ranging from severely ill with a diagnosed eating disorder to positive body esteem with balanced eating and exercise attitudes. Many people are comfortable in their bodies and it’s normal to have a little self-doubt about your appearance or to want to improve your eating and physical activity habits. However, thoughts and behaviors that require more emotional energy than are balanced may signify a problem.
Over-exercising, feelings of shame or guilt at missing a workout or eating the wrong foods, skipping social events that include food deemed unhealthy, and constantly comparing yourself to others are just a few of the destructive behaviors that lean toward the unwell end of the continuum. In medical terms, we call these behaviors sub-clinical — sometimes problematic, potentially harmful or unsafe, but not meeting full diagnostic criteria. The extent to which these behaviors cause suffering and harm has little to do with receiving a formal diagnosis.
We don’t know exactly what causes eating disorders. Genetics, personality traits, and neurobiology intertwine to put a person at risk. Social and cultural factors support their manifestation. Specifically for the United States, a blatant lack of diversity in entertainment media, a belief in oneself as defective in some way, and a highly individualistic culture provide those predisposing and precipitating factors for pathological and problematic eating, exercise, and body image issues.
For starters, standards established by Hollywood and spewed across the nation over the last seventy years, convey a culture steeped in sexism, racism, sizeism, and ableism through narrowly defined standards of beauty and attractiveness that are unattainable. Girls are taught that a lean body and youthful sex appeal are the pinnacles of womanhood. Boys are taught that height, muscularity, and a perfect V-shaped physique defines the ideal man. To this day, there is very little representation of the diversity that makes up America. People of color, queer folks, and other abled people remain tokens. And white is still the most preferred skin color.
This singularity contributes to the pernicious role of the media in the development of young people’s identities. There is a strong positive association between media consumption and increasing levels of depression, anxiety, reduced body-esteem, and risk for developing eating disorders in the United States. Research on first-time access to television and decreased body esteem and eating pathology experienced by girls in Fiji, conducted by Anne Becker and published in 2004 in Culture, Medicine and Psychiatry, provides insight into how this happens. Three years after the introduction of television in Fiji in 1998, it was found that the girls’ ideals for appearance were redefined. Where they were previously not motivated to reshape their bodies through diet or exercise, responses given by the girls that included exercise and diet modification for the purpose of weight loss along with other disordered behaviors pointed to their desire to cultivate an identity in line with their increasingly westernizing society.
In essence, they began to believe that they should look like what they saw to improve their social standing. This is not an accident. The distance between you and some random ideal portrayed in the media is contrived to make you believe it’s necessary to cross that divide. And right now, the amount of media consumption is significant. Understandably so, but still harmful.
Next, we believe our bodies can be controlled and shaped to meet the standard of the day and that it’s our responsibility to ensure they do. Americans spend an inordinate amount of time and energy on food and exercise as a means to control shape and appearance, avoid judgment, or simply belong. The core belief that physical appearance is an indicator of hard-work and self-discipline is born from a puritan form of Protestantism that equated work ethic to salvation and it’s never left. Researchers Quinn and Crocker in a 1999 article published in the Journal of Personality and Social Psychology, describe this ideology as the basis for individualism in America that equates a lack of success to moral failings such as a lack of discipline and self-indulgence.
To this way of thinking, it’s the individual who is responsible for their circumstances, and it’s the individual who needs to dig themselves out. Evidence that this belief is alive and well, is that fat people are shamed, blamed, and discriminated against for their size. These are incomplete views that disregard the full-scope of scientific evidence and reveal the inability by some to see complex issues in the nuanced way public health requires. They are also void of compassion and decency.
Lastly, in spite of an abundance of evidence to the contrary, many people including some of my colleagues in nutrition, medicine, and exercise science, vehemently espouse personal responsibility as the only solution for our “weight problems.” At best, this is unhelpful. Similarly, the dieting and exercising masses who successfully manage their bodies in this environment, take full credit for their success (as the Protestant Ethic indicates they will), citing their physiques as proof that discipline and will-power work. In actuality, the efforts some take to shape their bodies place them at greater risk for developing an eating disorder and in some cases, are signs of an eating disorder.
It’s these attitudes and beliefs that result in a cascade of events that can lead to potentially life-threatening circumstances. I see it in my office every day.
I have so many wishes for what life could be like when we recover from the pandemic. I wish for a culture that embraces diversity. I wish for a culture that is more supportive and encouraging and inclusive. I wish for a just culture and a culture filled with kindness. It’s the kind of place where people don’t have to make excuses for why they didn’t work-out or why they ate something. It’s a place where we can stop hating ourselves. It’s a place where time and energy are well spent on living instead of wasted on trying to attain the perfect body or eat the perfect diet.
