The problem with prevention

Most of you have probably noticed by now that it's Eating Disorders Awareness Week. For the first few days this week, my Facebook feed was inundated with message about loving your body and talking back to the media, and so on. It was like being at a high school pep rally, only about not wearing lipstick! and accepting our natural beauty! and loving our bodies!

I don't really like pep rallies, if for no other reason than I really don't do peppy all that well.

Rallying people and getting them motivated are great. Most of these war cries have to do with preventing eating disorders: that if we label digitally altered advertisements, we will decrease eating disorders. Or that people need to accept their natural sizes, which would eliminate eating disorders. They're nice thoughts, and they seem like really good ideas. It's why they have so much traction. People without eating disorders can relate to not liking how they look. They can relate to looking at beauty magazines and then feeling seriously ugly. They understand about dieting and wanting to be a Size Negative Eleventy Billion but not being able to lose those last XX pounds. Cindy Bulik calls this the "I just wanna look like a model" model of eating disorders.

The problem is that eating disorders aren't just extreme diets and treating them as such gets us nowhere. Writes Autumn Whitefield-Madrano, a recovering (?) eating disorder patient:

I just know that by the time I was discharged from Renfrew, I’d finally begun to learn that my dissatisfaction with my body wasn’t causing my eating disorder; it was merely a symptom of my disease, like restricting my food intake or binge eating...I’d begun to understand that loving my body wasn’t the point. The point wasn’t even to like it. The point was to learn how to eat.

I personally find body image--how the brain figures out what we look like--a fascinating neuroscientific and philosophical issue. My own body image issues long predated my eating disorder, but they didn't have anything to do with lipstick or models.My brain had a hiccup in figuring out what size I really was, likely due to problems in the insula and somatosensory cortex. Ridiculously altered images don't help, but they weren't a cause.

Others take a different approach towards eating disorders prevention. If we can educate people about how dangerous and pointless eating disorders are, then maybe people won't start. It's an attitude I had myself for a while, and the well-meaning philosophy feeds into tell-all newspaper articles and discussions about just how few lettuce leaves you survived on at your worst.

I never ceases to astound me just how many people give a shit about that sort of thing.

Except that this type of thinking essentially posits that eating disorders are choices, or voluntary behaviors. Perhaps that first step can be, I don't know. The problem is that most people who take that first step don't think they're going to develop an eating disorder as a result. So telling them that eating disorders are dangerous is kind of pointless, since they're not going to get an eating disorder from adding a little bit to their athletic training or cutting out junk food or whatever. By the time they have an eating disorder, it's too late.

To wit: a recent study on weight history in bulimia was just published, and researchers found that women suffering from bulimia ultimately gained weight as the result of their disorder. The Atlantic magazine wrote:

"Most patients lose a lot of weight as part of developing this disorder, and all dedicate significant effort, including the use of extreme behaviors, to prevent weight gain," said researcher Jena Shaw. "In spite of this, we found that most women also regain a lot of weight while they have bulimia," she continues. Maybe tell that to those kids with their pro-bulimia "ana-mia" Tumblrs?

{{Emphasis mine.}}

Nice thought, but it probably won't work to actually prevent an eating disorder. It's like telling someone who's sad to cheer up lest they get depression, or working to prevent bad moods everywhere! (Like pep rallies, unbridled optimism also makes me stabby, so I'm not sure I could tolerate this world for long...)

I'm not against the prevention of eating disorders, I'm just not sure that we have any clue how to do it yet.


Kathryn Koehler said...

I have to agree. While preventative efforts are wonderful and early intervention are essential, I too have pointed out that there is so much more to eating disorders we don't understand. There is no research saying definateively what causes an eating disorder so it follows we have no true means of prevention. Also early intervention is great but eating disorders are secretive diseases. No matter how hard people try to spot warning signs, people will be missed because of this. THus treatment will also always have to also focus on individuals with a much more deeply ingrained disorder.

Anonymous said...

Carrie, I half-yelled "THANK YOU!" to my empty room after reading this. I am so very glad there is someone out there writing this, and I hope at least a few people outside the F.E.A.S.T./ED'd cognoscenti stumble onto your blog. You've said exactly what I feel every time I read about "Barefaced and Beautiful!" and "Be Comfortable in Your Genes/Jeans!" and the rest of the misguided awareness campaigns out there.

My eating disorder is decidedly not about beauty or even body--I've actually always liked my face and body structure. Anorexia was never about wanting to change sizes or fit into a certain beauty standard, and it only became about weight when my team fixated on it and I discovered another number to obsess over (since calories and miles weren't enough). And "media"? As a kid, I never watched television or read fashion magazines (at all), and although I was seriously involved in ballet, I was told I had the "perfect ballet body" and never felt a pressure to lose weight for dance.

Of course I agree with you (and the legitimate research...) on the predisposition vs choice issue--and that "prevention" campaigns tend to support the myth that we actively pursue eating disorders. Where are the "preventing schizophrenia by loving your own voice" and "preventing bipolar by loving moderate moods" movements?

...anyway. yeah. But seriously, I appreciate this article and I deeply respect the insight, research, and clarity that is so apparent in your writing.

Anonymous said...

The "it had nothing to do with thinness or beauty" eating disorder experience is valid, but it is far from the only one. Just as not all eating disorders manifest in the same thoughts or behaviors, not all eating disorders share the same roots. Eating disorders aren't always actively acquired, but they can be.

My eating disorder is, essentially, an addiction. I was TAUGHT at a young age to cope with bad experiences by misusing a normal thing. Instead of drugs, alcohol, gambling or sex I use food, fullness, hunger, exercise. The comparison to schizophrenia is unfair because schizophrenia is purely biological, while eating disorders (and addictions) are not. To me, the ED prevention campaigns are the same as drug abuse prevention campaigns, not schizophrenia.

