Because it's easier and more sensationalist to blame the fashion industry, and because when people with eating disorder stop to think about their behaviours they may gain some insight into their environmental triggers but they won't be able to feel and identify the biological component. People with eating disorders are used to being judged on their looks - either as emaciated or as "you're a healthy weight/overweight, you can't have an ED" - and so understandably shy away from discussions of the physical nature of their illness, because it feels invalidating and reductive.

Having said that AND believed it at various points in my life, I found it invaluable to get over my own prejudices against biological explanations and learn more about them. It gave me an extra component to treatment: I forced myself up to a much higher weight than I would have otherwise once I understood that low target weights are correlated with low recovery rates; I learned that my ED thoughts and obsession were largely a product of malnutrition, and that starving myself would make them worse, not better; I ate much more than I would have because I understood about organ repair and the importance of hormones; once at my target weight I became MUCH more careful never to absentmindedly restrict, because I understand that even slight malnutrition changes the way my brain works in such a way that relapse would become very easy from there.

I know and understand all of the environmental aspects to my ED too, but it was only once I had dealt with refeeding and learned to separate myself from the illness that I was able to deal with them.

So I agree with you: I might be able to think of a few reasons why people ignore biology, but they are missing out if they do. It's been incredibly helpful to me, especially learning about the way that malnutrition and being underweight affects even psychologically healthy people, as in the Minnesota study. That's a fairly simple but very powerful message (undereating is bad for your brain!) that I take into the talks I do in schools all the time.

People are afraid to admit that that is true. That's why they don't mention it.

The Biology explanation means you have to treat. It shifts the "blame" from patient behavior. A lot easier to blame media, the patient, the family even. Not that there aren't valid foundations in that sometimes. But to understand that "curing" all external factors isn't always going to be a lifetime fix is a lot harder to swallow. That there is a reason why I have struggled for decades with this disease. That my brain works differently. That through these yrs of malnutrition or bad neurological pathway reinforcement it will always linger on the edges if I am not vigilant. That people may need care beyond a one stop fix it up moment our healthcare system wants to provide. So many reasons...

Easy- biology's boring. Life-sized Barbie is shocking and people want to stare. Same with sexual trauma stories or dysfunctional family stories. And emaciated pictures. Most people keep their tv and internet tuned in if something's shocking, and lose interest if it's not. News clips and shows are looking to get more views and higher ratings. Honestly, I think the news industry is out there to shock and entertain more than to inform. And you know what? The freaking evening news is one of the contributors to MY ed. When I was little my dad absent-mindedly left it on every evening. Every story of trauma- this person died in this horrible way, that kid got raped repeatedly and shoved in a closet, this meteor just might crash into the earth, those terrorists are on the move- as a little child, I had no business knowing ANY of that and wish I had been protected. Hearing those things reinforced that the world is full of danger, danger, danger and I was already terrified of everyone and everything in it. So I don't give the news much credit or much respect. I find my info elsewhere- I look for information that is NOT sensationalized. But people who have a higher tolerance for stress and shock than I do, which is probably most people, gravitate towards the sensationalism simply b/c it is more titillating than a scientist's viewpoint. Unless, of course, their viewpoint is something really exciting, like, "the world is going to end in 2012 for these scientific reasons..."!

I <3 my readers. You guys are spot on.

Here here! Everything the other smart commenters already said!

Actually, the reason we're reluctant to "blame" biology is because then you would have to prove it. If you say there's a scientific explanation for Anorexia then the natural next question is, "Ok, show me." Of course, no one to my knowledge has ever been able to prove some gene or protein causes calorie restriction,excessive exercise, induced vomiting, etc and chances are no one ever will. ED's are chalked up to control and anxiety issues because that's what they really are. DOES biology/genetics play a role? Maybe a minor one. I discuss it briefly on my website (http://eatingkids.com/genetics/). But if you want the role of biology to be taken more seriously as a cause for ED's you're going to have to prove it.

Dr. Katz,

For evidence supporting the idea that EDs have a biological basis, check out the research of Walt Kaye, Cindy Bulik, and Janet Treasure, for starters. No, biology doesn't tell the whole story, but then, it never does.

