I blogged yesterday about Part One of Linda Hill's talk on The Noisy Brain, and, as I promised, here is Part Two of her talk from the 2010 International Conference on Eating Disorders. In the second half of her talk, Dr. Hill talked about the need for structure in AN recovery, specifically with respect to meal planning.

In the world of eating disorder recovery, Intuitive Eating is pretty much the holy grail of recovery. It's not a bad ideal, but eating when you're hungry and stopping when you're full can really only work effectively if your hunger and fullness cues are fully operational. In people with eating disorders, especially in early recovery, this really isn't true. At my last residential treatment center, we were taught Intuitive Eating (which wasn't a bad thing), but then we were also expected to be able to put this into action even as we were still in the beginning phases of normalizing eating patterns. Some people found this effective; I didn't. I failed at it miserably, and I had always blamed myself. Perhaps I didn't want recovery enough. Or maybe I wasn't good enough at fighting the ED voice.

You can imagine what a relief it was for me to learn that although the concept of Intuitive Eating is very useful, I can't rely totally on hunger and fullness cues to nourish myself. I definitely couldn't early in my recovery, and I still can't quite totally rely on them now. Instead, I need more structure to help me eat properly, and it's not a matter of personal failure but more of a matter of the very issue that made me so vulnerable to anorexia.

Dr. Hill talked about the need for structure in meal planning as it relates to difficulties in decision-making in people with eating disorders. Here's a segment of what she said (I inserted the links to help define some of the more technical terms):

Automatic emotional reactions don't seem to fire well because the insula is blunted. People with anorexia doesn't appear to have a free-flow ability [to move between emotional aspects of decision-making and evaluating long-term consequences]. Their planning ability seems to be firing overly well.

The AN/BN brain is impaired in identifying the emotional significance of stimuli, but it has an increased ability concerned with planning and executing tasks. There is an emotional blindness to decisions. If there is little or no internal regulation to help the person in decision making, it's easier not to decide. I need few to no options to help me in those decisions. [For people in recovery from anorexia], we need to increase structure and limit options for decisions. To compensate for inability to know what to do, the anorexic turns outward to social cues for rules and answers and to experience reward. In EDs, we begin with a meal plan, and then dose food level to match energy level. We take choice out of it.

So instead of saying "What kind of grain do you want with dinner?" it's more useful to ask "Did you want rice or pasta?" The first option is so open-ended and provokes so much anxiety that it's simply easier to skip that carbohydrate. The number of decisions I have to make when figuring out what to eat can be so overwhelming that I have to find ways to make it easier for myself. In my meal planning post, I wrote about how I have managed to work enough variability into my meal plan while simultaneously keeping the number of choices from getting overwhelming. My solution is the mix-n-match method (or what my dietitian jokingly refers to as the Deal-a-Meal) that keeps me from getting in an anorexic rut, fulfills my necessary exchanges, and allows for enough flexibility that I can go to a restaurant.

The balancing act can be rather precarious, and I think the eventual goal is to move off of a formal meal plan and into a more Intuitive Eating pattern. But the idea is that we use meal planning to shore up those areas in which we might have difficulties and let our strengths speak for themselves.

I used to think that eating disorders were an extreme diet (this was a very long time ago). I thought there were people who didn't diet, people who dieted, and people with eating disorders, all arrayed on a nice little continuum, one blending seamlessly into the next. I've since learned that scholars are still considering this question, albeit in a more academic, less hand-waving sort of way.

Eating disorders are currently classified into three major categories: anorexia nervosa, bulimia nervosa, and eating disorder- not otherwise specified. What we don't know is whether these categories are just humanity's attempts to corral people with eating disorders into three categories, or if these are, in fact, three different eating disorders. Nor do we know if eating disorders are dimensional (ie, they exist along a continuum) or they are taxonic (ie, they have their own category, sort of like humans are a separate species from chimps. We don't have a human-chimp continuum, the behavior of several of my relatives notwithstanding). Perhaps a better analogy would be the difference between a light on a dimmer switch (dimensional model) and a light with an on/off switch (taxonic model). The methods for determining the difference between these use a lot of advanced mathematical models and some really fancy words--I'm not especially concerned in understanding precisely how the determination is made. Rather, I intend to look at whether we can make a distinction, and what that distinction is.

Like many new ideas in science, there is evidence in favor of both views. So let's start with a brief review of the evidence.

Eating disorders are dimensional

Thus far, one study has evidence that restricting anorexia exists along a continuum with "normal eating," although this study also found that bulimia and binge eating disorder do not exist along a continuum (Gleaves et al, 2000a). Perhaps one of the reason why restricting anorexia didn't appear quantitatively different from "normal eating" has to do with the prevalence of dieting behavior, which is more common than not in the college students surveyed in the study. In general, dieters have higher scores on the restraint/weight subsection of the EDI-2, but have similar psychopathology scores as non-dieters (Lowe et al, 1996), which really helps muddy the waters.