Until then, it would be incredible if the self-deprecating comments and self-loathing brought on by our culture came to an end. It’s possible. One way to do this is not by asking yourself if you have followed an eating and exercise plan with impunity, but rather are you caring for yourself in a manner that supports your well being? Do you leave room for joy and pleasure? Are you able to see that eating and joyful movement are not all or nothing endeavors? Are you doing the best you can, considering where you live and what community support is available to you? Can you allow yourself a break during a global pandemic?
However you approach this issue, you don’t need to explain or justify your food choices to anyone, especially not yourself. No one ever has to earn the right to eat. No one ever has to make up for anything they eat by exercising more or restricting food intake later. Not even athletes.
Start by rejecting ideal beauty standards that do not represent humankind in its abundant diversity. There are better standards to meet. Some of these standards may be physical such as quality of movement or athletic performance, but they should not be based on such superficial things as your appearance — and certainly not because of some perfectly crafted social media image passed off as reality.
Next, learn to trust the wisdom of your own body and reject the paradigm of individual responsibility. There is nothing for you to change about your body and the things that need changing the most like our broken food and healthcare systems, are not our burdens to bear.
One thing you can do for yourself is to evaluate your relationship with food and eating. A tool I recommend that is free to everyone is a hunger-fullness journal. A hunger-fullness journal is far more revealing than measuring and weighing everything you eat and keeping a daily record. This is not to say that journaling as a technique for evaluating intake is not useful in some circumstances, more so with professional guidance. However, attempting to identify, accurately measure, and calculate exact consumption, is an exercise in imprecision that can cause more harm than good. And it’s not what matters most.
Scanning for patterns, identifying trends, and evaluating food quality is how I teach my clients to use journals, followed by learning to listen and respond to hunger and full cues. Originally conceived of by Dr. Karin Kratina and written about in her seminal book Moving Away From Diets, the zero to ten hunger-full scale helps people identify underlying beliefs with the aim of healing people’s relationships with food and their body by increasing and improving their ability to tune in to their natural physiological cues of hunger and fullness.
Over time, the goal is to honor your body as the ultimate authority in determining when to eat and how much is right for you. This is valuable work given how disembodied people are today. And for anyone at risk of developing an eating disorder; anyone with a history of an eating disorder; or anyone with a history of chronic dieting and weight cycling, this kind of healing work is imperative.
Lastly, legalize all foods and the option not to exercise. By doing so, you will be liberated from rigidity, fear of judgment, and the cycle of failure. If everything is on the menu, you are free to make choices from a place of peace and awareness. Only from this position can you undo long-held beliefs that perfect eating exists and that you are defective without a six-pack. Only then will you truly be able to enjoy a slice of cake when you want one, and feel equally comfortable declining if you don’t. And only then will you be confident in the knowledge that it’s no one’s business how you eat, or what size your body is, or if you exercised this week.
Maybe then, the time we deserve for the things we cherish, for the things we wish to devote ourselves to, or just to be, will be returned to us.
The knowledge I gained from a science education and 20 years of experience as a nutritionist is of little value in a culture where people want quick fixes and everyone is an expert. In 2018, the diet and weight loss industry was worth $72 billion. That’s nearly equal to the U.S. federal budget for the Environmental Protection Agency, NASA, conservation of natural resources and the National Parks, the National Science Foundation, and the Department of Energy combined.
Americans are desperate for help and willing to try anything. I appreciate why people are drawn to the latest and greatest, especially when [insert diet] (paleo, intermittent fasting, keto, low-glycemic, gluten-free, local, vegan, other) is working for someone they know and have reason to trust. The sense of community and support that comes with following a particular diet can be very helpful.
The medical community has little to offer in the way of effective and lasting help. The U.S. model for healthcare is based on illness and disease. In many cases, my patients can’t use their health insurance for nutrition therapy until they’re sick. We spend zero on prevention and few medical professionals have the depth of knowledge, and skill required in nutrition science to be helpful.
Heart disease and cancer remain the top two killers in the U.S., with diabetes, stroke, and hypertension in the top ten. We move so little, research labs now study the effects of being sedentary on the human body and brain. A lack of walkable, bikeable, and safe communities contributes greatly, as does the war on public transportation.
A majority of institutional foodservice operations are flat out harmful. Our childcare centers, schools, prisons, and hospitals, serve meals that make us sick and keep us sick. Mental health care programs often serve food that prevents patients’ guts from healing, very likely impairing their body’s ability to make the chemicals they need to recover. The day food and nutrition services were expected to generate revenue, was the day things went terribly wrong.