As well, a problem with one gene rarely causes any disorder. It doesn't for cancer, heart disease, diabetes, depression, or schizophrenia, either, but that doesn't mean that there's not something biological going on or going wrong. What a lot of these illnesses (and eating disorders) have in common is likely a large number of small gene variations that work to increase risk. Many of them are probably located next to each other on the chromosome, and so are inherited as a group. Others are located on different chromosomes and so are inherited separately (Google "meiosis and crossing-over" for background).

There isn't going to be a cancer gene, and you're right--there isn't going to a be an anorexia gene either. But that is far, far different than saying there's no biological explanation for eating disorders.

Katie, your comment is so helpful. As are all the comments and the post!!!!! Thanks all x

Perhaps it is better to say that the predisposition can be inherited and is likely strongly genetic.

Like Carrie said, I don't think there will ever be evidence that a set of genes causes a specific cellular pathway dysfunction, gross anatomical change or functional difference in brain circuitry. I actually don't know anyone who would take such a simplified view and I have never heard any researcher/clinician propose this. . .

However, this does not mean that biology is relegated to a small role in terms of causation -- simply that it is necessary but not SUFFICIENT to cause the disorder.

There is simply too much evidence to support a strong biological component.

Individuals with ED's have a certain behavioural phenotype (perfectionistic, obsessive, harm avoidant, anxious, etc) that predisposes the ED itself. There is a high incidence of mental illness in unaffected family members of individuals with EDs. EDs are highly heritable and often accompanied by other mental health issues -- this might suggest the predisposition can support the development of a variety of mental illnesses.

Individuals with AN have been found to have higher levels of serotonin after recovery that might indicate involvement of the sertonergic system --> also, genetic polymorphisms in genes involved in serotonin regulation have been found to have a higher incidence in individuals with AN. Similar findings support evidence of chronically low dopamine levels.

I think the key here is that these genetic (biological, whatever. . .) differences create a non-specific predisposition but NOT cause the illness itself.

Other environmental factors (epigenetics, obstetric difficulty, childhood anxiety/stress, etc.) interact during development with biology (ex. over-activity of the HPA axis) to further enhance this risk.

Need for control and anxiety are the result of interplay of environmental factors (family situation, social situation, etc.) and innate biological predisposition. It IS true that these needs/fears/worries are VALID and also need to be addressed in recovery. However, that individuals with EDs have certain psychological issues that need to be addressed in therapy AND can lessen the severity of the disease does not preclude biology as an influential factor in development.

A:)

@ Dr. Michael Katz:

It is true that at present no-one knows the precise biological basis of EDs, and neither do we know precisely how genes are involved. Yet, there is sufficient research evidence to suggest both a biological and genetic basis for EDs. (For example, see papers from the authors Carrie cites above).

We can estimate the role of heritability of (e.g.) AN on the basis of statistical analyses of various data (especially from twin studies), and there are now studies with large sample sizes and good statistical power which suggest that inheritance plays a dominant role. On the basis of genetic studies of AN (and/or relatives of individuals with AN) to date, it would seem most likely that role of genetic factors is via an influence temperament and personality development via (e.g.) emotional and cognitive traits. Such studies also suggest that there is shared genetic risk for not only eating disorders, but also for anxiety disorders, depression and addictive disorders.

I don't think that anyone disputes that the cause of EDs is multi-factorial, with culture playing some sort of a mediating, or more likely, a maintaining role. But while everybody is exposed to our culture, most people don't develop EDs, and in particular AN, the incidence of which doesn't appear to be any greater in the 21st Century than it was in the 1960s/1970s.

Blaming Barbie for eds is kind of like blaming McDonald's for obesity. Toy companies will make skinny toys and fast food chains will make shitty, greasy food. Consumers need to be aware of risks and implications and consume within reason. Informed people in a free society can vote with their dollars.

Anyway, they've done studies recently on children in culturally isolated communities and still found eds- that implies that if you remove cultural influence, you still have eds. The fact that there are children who have eds but no sexual trauma in their past implies that if you remove sexual trauma, you still have eds. The fact that children who come from loving, stable homes still sometimes develop eds implies that if you remove dysfunctional family dynamics, you still have eds. So what's left? Biology. That's it. That's the one factor you can't do away with, across the border. How on earth is that not just so, so logical? Why is the biology issue not front and center???