Interestingly, the Gleaves study found that the binge/purge subtype of anorexia was much closer to bulimia nervosa than the restricting subtype of anorexia, indicating that binge eating and purging is, in fact, taxometric, whereas restrictive behaviors are more dimensional.

When looking at nonbehavioral eating disorder symptoms (such as fear of fatness, obsession with food/calories), researchers failed to find any sort of eating disordered category, which would indicate that yes, indeed, eating disorders exist along a continuum (Tylka and Subich, 2003). A more recent study, building on this one, found that although eating disordered thoughts are common among people without clinical eating disorders, eating disordered behaviors are rather uncommon (Miller, Vaillancourt, and Hanna, 2009), which has implications on what, precisely, is measured on future studies.

Eating disorders are taxometric

The evidence for both binge eating disorder and bulimia nervosa seem to indicate that these disorders exist as their own categories; that is, either you have them or you don't (Lowe et al, 1996, Gleaves et al, 2000a, Gleaves et al, 2000b). Of course, a diagnosis is rarely as simple as one of those notes you likely received in sixth grade that said "Do you like me? Check yes or no."* There are lots of issues still to be worked out, not the least of which is where do we draw the line?

Perhaps one of the most interesting studies found a middle of the road for this discussion: some eating disorder symptoms existed on a continuum, and some, such as binge eating, fear of fatness/compensatory behaviors, and drive for extreme thinness, did not (Williamson et al, 2003).

Conclusion

At this point, the only consensus on the issue of eating disorder taxometry is the need for more research. Preliminary evidence suggests that bulimia and binge eating disorders are discrete symptoms; the evidence is less suggestive for restrictive anorexia. That being said, eating disordered thoughts are quite common, even if the behaviors are not, which could have significant implications on what is measured and studied in the future.

With the upcoming (and much-heralded) publication of the DSM-V in several years, these seemingly esoteric ideas could have a large impact on how we diagnose, treat, and prevent eating disorders.

Coming tomorrow: Classifying eating disorders, part two (What's temperament got to do with it?)

*Full disclosure: I neither sent nor received any of these notes.

Would I love an answer to that question or what. After a decade of anorexia, I can tell you that I really have no clue what "normal eating" is. And the other fact is that, after taking a good, hard, look around me, most other people don't, either.

A World of Psychology blogger asked this very question: What is normal eating? The answer, it seems, depends on who you ask.

I like the definition from Ellyn Satter used in the blog post:

“Normal eating is going to the table hungry and eating until you are satisfied. It is being able to choose food you like and eat it and truly get enough of it—not just stop eating because you think you should. Normal eating is being able to give some thought to your food selection so you get nutritious food, but not being so wary and restrictive that you miss out on enjoyable food. Normal eating is giving yourself permission to eat sometimes because you are happy, sad or bored, or just because it feels good. Normal eating is mostly three meals a day, or four or five, or it can be choosing to munch along the way. It is leaving some cookies on the plate because you know you can have some again tomorrow, or it is eating more now because they taste so wonderful. Normal eating is overeating at times, feeling stuffed and uncomfortable. And it can be undereating at times and wishing you had more. Normal eating is trusting your body to make up for your mistakes in eating. Normal eating takes up some of your time and attention, but keeps its place as only one important area of your life.

In short, normal eating is flexible. It varies in response to your hunger, your schedule, your proximity to food and your feelings.”

Satter may have told me to build a particle smasher for all of the fact that this definition helps me figure out how to eat normally. It's perfect as a goal to work towards and a philosophy to embody. But how do you get there?

I know my history of an eating disorder means full-on intuitive eating is probably not a good idea for me. I get depressed, I lose my appetite. I start losing weight, it spirals out of control. So meals are necessary, whether I feel like eating them or not. I certainly look forward to the day when I'm not thinking of food or weight all the freaking time. I don't know how soon it will come, or how long it will stay, but I really do want to think about something besides food. There aren't that many recipes out there.

Nor do I think there will ever be one definition of normal eating. We each have to define that on our own, from a non-eating disordered perspective. What is normal for me--either the types of food, the amount of food, the times and places in which it is eaten--may not be normal for others. That's okay. I think "normal eating" is mostly about learning to trust yourself and your body to tell you what it needs and when.

How have you started to define normal eating? Is there an aspect you're particularly working towards? An aspect you've come to master?

A short story:

I'm walking down the hall in my office*, and I pass one of my co-workers. A young, female co-worker, to be exact.