Time, energy, and money spent trying to combat the food and beverage industry is an utter waste. The food and beverage industry has never been about nutrition, wellbeing or food. It’s about sales. Let that be very clear.
Time and energy spent circumventing the current state of politics to repair the Farm Bill? Yes. Honest and effective policy is desperately needed, but we are past that. The political will required to affect change is non-existent. For the optimist, I point you to well-conceived policy recommendations on food as medicine from the Friedman School of Nutrition Science and Policy at Tufts University. This document describes policy change that would make our entire food system more sustainable, nutritious, and fair. It also addresses military readiness, healthcare costs, and social disparity. Tufts will be presenting their solutions at the 50th Anniversary of the White House Conference on Food, Nutrition, and Health on October 3–4, 2019.
Americans do more, try more, and spend more on health and fitness with disheartening results. We condemn the obese for eating cheeseburgers and believe thinness and health are synonymous. We blame individuals even though our environment and culture cause harm. Our ability to cast shame is epic. Dieting as an intervention for weight loss is an abysmal failure. It is well understood that human biology works against weight loss efforts. Yet, we continue to espouse personal responsibility knowing health is not determined by size or appearance, or one cheeseburger. If you think this, you’re part of the problem.
To all of this, I call bullshit.
I say please stop spending excessive amounts of time thinking about your body, food, and exercise. Please stop listening to everyone else talk about their latest diet, exercise program, or how much they loathe their own body. Please don’t spend your hard-earned money on the next thing. Please stop consuming toxic media. Please stop being unkind to yourselves and others.
Please stop discussing, debating, and researching the optimal human diet. We already know what it is. What is most important, and this is well researched, is the pattern of your dietary choices over time. This has been observed in Seventh Day Adventists, Okinawans, Sardinians, people from the Mediterranean, and those who follow the DASH diet (Dietary Approaches to Stop Hypertension) in the United States. They are variations on a theme.
Seventh Day Adventists are primarily vegetarian and avoid processed foods. Okinawans include nutrient-rich starches like legumes and sweet potatoes with a high carbohydrate to protein ratio. Sardinians include plenty of legumes, goat’s milk, and cheese made from grass-fed sheep. The Mediterranean diet includes plant fats (nuts and oils) and fish, as well as pasta and bread. The DASH diet is low in sodium and emphasizes vegetables, fruits, low-fat dairy foods, and moderate amounts of whole grains, fish, poultry, and nuts.
There is more nuance and depth to each diet and culture than described here, but they share two important things. Meat is served as an accent or not at all, and vegetables are consumed in abundance. These groups share other beneficial behaviors like rich social connections, gardening and walking, adequate sleep, and relaxation. Combined, these are powerful antecedents to living well and eating well that requires no further debate.
Instead, do three things.
Eat your vegetables. There are no weight-loss diets, popular health diets, or evidenced-based recommendations by national health organizations that do not include eating an abundance of vegetables. There should be no comments to the contrary. Half a plate twice per day. Get them in however you can from the sources most available to you. Frozen works just as well as fresh. That’s it. The rest is noise.
Cook at home. This will not be easy. This requires opting out of 60 hour work weeks for some. For others, it means learning new skills. For others still, it will require banding together as friends and family to make eating at home more possible. Some of us live with very difficult circumstances, work 2 or 3 jobs, or provide care for loved ones on top of everything else. Do your best.
Eat real, whole food which I define as food grown and harvested as it was intended and anything prepared with a few simple ingredients. Whole real food is loaded with the kind of nutrition and live microorganisms human beings thrive on. By default, this results in the avoidance of preservatives, dyes, gums, excess sodium, trans fat, and products otherwise devoid of nutrition. I refer to the latter as not food- but let me be very clear this definition includes any kind of treat or fun food made with quality ingredients, or not, on occasion.
Lastly, approach food and nutrition with a sense of curiosity, flexibility, and compassion. There is no such thing as perfect eating. In fact, it’s contraindicated for health and wellbeing. Dieting, over-exercising, and excessive worry are distractions that prevent you from spending time on the things that matter most to you.
Spend an appropriate amount of time and energy attending to self-care. Yes, plan and prepare nutritious meals. Move your body in a way that brings you joy and fitness. When eating or exercise becomes a source of stress and anxiety, this may be a sign that something else needs attention. If this describes you, please seek the advice of a therapist or medical professional experienced in this area.
Is eating this way and cooking at home always possible? Of course not. The ability to grow and access safe and nourishing food remains an issue of social justice. Growing food in a way that restores the land, keeps water clean, and nourishes people is daunting, leaving many farmers broke and without health insurance. Accessing nutritious and safe food for many Americans, ashamedly, remains incredibly difficult.
But on these points, I have hope.
Victoria Lambert, MS, RD