When Eating Isn’t Simple
Understand the differences between eating disorders and disordered eating, and learn what you can do to support clients.
What is “normal” when it comes to eating food? Your definition might be based strictly on nutrition science, or it may be bound up in social constructs or a personal pathology. Here’s another definition: “Normal eating includes the ingestion of healthy foods, the intake of a mixed and balanced diet that contains enough nutrients and calories to meet the body’s needs, and a positive attitude about food” (Pereira & Alvarenga 2007). While this statement may seem a bit succinct for a complicated issue, it’s probably close to what we as fitness professionals tell our clients.
Unfortunately, this relationship to food—with the balance and positive attitude it alludes to—is not something that comes easily to everyone. In fact, it is estimated that 11 million people suffer from clinically significant eating disorders (ED) in the United States, and although women represent 90% of those who seek medical care, men are not exempt (Joy, Kussman & Nattiv 2016).
That estimate includes only reported cases of clinically significant ED and does not cover unreported cases or instances of disordered eating (DE), an overarching term used to define all eating-related problems. Many people don’t seek medical attention, and their numbers therefore stay in the dark. In addition, because DE is a description of a behavior, not a diagnosis that follows narrow criteria, estimating the number of people with DE is very challenging.
In short, DE and ED are more prevalent than many people realize, and it’s crucial for fitness professionals to know how to spot and identify symptoms and risk factors, as well as help clients or colleagues who show symptoms. Early detection plays a big role in health and healing.
Defining Eating Disorders and Disordered Eating
In today’s world, behaviors like eating in the car, skipping meals, and relying on shakes and nutritional bars as the main source of nutrition have not only become socially acceptable; they are even considered normal. Nothing could be further from the truth. These behaviors are not considered part of balanced eating, and although they aren’t defined as clinically significant ED, they are categorized as DE behaviors. Often, these two terms are used interchangeably, but there are clear distinctions between them.
Identifying ED and DE can be challenging. Unlike anorexia nervosa (AN), which is often recognized by severe weight loss, some eating problems have no clear physiological signs. For many fitness enthusiasts and athletes, for example, the symptoms can be a gradual progression from “athletic eating” to unusual eating habits (eliminating all carbohydrates, abstaining from fats, doing frequent cleanses, etc.) and more pathological dietary behaviors. Currie (2010) describes the difference between athletic eating and DE this way: “Athletic eating is more likely to be directed toward improved performance rather than weight loss or altered body shape.” That said, the line between athletic eating and DE is often very fine. It’s therefore important for fitness professionals to learn not only about conditions that are clearly definable but also about ones that are not.
The statistics paint a picture of the diversity of people with ED and DE:
- 13.4% of girls and 7.1% of boys aged 9–14 exhibit DE behaviors (Lee & Hoodbhoy 2013).
- In women over 65, strict dieting, fasting and binge eating tripled from 1995 to 2005 (Harvard Medical School 2012).
- 46.7% of athletes from leanness-focused sports report DE behaviors (Kong & Harris 2014).
- Among more than 800 Norwegian fitness instructors, 22% of males and 59% of females had DE symptoms (Bratland-Sanda, Nilsson & Sundgot-Borgen 2015).
- 13% of young women meet DSM-5 criteria for ED (see “Eating Disorders” below) (Stice, Becker & Yokum 2013).
Let’s take a closer look at both disordered eating and eating disorders.
Disordered eating behaviors are defined as “the full spectrum of eating-related problems from simple dieting to clinical ED” (Pereira & Alvarenga 2007). Although DE does not have specific criteria for diagnosis, fitness professionals can watch for certain signs and symptoms to identify clients who may be suffering from DE behaviors. Examples include yo-yo dieting, frequent weight fluctuations, binging, use of laxatives or diuretics, purgative behavior, food restrictions (no carb, fat-free, etc.), and a preoccupation with food and exercise (Anderson 2015).