Actually, Dr. Katz, the burden of proof really should be on those who say it isn't.

Oh "Doctor" Katz! One day you will eat your words (pun, obviously intended). Please, it is clear that you were able to survive medical school you should be able to do basic research -- please visit the UCSD Eating Disorders website at:

http://eatingdisorders.ucsd.edu/

and get yourself caught up on the current, evidence-based literature. Do yourself, and more importantly, the patients and families who listen to you a favor. Please. Seriously.

Perhaps it is better to say that the predisposition can be inherited and is likely strongly genetic.

Like Carrie said, I don't think there will ever be evidence that a set of genes causes a specific cellular pathway dysfunction, gross anatomical change or functional difference in brain circuitry. I actually don't know anyone who would take such a simplified view and I have never heard any researcher/clinician propose this. . .

However, this does not mean that biology is relegated to a small role in terms of causation -- simply that it is necessary but not SUFFICIENT to cause the disorder.

There is simply too much evidence to support a strong biological component.

Individuals with ED's have a certain behavioural phenotype (perfectionistic, obsessive, harm avoidant, anxious, etc) that predisposes the ED itself. There is a high incidence of mental illness in unaffected family members of individuals with EDs. EDs are highly heritable and often accompanied by other mental health issues -- this might suggest the predisposition can support the development of a variety of mental illnesses.

Individuals with AN have been found to have higher levels of serotonin after recovery that might indicate involvement of the sertonergic system --> also, genetic polymorphisms in genes involved in serotonin regulation have been found to have a higher incidence in individuals with AN. Similar findings support evidence of chronically low dopamine levels.

I think the key here is that these genetic (biological, whatever. . .) differences create a non-specific predisposition but NOT cause the illness itself.

Other environmental factors (epigenetics, obstetric difficulty, childhood anxiety/stress, etc.) interact during development with biology (ex. over-activity of the HPA axis) to further enhance this risk.

Need for control and anxiety are the result of interplay of environmental factors (family situation, social situation, etc.) and innate biological predisposition. It IS true that these needs/fears/worries are VALID and also need to be addressed in recovery. However, that individuals with EDs have certain psychological issues that need to be addressed in therapy AND can lessen the severity of the disease does not preclude biology as an influential factor in development.

A:)

America has this idea that saying "thank-you", "please", "I'm really sorry." and "I don't know" are not okay.
i sat in my therapy session last week overwhelmed because i feel lousy, panicky much of the time, depressed much of the rest and frankly in some ways worse than i felt before we started refeeding. so i said all that and that i was concerned because BIOLOGICALLY this is sort of normal but i want to have some clue when it will diminish because i'm feeling like an epic failure. my therapist looked at me and said that the treatment might fail, that she might fail, but that i am not failing and will not fail and am not a failure. she said that would be a little like telling a cancer pt. that because the chemo didn't work they failed. she told me that because she does know that there is a huge organ involved called my brain. another one involved is (thank you God) her brain. she knows that if we put all the factors together that she only knows a few ways to get things back to right again, assuming they ever were, and that sometimes the kindest thing to do is to tell people the truth.
"I don't know, but I'll do my best to find out." what is shameful is saying "I don't know." and walking away from the problem like an infant covering their eyes and thinking Mama isn't still on the other side.
talking about biology means admitting that much of the testing on disease in this and other industrialized countries doesn't EVEN HAPPEN with female subjects and that statistically it SHOULD in EVERY case of disease, not just eds. it means admitting that because of the labels we're still shoving Auntie Lou up in the attic as a society and paying lip service because the 'smart' people haven't got all the answers. do they really think we expect them to? proof from one person to the next is always going to be variable. do they really believe we're so weak minded and simple that we don't know that right now?
it frustrates me, it sometimes makes me angry, but ultimately it is crippling, because if nobody knows how to help, for good, not just for now, then i might as well go empty the frig of all the shit i'm not even interested in and donate it to the homeless. at least if i ask most of them a complex question i'm pretty sure they'll shoot me straight and just say "I don't know." there's an honest answer i can live with.

i was going to apologize for ranting but i think maybe this time i won't.

