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Jane Rachel Kaplan, Ph.D., MPH

902 Curtis St.
Albany CA, 94707

From Food As Nourishment To Food as Dominating Force

by Tami Lyon, R.D., M.P.H., C.D.E.

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Food is the vehicle of an eating disorder. Food influences your physical and mental health, and consequently, your very existence in the world. Food is vital to your recovery from an eating disorder.

Adequate nutrition allows your brain to think-- to examine and understand both internal and external experiences. Adequate nourishment allows your body to perform vital processes for survival and health; however, in anorexia and bulimia, food moves beyond the role of nourishment for the body and becomes the object of rules, regulations and judgments that dominate one's life. The lack of food, via restrictive intake, purging and/or excessive exercise, physiologically drives the mounting obsession with weight and body shape so characteristic of an eating disorder.

Let's look at the transition of the healthful use of food as nourishment to the painful use of food as a dominating force of esteem using a metaphor. As an eating disorder begins, so do food rules. The persistent, progressive evolution of "food rules" can be likened to the development of a large, complex computer file complete with a directory and subdirectories.

Rules are logged alphabetically in the directory. For example, all food rules related to fat can be found under "F" and in the subdirector under "Fat." Initially, food, health, exercise and weight beliefs did not require so much organization and memory. Simple, healthful guidelines easily fit in a small, basic file. There was no need for a directory or subdirectories. But, as an eating disorder develops more rules and regulations about food, weight, and nutrition are written and enforced. All of these new rules require memory space and greater organization. The file becomes complex, demanding and powerful. Other files that contained information about health, eating, weight and exercise are deleted to accommodate the memory needed for this new file, the Eating Disorder. Files which contained information on interests outside food and eating are either shortened or deleted. This master file is stuffed with rules and guidelines about food, eating, exercise and weight, and continues to grow as the eating disorder develops and influences a person's life. If you are a person with an eating disorder, you may feel controlled by the rules contained in these files--they become your central rules for living and it may feel as if you cannot live without them.

Through the new rules and regulations food takes on a different meaning. Foods you once enjoyed are now categorized as "bad" and only permitted in small quantities or not allowed at all. Guidelines from various diets you may have read about are merged, producing the strictest rules possible to lose weight or maintain a goal weight. Nutrition and health guidelines for the general public, delivered through the media and marketed by authors of diet books, are rigorously enforced as if they were written precisely for you. Frequently, they are enforced at a level several times beyond the general recommendation. The rules of the Eating Disorder file demand it.

Choices seem to disappear. Eating becomes rigid, limited, and a source of personal judgment and scorn. Every action must be in accord with the rules, which constantly up the ante for weight loss and discipline.

Many professionals believe that dieting is one entry path for an eating disorder. The impetus for dieting can come from a variety of events or situations, culminating in a desire to lose weight. An offhand, weight-related remark from a friend or a stranger, the break up of a relationship or the loss of a loved one can trigger the desire for weight loss in some individuals. Frequently, eating disorders begin during adolescence, when young women and men experience the changes of puberty in their bodies. These natural changes in body shape and composition are frequently viewed by young women as undesirable and they feel out of control.

Women in our society experience cultural pressure to achieve an unrealistic, prepubescent, thin body shape and are encouraged to sculpt their bodies by any means possible to achieve this commercially promoted ideal. For some, dieting unleashes the Eating Disorder file, causing eating and weight to take on some new, unhealthful, meanings.

Some research has been done on eating patterns in anorexia and bulimia. There is no exact eating pattern in any situation, but trends do emerge. In anorexia, there is an absolute reduction in caloric intake, many times accentuated by a significant increase in activity.

The primary dietary trends are the consumption of a low fat diet, vegetarianism and a preference toward or avoidance of sweets such as candy or frozen yogurt. Individual eating styles are unique, but what is universal, when evaluated alone or with energy expended through activity, is that the amount of energy consumed is inadequate for good health. Because overall food intake is low, intake of the macronutrients protein, fat and carbohydrate suffers. Many times carbohydrate, found in vegetables, fruits, breads and cereals, etc. becomes the mainstay of the diet to the exclusion of protein and fat. Frequently, dietary intake of fat is drastically reduced. This reduction may emanate from the well-publicized emphasis on a low fat diet for good health and weight loss. However, the levels permitted by the Eating Disorder file are usually far below those recommended for good health.

Protein intake is also reduced, frequently to unhealthful levels. This reduction may occur as part of an individual's overall decrease in calories or protein may be specifically targeted for its supposed high fat content. This creates a deficit in the raw materials that the body needs to function.