It’s important to take DE behaviors seriously even if they’re not diagnosable as a specific disorder, because the consequences of DE can affect every system in the body and be detrimental to psychological and emotional well-being. Often, signs of DE signify the first steps in what could become a more problematic ED.
Eating disorders are psychiatric illnesses clearly defined in the Diagnostic and Statistical Manual of Mental Disorders (APA 2013). The fifth edition, DSM-5, lists eight specific categories of eating and feeding disorders. Because some of these categories often occur in combination with other mental disorders, this article focuses only on the four most prevalent ones: anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) and “other specified feeding or eating disorders” (OSFED).
Anorexia nervosa is often the first ED that comes to mind because, in many cases—especially severe ones—it’s recognizable by serious weight loss and starvation. Although not all people who suffer from AN are underweight, it’s often what people associate most with this disorder.
To be diagnosed as having AN, according to DSM-5, an individual must meet the following criteria:
- Persistent food restriction or refusal to eat, resulting in significantly low body weight.
- Disturbance in how the person views his or her body/shape.
- Intense fear of gaining weight or becoming fat.
Although excessive exercising is not a criterion for AN, fitness professionals may want to be vigilant about its occurrence. Early detection of any AN symptom can be lifesaving, because this disorder is not just the deadliest ED; it is one of the deadliest of all psychiatric disorders (Joy, Kussman & Nattiv 2016; Harvard Medical School 2012). Women are at higher risk for developing AN than men are. In fact, the lifetime prevalence of AN and BN is three times higher in females than males, and the risk of premature death from AN is 6–12 times higher in women than men (Joy, Kussman & Nattiv 2016). Treating AN is very challenging because starvation not only damages the body but also harms the brain, distorting emotions and behaviors (Harvard Medical School 2012).
Although AN is often more recognized than BN, but BN is actually more common (Hudson et al. 2007).
Minimum criteria for BN are as follows, according to DSM-5:
- Binge eating occurs, on average, at least once a week over a 3-month period, followed by compensatory actions such as vomiting, use of laxatives or diuretics, and/or excessive exercise. Binge eating is defined as recurring episodes of eating significantly more food in a shorter period of time than most people would eat under similar circumstances.
- Body shape and weight influence self-evaluation.
Although people with AN have higher mortality rates, the suicide rate for BN is greater, with suicides accounting for 23% of deaths among people with BN, compared with 20% among those with AN (Joy, Kussman & Nattiv 2016).
Binge Eating Disorder
BED is the most prevalent eating disorder, with 2.8% of U.S. adults suffering from it (Hudson et al. 2007). Women aged 45–64 are more likely to binge and feel guilty about food than younger women (Harvard Medical School 2012).
DSM-5 lists these criteria for a BED diagnosis:
- Binge eating happens at least once a week for 3 months.
- Binge eating episodes are associated with at least three of the following: eating more rapidly than normal; eating alone because of embarrassment; feeling disgusted, depressed or very guilty after eating; eating without being hungry; and eating until uncomfortably full.
- Binge episodes are marked by feelings of lack of control.
- Binge eating is not followed by compensatory actions associated with BN.
Other Specified Feeding or Eating Disorders
Eating disorders in this category are clinically significant but not severe enough to meet the criteria for AN, BN or BED. Often, it is the frequency or severity of a behavior that distinguishes the more serious disorders from OSFED.
DMS-5 criteria for OSFED are specific to the disorder:
Atypical anorexia nervosa. All the criteria for AN are met except for extreme weight loss. Individuals with this disorder are within normal weight range.
Binge eating disorder. All criteria for BED are met, but at a lower frequency and/or for less than 3 months.
Bulimia nervosa. All criteria for BN are met, but at a lower frequency and/or for less than 3 months.
Purging disorder. Recurrent purging behavior influences weight, but without binge eating episodes.
Night eating syndrome. The disorder is defined by recurrent episodes of night eating or excessive food consumption after dinner.