I honestly think another reason is because, in general, America's relationship with food is pretty messed up. I think a lot of people would agree with that. I can see how it would be very easy to assume that eating disorders are caused solely by culture because we are bombarded by disordered attitudes on a daily basis. For someone who is unfamiliar with eating disorders, it would seem logical that the same cultural elements that cause one person to worry about his/her weight could then potentially cause someone to “go overboard” and starve or develop some other ED symptom. I do get the feeling that EDs are still seen as a diet that someone's taken too far. (I absolutely do not buy into this, but am trying to see it from the perspective of someone unfamiliar w/the subject.)

And as others have suggested (and stated explicitly), it's much simpler to point to a tangible object like Barbie (or even a concept, like culture) and say it's to blame than it is to explain sometimes very difficult scientific concepts in an way that is understandable (and interesting) to the public. Which is why I love this blog. Carrie, you are one reason why I've been able to let go of some of the guilt of my ED. Your emphasis on biology has helped me understand some of the workings of my own brain, instead of thinking I'm a cultural product who's just obsessed with losing weight. So thank you for that. :)

Ms. Arnold,

Clearly you are correct that there is "evidence supporting the idea that EDs have a biological basis." I re-read my post and I think I gave the unintentional impression that I didn't agree.

What I should have said was that, in mainstream media reporting, it often isn't helpful when "suggestive" stories are reported that discuss "possible" links between biological abnormalities and clinical disease. In ED's, as in some other diseases, many people are looking for some ONE to blame, and not some THING - and genes, proteins, etc just aren't good villains.

Until one of the many talented scientists researching this issue is able to show conclusively that such-and-such abnormality (seratonin receptors, reward centers, etc) is the "cause" of ED's, we're going to have to deal with the news playing the "blame game."

Side note: One of the problems with some of the studies done on patients with ED's (brain scans, PET, etc) is that it can be difficult to tell whether the abnormal scan is caused BY the ED or is the cause OF the ED. Remember that, over time, behavior can change how the brain functions.

I'm really enjoying this conversation and appreciate your raising the question to begin with.

Carrie- I sincerely would like to hear your thoughts on those of us who do have diagnosed eating disorders and who do know that the disorder was sparked and motivated by the ideal that Barbie represents. I know the "trend" is to discount people like me as merely having disordered eating (not an ED) but that's circular reasoning. Why does it have to be impossible that Barbie triggers EDs in a sizable minority (maybe majority?) of people predisposed to them? And, if so, doesn't it make sense to minimize this cultural ideal?

I do believe that Barbie is a trigger. I believe that super thin models are triggers. I believe that the sensationalism on the evening news was traumatizing for me as a child, and maybe is for other kids too with the same nature. I believe that McDonald's contributes to obesity. I believe a lot of things in this country are unhealthy and downright dangerous.

BUT that is the drawback of living in a free country. The burden of what gets sold and gets watched is on us, the buyers and the watchers. What we continue to consume gets produced. What we watch gets noted and reproduced.

Those of us who see the truth in the dangers out there need to step up and inform consumers. And there's a place for everybody with something to say- there's this girl with her life-sized Barbie. Kudos to her for talking about that trigger and bringing it to peoples' attention. Whether it's a trigger for everyone with an ed is really irrelevant- it is a trigger for some (probably lots) and it's great that it's getting addressed. Now some people who know a thing or two about biology and genes need to step forward and inform people of genetic triggers.

Hmmm... anyone know of a good author who could... say... write a book on biology and eds??? ;)

Anonymous - The way I see it is this. Five people have the genetic predisposition for developing anorexia. One gets really stressed out about his exams and can't eat as much as usual. One is surrounded by friends who are dieting and so decides to lose 5lbs herself. One develops a physical illness such as IBS or coeliac disease which causes digestive problems and leads to weight loss. One is raped and quite by chance, discovers that not eating distracts her from all the chaos in her head. One goes to university, doesn't really take very good care of himself and loses weight by accident.

Because they have the predisposition for developing anorexia, once they are a little malnourished and have lost some weight their brains are affected in such a way that all those personality traits which predispose them are heightened, and the effects of malnutrition lock them into the pattern of restricting and being terrified to change.