Proteins which are found in meat, fish , poultry, eggs, cheese, milk, beans and legumes, are the building blocks of the body. Protein's primary role in the body is to repair and build new tissue. Skeletal muscle, hair, eyes, the immune system, heart, skin are all made of protein. When dietary protein is inadequate, these tissues are not repaired and begin to break down (hair loss, weakened heart, brittle nails for example.) Inadequate fat intake also has its consequences. It can lead to poor absorption of fat soluble vitamins such as vitamins E, D and A, cold intolerance, dry skin, loss of menstrual function, and even a clinical deficiency of essential fatty acids.

Dietary trends seen in bulimia include a number of different eating patterns. Similar to anorexia there is a pattern of restricted food intake. Individuals may classify this minimal food intake as "good" and necessary to achieve or maintain a desired weight. In addition, there is binge eating, classically described as consuming a large quantity of food in a brief period of time.

Looking beyond the definition, a binge is a very subjective experience and can be defined in a number of ways, 1) eating more than allowed on the "good" plan, by a lot or very little, 2) eating in a very frenzied, "out of body" fashion, not tasting the food, just stuffing it down, or 3) eating a forbidden food (a food not allowed in the "good" diet.) Binge eating can be spontaneous; a "good" meal goes too far: you begin eating and just can't stop, an unrestrainable hunger emerges. Or, binges can take on a life of their own; planned, guarded, feared and relished. For some, every eating episode is a binge, and eating in control is no longer a possibility.

Purging, ridding the body of the unwanted food is a component of bulimia. This may be accomplished through vomiting, laxatives, diet pills, exercise or food restriction. Each of these purging methods affects the way the body functions and can be life threatening. Tangible problems such as electrolyte imbalance, cardiac arrhythmia, esophageal tears (leaving blood in vomit or stools), dehydration, colonic damage, etc. can and do occur from purging. Feeling like one's been hit by a Mack truck is a common sensation after a binge/purge episode. The body is reacting to receiving and losing (possibly violently) nutrients, water and electrolytes. Individuals struggling with anorexia may also use binge eating and purging and experience negative physical effects.

As you can see, eating disorders are not without consequences. Most of the physical consequences are related to malnutrition, starvation and purging. Physically, you might notice hair loss (by the handful is not uncommon), bruises and cuts that do not heal, dry and cracked skin, fine downy hair on your face and arms, being cold (even on a warm, sunny day), dizziness when sitting up or standing, and extreme fatigue. These symptoms occur through a number of different pathways in the body, but the common cause is malnutrition. The body is not receiving enough nourishment to function; that means there are not enough calories, protein, fat, carbohydrates, vitamins, minerals and fluids.

A medical clinician can assess additional parameters where eating patterns affect one's health. These may include pulse, blood pressure, and temperature. Blood tests that evaluate electrolyte and hormone levels may also be taken. And, if appropriate, bone scans may be completed to assess bone density. Individuals with eating disorders frequently have decreased pulse rates, low blood pressure (below a level that is healthy), and low body temperature. Tests of electrolytes and hormone levels may also come back abnormal.

Electrolyte imbalances resulting from starvation and/or purging play havoc with the body's ability to conduct electrical impulses. These impulses are the workhorses of basic bodily functions, such as heart beat. Women with anorexia and some women with bulimia lose their periods. For most, this is due to hormonal changes resulting from weight loss brought about by poor diet, and sometimes, by excessive exercise. Others may lose their periods prior to weight loss, due to chaotic and poor eating habits. To protect itself, the body makes hormonal changes which then can often put individuals with eating disorders at risk for losing bone density, which may not be recovered.

There have been studies of what happens to the body when it does not get the energy and nutrients it needs to function, resulting in significant weight loss--it starves. An important note, significant weight loss does not have to occur for the body to be malnourished. Many individuals with bulimia, including those whose weight hasn't changed or has increased since the beginning of the eating disorder, are malnourished and may be at medical risk.

During starvation, the body must look to itself to supply the energy that is not being provided through food. The body uses stored carbohydrate and fat. But it does not use these alone. The body also goes to internal sources of protein, including skeletal muscle, heart tissue, and blood proteins for energy.

The body begins to break itself down to survive using a type of "cannibalism." There is a loss of lean tissue, skeletal muscle for example, with any weight loss, but drastic reductions of energy intake result in much higher levels of lean tissue loss. As weight loss progresses, there is no carbohydrate or fat left to process, only lean, functional tissue, that which makes a person breathe, think and move. This loss of protein affects the whole body including the heart. The heart gets smaller and weaker and is not able to function very well. It becomes vulnerable to malfunctions, such as heart attacks.