There are many different aspects and layers to ED and DE, making it hard to pinpoint a single cause for any disorder. However, numerous risk factors can indicate the beginnings (or even a progressed case) of an ED or DE. Being able to spot these factors (described below) can be very important in helping someone in the early stages. That said, showing signs of risk factors doesn’t necessarily mean a person will develop a disorder.
It’s important to note that ED and DE share common risk factors with obesity, and what prevents one may increase risk of the other (Lee & Hoodbhoy 2013). For example, advising a personal training client to maintain weight by tracking calories and increasing exercise frequency may stave off weight gain, but if the client has anorexic or bulimic tendencies, that same advice might lead to an overemphasis on tracking food and activity.
A very powerful risk factor for ED and DE, body dissatisfaction happens when an individual’s image of his or her body doesn’t match the perceived ideal portrayed by the media. This problem is not limited to people who think they’re overweight. It can also affect very muscular individuals who think they’re not muscular enough.
Research indicates that people with perceived rather than real excess weight who relentlessly pursue thinness may increase their risk for weight gain and eating disorders (Saarni et al. 2006). Big risk factors for body dissatisfaction and DE are media internalization and the use of social networking sites (Brown & Tiggemann 2016; Derenne & Beresin 2006). Aggressive ideal-beauty marketing dictates the perfect body type, to which everyone should seemingly aspire. Exposure to such messaging has increased with the rise of social networking sites like Instagram that rely heavily on images. Because pictures on these forums are from people rather than marketing firms, they’re perceived to be more realistic, which makes them more dangerous. In reality, presenting a false image by filtering and doctoring a photo before posting is easier than ever.
The pressure to compete with pictures from celebrities and peers is amplified. A study by Brown & Tiggemann (2016) concluded that “exposure to attractive celebrity and peer images can be detrimental to women’s body image.” Pressure from peers and family has been shown to have significant influence, especially on young females (Kong & Harris 2014). The objectification theory proposes that women living in sexually objectifying Western cultures eventually see themselves as “objects” for others to evaluate. Self-worth becomes attached to appearance. This type of self-objectification is linked to increased risk for anxiety, body shame, ED and DE (Prichard & Tiggemann 2005).
Both type 1 and type 2 diabetes are linked to higher rates of ED and DE. Subclinical ED are more prevalent in people with type 1, while subclinical and clinical DE behaviors are more prevalent in those with type 2. Adolescents with type 1 have a 2.4 times higher risk of developing an ED, and women with AN have a 15.7-fold increase in premature mortality (Joy, Kussman & Nattiv 2016; Pereira & Alvarenga 2007). There is evidence that ED or DE precede type 2 in the great majority of patients, and according to a German study, “the comorbidity of binge eating disorder and diabetes type 2 is associated with weight gain and insulin resistance” (Munsch & Herpertz 2011). Researchers have hypothesized that core symptoms of ED may contribute to the development of type 2 diabetes because of interference with the body’s glucose metabolism (Raevuori et al. 2014).
Advances in technology have changed the way we do things in all aspects of life. In regard to health behaviors such as eating and exercising, we can now track everything, work out remotely with our clients, and give and get immediate feedback. There are apps and tracking devices like Fitbit® to continuously tell us if we’re doing enough or whether we’re being “good” or “bad.” The term “techorexia” describes the compulsive behavior normalized by the popularity of health technology (Simpson & Mazzeo 2017). Although these trackers can be very helpful, especially for overweight people trying to lose weight and people who want to be more aware of their habits, they can also be very harmful to people with or at risk of developing ED or DE.
In fact, fitness trackers and ED are correlated (Simpson & Mazzeo 2017). Individuals who use calorie trackers have higher levels of concern about eating and dietary restraint. Compulsive and perfectionistic thinking about weight is common among people with ED. For them, using trackers can become a way to quantify self-worth. Not meeting a set goal (calories, steps, workouts, etc.) can quickly turn into a negative, increasing their dissatisfaction, anxiety and guilt.