It doesn't matter what the initial trigger is on the scale of the general population - it can be anything which causes someone to eat chaotically or restrictively. The important thing is how a person reacts biologically to those changed eating patterns. If they have the predisposition for an eating disorder they will develop one, if not they will just diet then get bored, or gain the weight back healthily if it was unintentional weight loss.

So there is nothing to suggest that people with body dysmorphic/cultural triggers have a "lesser" form of ED. You are just as included in the biological explanations as any of the rest of those hypothetical people.

Of course it's a free country. No one is proposing a Barbie Ban. I just don't understand the point of the outrage/ indignation/ whatever being directed at a college student who feels Barbie contributed to her ED. Barbie's role doesn't make biology any less important, but Barbie DOES have a role and I think, as a community, we should be more supportive - and not outraged - when someone tries to address that.

I 100% agree with you. Eds are complex issues---and certainly culture and psychology have a great deal to do with them. But, as with any other disorder or disease, we cannot forget about biology. I believe biology has an equal hand in influencing eating disorders. Probably the reason that many people "shy away" from the biology factor is a lack of understanding. Science can seem unnecessarily confusing to some people, so they ignore it in favor of "simpler" explanations. But whether or not they acknowledge biology, it's still there, coursing through our veins. I appreciate that you've emphasized this, because it's a concern of mine too.

hi all,

actually there has been a VERY good book written about EDs & biology & neurotransmitter sby dr kathleen des maisons - 'potatoes not prozac'. how we as ED'ed have much higher pain levels & lower levels of self-esteem than 'normals', all due to low beta-endorphin, serotonin & dopamine.i had no idea that low BE ( beta-endorphin) = low self-esteem.

studying 'addiction counselling'at masters level, i can now see how this fits with alcoholics & drug adicts too

it is a fascinating read & i finally 'got', why none of those years of expensive talking-therapy worked.

i am absolutely amazed that dr katz does not have anything on 'biology' on his website - kids love to know that eating sugar, white flour, bad fats & alcohol raises BE - u get a high & raise self-esteem & feel like u could be president but only for a short time, then u crash.

i love love love carrie's blog & cant wait for her new book

warmly
ana

Anon,

I'm not outraged that people are bringing up Barbie. I'm more annoyed that people are bringing up Barbie as if it tells the whole story on eating disorders. That somehow banning Barbie and unrealistic body images would somehow eliminate eating disorders. Eating disorders existed long before Barbie, and they'll exist after every last girl has ripped off her little plastic head.

I don't think cultural issues are irrelevant. I just don't think they tell the whole story--that's where my objection lies.

first of all, thanks so much for bringing that subject up! at the moment, (since I "started" recovery, actually and got in touch with psycho-therapists and physicans), but now even more so, I keep thinking about it...

somethings might surely have been said before...sorry for the redundance, I'll have to come back later to read ALL of the comments^^) where I live, the way eating disorders are dealt with- especially in the media- doesn't really differ from other western countries...
First of all, I think it is easier to make the media responsible, because it's so obvious and esay to put a finger on and the media likes to overestimate its influence. Furthermore it tries to reach a lot of people- in deph stories are not everyone's business. A lot of people simply can't really grasp the idea, that eating can be really a hard thing, and by blaming beauty ideals and such, people can relate to it. Biological reasons make it an real illness, something that isn't about willpower or else, and something that has to be treated. By doctors, physicans, therapists...it takes the blame away from the patients. Now, my impression is- if a therapy doesn't help, it's not the therapists fault, the patient wasn't motivated enough, was in denial , didn't "chose" recovery...Argh. It is not something just in your head to switch on and off and "decide" on it...!
And that just makes the point clear- even the manual of diagnosis (ICD-10 or DSM_IV) - even this manual somehow undermines this issue, as anorexia is characterised as the "refusal" to maintain a certain weight.
It just makes me angry...

Not acknowledging biological factors makes women look "superficial" and kind of stupid, and it also (please don't get me wrong) sends this message: "Everyone can get skinny, no matter what, it can get pathologic, yes, but anyway, it looks good to a certain degree, too..."