The body will try to save itself from this "cannibalization" by reducing the metabolic rate, therefore reducing the amount of energy expended. This reduction in metabolic rate is reversed when adequate energy and nutrients are consumed in the diet. Serum cholesterol levels can be very low or high due to changes the body makes to survive starvation. An elevated cholesterol level in this situation does not warrant a low fat diet! Electrolyte imbalances can occur, especially if one vomits and/or uses laxatives. Initially, an eating disorder can cause your body systems to begin showing signs of stress (low blood pressure, pulse and temperature), if unchecked, ones entire body systems can fail (heart attack, kidney failure, death).

Other changes associated with the malnutrition of eating disorders include early satiety (feeling full) and bloating due to delayed digestion in the stomach. You may experience decreased appetite for brief or extended periods of time due to increased levels of metabolites from an alternative energy pathway.

Sometimes, when you are in this state, eating will cause the lack of appetite to go away and an intense hunger may appear. The hunger is real, not a betrayal by your body. Actually, it is a much more accurate reflection of your body's nutritive state. Constipation can occur due to low calories and altered metabolic rate. In many cases, the small amount of food consumed does not provide enough bulk for normal bowel movements.

The malnutrition of an eating disorder also affects the way your brain functions. It may be more difficult to identify these changes, because in many ways they work with the eating disorder's rules and regulations. Behavioral changes seen in starvation and eating disorders include a preoccupation with food, binge eating, or a loss of control when food is available, impaired concentration, indecisiveness, mood swings, depression and social isolation. These consequences make it difficult to clearly assess what is going on, therefore enabling the eating disorder to thrive.

Recovery can be a very difficult process, and understandably more than an individual can do on her or his own. Because an eating disorder is so pervasive, treatment usually includes a team of professionals so that each area of your life and health can be appropriately addressed. Nutrition is vital to recovery. Changing your diet by incorporating the energy, nutrients and fluids necessary for proper brain, heart, and immune function makes it possible for you to become physically stronger. This strength enables you to move to a new place. A place, perhaps, where you can continue on a path leading to recovery. It is difficult, if not impossible, to think about such a process with a brain that isn't functioning well. The Eating Disorder file is running the show, and the weakened physical state frequently seen in eating disorders (even if you exercise a lot) makes it so difficult to make changes.

The good news is that much of the medical deterioration from an eating disorder is reversible with time and nutritional rehabilitation. This requires providing your body with the energy, nutrients, vitamins, minerals and fluid necessary to function. Nutritional recovery is not about excesses. It is not about "fattening up." Nutritional recovery is a progressive process where food, an element vital to life, is reintroduced in a fashion to promote your health and well-being. The help of a health professional, a Registered Dietitian, can make dietary changes seem more attainable by providing education and constant feedback as to your nutritional state and the rationale for changes. Meal plans that focus on goals that directly improve your health can complement other areas of treatment, namely therapy and medical visits.

When seeking help to improve your food intake, it is important to work with a health professional who is qualified and knowledgeable. It is important to know that anyone can call themselves a nutritionist. There are no education or training requirements for a nutritionist title. For help with nutrition, seek out a Registered Dietitian (R.D.) A Registered Dietitian is the health professional who is trained to help individuals make positive changes in their eating habits, promoting better health. All R.D.'s have completed prerequisite education and training in nutrition, including a bachelor's degree and required classes in biochemistry and nutrition, and clinical training in nutrition as part of a dietetic internship.

All registered dietitians are nationally registered with the Commission on Dietetic Registration. There is one catch: many Registered Dietitians call themselves nutritionists. So, when inquiring about a nutritionist's qualifications, be sure to ask if they are a Registered Dietitian.

There are R.D.s who specialize in working with individuals who are recovering from eating disorders. As with most health professionals there are many ways to locate a Registered Dietitian. Your therapist and/or medical clinician may be able to provide you with referrals. You can also contact eating disorder treatment centers and inquire if the dietitian is available for individual consults or has a private practice. Large medical centers may also offer outpatient nutritional counseling by a dietitian.

There are also many R.D.s in private practice. You can check the Yellow Pages under the headings "Dietitians," "Eating Disorders Information and Treatment Centers" or "Nutritionists." The American Dietetic Association provides a National Nutrition Referral Service. Registered Dietitians across the U.S. are listed by location and specialty. The service is free and the toll-free number is 1-800-366-1655. You can also locate registered dietitians who specialize in eating disorders under Finding a Dietitian at the American Dietetic Associations web page, located at http://www.eatright.org.

OPTIMAL EATING thanks Tami Lyon, R.D., M.P.H., C.D.E. for this informative and interesting article.

© Copyright 1997-2012 Jane Rachel Kaplan, Ph.D. All rights reserved.


Dr. Jane Kaplan Ph.D., Psychologist Provides Eating Disorders Therapy in the SF East Bay area, near Berkeley, Albany. Weight Management Coaching, Psychology of Nutrition and Healthy Eating Counseling, Individual, Group and Family Therapy for Anxiety and Depression.