Our cultural obsession with thinness & beauty can pull the trigger on girls who already are holding a loaded gun (insecurities, lack of good coping skills). These campaigns are aimed at that type of girl. Sure, not all eating disorders can be prevented, but that doesn't mean none of them can, and it doesn't mean we should stop trying.


Carrie Arnold said...

Actually, Tempest, when you look at the studies, anorexia and schizophrenia have approximately the same breakdown of environmental and biological risk, with up to 80% of risk due to biology. Environment also includes things like what bacteria and viruses you were exposed to, the time of year you were born, and so on. Even things that happened in utero.

These campaigns sound nice, but I don't know that they're going to be doing nearly the amount of prevention we might like to think.

Carrie Arnold said...

Actually, Tempest, when you look at the studies, anorexia and schizophrenia have approximately the same breakdown of environmental and biological risk, with up to 80% of risk due to biology. Environment also includes things like what bacteria and viruses you were exposed to, the time of year you were born, and so on. Even things that happened in utero.

These campaigns sound nice, but I don't know that they're going to be doing nearly the amount of prevention we might like to think.

Anonymous said...

Brilliant post, Carrie :) I absolutely agree. I blogged on this a while back:

I honestly don't think that EDs are preventable. I think the best option is to catch them early and treat them aggressively, for as long as is needed to change brain function and thinking.

Unknown said...

If it is true that those who develop EDs tend to have many personality traits (the drive for perfection, anxiety, etc.) and cognitive styles (weak central coherence, set shifting difficulties, issues with impulse control - too much for those with AN and less for BN) in common, all of which driven by genetics and possibly increased by malnourishment, then wouldn't it be helpful for at least one avenue for "prevention" measures to focus on alerting parents that these traits in children are risk factors for the development of EDs? If we had known this when we were dealing with issues in our daughter's adolescence prior to succumbing to AN years later, we would have been far more proactive in enlisting help for her in high school so that she could possibly have developed coping skills that might have helped prevent the slide down that slippery slope once she left home to go to college. Having said that, of course most parents won't go out to listen to a talk about an issue that hasn't affected them yet, but what if there were a film created that could be sent to PTAs in elementary, middle, and high schools, and put on Netflix, etc. that people could have access to? What if the film was based on interviews with parents whose children ended up with EDs? I bet we could come up with a list of questions about how the kids were in childhood, and I would bet that 80-90% of parents would answer the same to 80-90% of the questions. This would clearly demonstrate that these are risk factors and would give parents knowledge they need to detect potential problems early on.

hm said...

I don't think you can prevent the propensity towards an ed... but I do think you can catch early onset ed symptoms and prevent a full blown ed from developing. That is- you might not be able too "educate" someone out of beginning to starve, over-exercise, or purge- but if you suspect that someone has the propensity towards these behaviors and then you suspect that they are beginning to exhibit some of these behaviors, then you can put an aggressive stop to the behaviors before they cause significant psychological or physical damage.

But truly- it is about psychological propensity and not about self-acceptance. It is about a brain that is geared towards controlling anxiety in a disordered fashion- even if that person does start out feeling fat and wanting to diet- practicing ed behaviors still then revolve around subduing the anxiety they feel as a result of feeling fat. Loads of people feel fat. Most of them do not end up with an full blown eating disorder.

I am very interested in the link between schizophrenia and anorexia. I've seen articles referencing the ed "voices" as "auditory hallucinations" similar to what the schizophrenic experiences. I've seen articles stating that the same meds might work for both. And linking both diseases to dopamine activity.

If anyone has any pertinent information on that subject, I'd be grateful if you'd share.

A said...

I love this post. Bookmarking to refer people to. Personally my ED started as a diet gone horribly wrong so I do see the point of the "love your body stuff". Maybe if I hadn't been told by all mainstream media that I needed to be thinner I might never have started down that path. But thinking that this is a way to eliminate EDs is ridiculous.

I saw that Atlantic article too and wanted to roll my eyes. I didn't think that cutting out meals was going to lead to an ED. All I knew was I felt better. Telling me the horrors of EDs wouldn't have changed a thing.

Niika said...

I think prevention would have more to do with teaching children how to cope, emotionally and psychologically, with life than anything about body image or food or any of the "surface" eating disorder stuff.

Anonymous said...

Niika summed it up well. Even if biology accounts for 80% of anorexia (which, with the extremely narrow diagnostic criteria, increases the similarity of patient profiles), aren't most eating disorder sufferers EDNOS? And what about the vast number of people with subclinical disordered eating patterns?

hm said...

I hope the new DSM will clarify eds a bit better- right now the criteria is so rigid that as soon as you put on a bit of weight you're suddenly not actually called "anorexic" anymore- you live life in the vagueness of ednos- with fewer treatment options and less available/willing help.

Yvonne Madden said...

Dead right! We don't have a clue how to prevent eating disorders yet.

We can pinpoint many symptoms,causes,treatments etc but we need to understand the causes far more before effective prevention could ever exist.

So far,any attempt at prevention,globally, hasn't worked.It kinda says it all really!

the Weather in Anorectica said...

We need to prevent more restriction triggers so we never know we "have an ED" in the 1st place!

the Weather in Anorectica said...

There are plenty of sufferers who loved and accepted their pre-ED or asymptomatic bodies, and whose self-esteem was no worse than that of someone without an ED. I've known sufferers who could not stand the sight of themselves as their illness progressed, but they just couldn't find a way out of the ED box they were trapped in.

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I'm a science writer, a jewelry design artist, a bookworm, a complete geek, and mom to a wonderful kitty. I am also recovering from a decade-plus battle with anorexia nervosa. I believe that complete recovery is possible, and that the first step along that path is full nutrition.

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