And explaning that malnutriton affects behavior and feelings makes some of the symptoms look less "exotic" in a documentary, I guess. And sometimes biological things can be proven or falsified better than most systemic, psychoanalytic theories can be- a benefit for biologists and to the dismay to the therapists who find their superior position threatened...
best wishes

...from L.M.

You want, you think, you don't like, you understand but nobody else is getting it right... get over yourself.

Anon above,

Um, this is a blog. MY blog. What else do you do on blogs but think and like and don't like and throw out a bunch of pathetic navel gazing that you think others might be interested in.

Here's what I know: "Genetic factors significantly influence the risk for anorexia nervosa."

If you need more evidence, read any of Walt Kaye's research papers.

That's not thinking or liking. That's knowing. That's proof.

Brave, reasonable, grounded, and often unpopular truth.

Aaaaaand we're back to... it's a free country. No one is REQUIRED to read this blog, or anyone else's. Of course, if they've got nothing better to do than read things that annoy them and then bitch about it... as said, it's a free country. But who would do that? People are weird. This blog is definitely a "fit" for me and my interests- I can't imagine sitting around reading blogs that didn't fit and then criticizing them. What a waste of time!

You gotta love trolls don't you (not!). They're everywhere Carrie - they thrive on their own stupidity - just don't listen :)

Some good points made here. I think the answer goes even beyond popular views of anorexia.

The fact is, humans are likely to base their opinions on beliefs rather than on evidence. Historically the scientific method has been the exception, not the rule. Just think - it took about 50 years for the medical community to accept handwashing, even after proof that it prevented spread of infection. Even in this group that we expect to be science-oriented, the idea was rejected because it just didn't jive with preconceptions.

Many people have a deep belief that our natural state "should be" good health, and that if we are unhealthy, someone or some activity must be to blame. For some it is a religious view - if we are "made in god's image" we have been designed to be perfect, and if an individual is not perfect, they - or their mother, or the wicked witch in the woods, or the wicked culture on the TV - must be doing something bad. I have seen this tendency even among folks who are not particularly religious. We've been blaming our problems on bad behavior since we held Adam and Eve responsible for the sad fact that we don't live in Paradise. Well, mostly Eve. And probably since long before that.

We may think ourselves as the pinnacle of evolution (some scientists have a lot to say about this as well), but in fact our messy birthright of genes, microbes, brain chemistry and whatnot is just not always arranged to suit our desires. Science gives us evidence of this, and miraculously often gives us help in dealing with it. But folks are still happy to fall for the time-honored practice of finding someone or something easy to blame when things don't go their way.

Carrie, keep up the good work. Evidence will prevail.

Jane, I bow at the altar of your intelligence. :)

You bring up a great point. I think as a culture, we like having things to blame to ease conscientiousness. By using the media or control issues as a scapegoat it does two things: wraps up EDs into pretty little bite-size packages (no pun intended) and also makes us sufferers appear passive and susceptible and helps to shift all responsibility onto us.

I think it goes without saying that environmental/cultural factors definitely contribute to eating disorders.

For instance, Locke and LeGrange have shown that calorie restriction can trigger severe EDs in people with the genetic predisposition. Therefore, it's not really a surprise that EDs are common in societies that encourage dieting.

But then don't you have to ask why we diet, and look back at history and philosophy and religion to see how the human body, and particularly the female body, have always been feared and vilified?

I am not at all disagreeing with your point about biology, and I think a lot of people have this idea that if you just get your head straightened out with some feminist enlightenment or whatever, that you'll cease to have an ED. And it seems like people (including me as a sufferer) have trouble understanding that there is a biological component at work unconsciously.

But at the same time, I really resented my parents for going with the "it's all biological" theory, because it meant in their minds I was reduced to a mere malfunctioning brain instead of a person, as if I couldn't possibly have a negative thought or emotion that was "valid" -- it must just be the ED talking.

I 100% believe that biology plays a role. But I think it's every bit as harmful to say it's "just" biology as it is to blame fashion magazines. Like, don't tell me something's wrong with my brain and then expect me to accept a society in which extreme thinness is glorified...because it seems like my brain is working pretty well if it notices that being thin is a great thing to be in this world. That's enough to make anyone crazy.

They don't get it.
We're not dolls, we're real people, with real problems.