In general, diets can lead to a preoccupation with eating and unhealthy eating behaviors. Very restrictive diets may trigger periods of binging. Research has indicated that the more someone diets, the higher the risk that he or she will gain more weight in the future (Pietiläinen et al. 2012; Saarni et al. 2006). According to one theory, this phenomenon may reflect the postdiet body’s attempt to restore itself by favoring fat store (rather than protein) replenishment, thereby leading to excess body fat. Dieting and weight loss may trigger a slowing of the metabolic rate, otherwise known as metabolic adaptation or adaptive thermogenesis (Fothergill et al. 2016). When the resting metabolic rate drops, fewer calories are burned, making it more difficult to lose weight. Researchers found that among males, going on just one diet significantly increased the risk of becoming overweight, and in females, that same risk doubled (Pietläinen et al. 2012; Saarni et al. 2006).
Exercise and Eating Disorders/Disordered Eating
One core factor in the symptomology of ED and DE is excessive and/or compulsive exercise, with 39% of people with ED overexercising (Bratland-Sanda, Nilsson & Sundgot-Borgen 2015; Pereira & Alvarnega 2007). Exercising for weight control, body tone, appearance and attractiveness is associated with increased body dissatisfaction, disordered eating behaviors and lower self-esteem (Vartanian, Wharton & Green 2012). Healthy reasons for exercising, such as enjoyment, health and increased fitness, have been found to improve self-esteem and body image.
Addressing excessive and/or compulsive exercising can not only play a big part in recovery but may also be lifesaving. Hausenblas, Cook & Chittester (2007) state that in individuals with ED, excessive exercising is the behavior most strongly associated with suicide. It can be very challenging to detect excessive/compulsive exercise, however, because “excessive exercise” is not clearly defined. What about the athlete who is training for a competition or the recreational fitness enthusiast who’s preparing for an obstacle course race? How do we determine how much is too much?
Often, it can be detected by “overtraining syndrome,” symptoms of which include fatigue, weight loss, depression, insomnia and poor performance (Kreher & Schwartz 2012). Another sign is when working out becomes a need that interferes with normal, day-to-day life, rather than being a healthy habit. For example, if a client chooses to exercise rather than spend time with friends and family, or exercises even though injured, she may have a diagnosable problem.
What About Treatment?
Treatment for ED and DE begins with an emphasis on nutritional rehabilitation and weight restoration. It should also include psychotherapy, nutritional rehabilitation, medication and possibly hospitalization. Interventions and educational programs are aimed at decreasing body dissatisfaction and sharing how dietary restrictions and/or purging behaviors negatively affect sport performance. Peer-led education can be beneficial. The National Collegiate Athletic Association has developed 10 strategies for coaches that can be very helpful in working with athletes (Joy, Kussman & Nattiv 2016).
Considering that the prevalence of excessive exercise in people with ED is 39%, it should come as no surprise that exercise is not an established ED treatment (Hausenblas, Cook & Chittester 2007). On the contrary, addressing excessive exercise is a big component of treatment for those with ED or DE. Finding a healthy relationship with exercise can be as difficult as building a healthy relationship with food and body.
Note: Diagnosing and treating ED and DE are not within a fitness professional’s scope of practice. If you suspect that a client has an ED or DE, it’s essential that you approach him or her early, directly and confidentially (Currie 2010). If you garner permission, refer the client to the appropriate health professionals.
A Healthy Body and Mind
As fitness professionals, our goal should be to help our clients lead healthier lives but also be healthy ourselves. The prevalence of unhealthy eating and exercising behaviors is high in the fitness community, and it is essential that we have open and honest conversations about body image, eating disorders and compulsive exercising, to create awareness not only for our clients but also for our peers (see the sidebar “Fitness Professionals and Eating Disorders”). Learning how to detect early signs of these disorders can be crucial for the success of treatment and rehabilitation. Fitness professionals can play a helpful role in the recovery and treatment of people with ED and DE, but it is important never to forget that treatment requires a multidisciplinary approach, and fitness professionals play only a small part in that team effort.