She is unwrapping a Snickers bar.

I smile at her as I walk by. She moves her hand to cover the "Snickers" name.

She is ashamed.

How sad. I wish she could enjoy her food without shame. I with we all could.

*Yes! I work in a real office! With real people! Who aren't competing to lose weight! How lovely!

We hear a lot about intuitive eating. The premise is one of those "simple but not easy" things.

Eat what you really want.
Eat when you're hungry.
Stop when you're full.
Move your body for fun.

And I do think it's a wonderful goal for recovery. Your ability to do these things (without guilt) is a fine indicator of recovery. See also the pizza test.

However.

However, those of us with histories of eating disorders have a neurochemical difference that makes true intuitive eating kind of dicey at times. There are times when I might not be hungry, when I don't "feel" like eating. True intuitive eating would say to honor your body's signals. But for those of us who find starvation soothing, this might not be the best option.

Enter responsible eating.

My psychiatrist in my last round of residential treatment used an intuitive eating approach. We all had a required amount of calories to eat each day. Unlike many places, we didn't have exchanges, and we didn't even know the range.* This was to help the transition to intuitive eating.

But she also said something to me during one of our sessions (when I had a cold and was griping about having to eat when I wasn't hungry) that really stuck with me. "You might not have the luxury of practicing true intuitive eating all the time. You need to be responsible."

When I had the flu earlier this year, I flat-out didn't want to eat. And even when I did, I was often to tired and achy and ick to actually prepare something. With a horrific sore throat, I ended up eating a lot of these high calorie ice cream sandwiches sold in the party store down the street (they had a chocolate chip cookie on each end- yum!). I knew I needed to eat, swallowing was a bugger, but I couldn't make something myself. Without this insight, I probably would have gone right back to bed and to hell with eating. Yet because of my history, I knew this was the fast track to relapse.

Responsible eating.

Then there are times when looks a little different. I visited the zoo in Chicago with a good friend of mine, and we had decided to eat lunch there. Which was fine. The place we found had some yummy looking curly fries and that was really what I felt like having. With a late breakfast, I wasn't profoundly hungry and guessed the fries would have been more than enough, especially given the huge portion. But I also knew that I needed protein to hold me over until dinner. I know I could have ordered the fries as a side, but I'm not going to pay $5 for something and throw half of it out. Nuh-uh. So I searched the menu for the protein-containing item that sounded the best.

It's a dance, learning how to eat again. I'm a terrible dancer. My sense of rhythm is minimal at best. And this kind of dance isn't any easier, but I'm learning.

*Unless you're a veteran calorie counter, through which you have a pretty good idea. But it's the thought that counts.

Okay, so I'm apparently the last person in the blogosphere (well, the part that looks at eating and weight issues) to have written about this, but here goes.

Apparently, most American women have a screwed-up relationship with food.

Raise your hands if you're astonished. Anyone? Anyone?

Didn't think so.

What makes this news is several things: 1) the number of women surveyed and 2) exactly how screwed up we all are.

Self magazine, combined with the UNC Chapel Hill Eating Disorders Program, surveyed 4000 women, asking them detailed questions about eating, exercise, height, weight, etc. And the results weren't pretty.

Over 3/4 of woman say weight is a significant part of how they feel about themselves. Less than 1% said they didn't judge themselves based on their weight.

Half of women say that gaining 5 pounds would make them extremely upset.

3/4 of women have spent at least half the time over 18 dieting.

1/3 of women have an unhealthy relationship with exercise (workout when they're sick, or restrict to make up for not exercising)

3/4 of women have counted calories to lose weight

2/3 have eaten the same foods every day.

1/3 have fasted to lose weight.

1/4 have vomited.

1/4 have used laxatives

1/3 used diet pills or diuretics

1/5 binge one or more times per week

1/2 of women think about food more than once per hour

Granted, a group of women who read a magazine with every issue chock-full of diet and exercise tips might not be entirely representative of women as a whole. But then again, it might.

The story was featured on The Today Show, and the text version opened with a vignette that many of us could probably relate to:*

Ms. X seems like the perfect dieter. If you ran into the...marketing specialist checking food labels for calories in the supermarket or powering through one of her seven weekly workouts, you’d envy her ability to control her intake and burn off any excess, too. But Ms. X, who had her first baby nine months ago and is now below her prepregnancy weight (“I’m the tiniest I’ve ever been!” she says), could be the poster girl for an unrecognized epidemic among women: disordered eating.

Most people reading this (myself included, alas) will likely envy Ms. X. But then all of us--every last one of us--must take a step back and ask why. Why do we want this life? Why do we want to be ruled by calories and pounds? Why would we rather focus on food and weight rather than the life we just shoved through our loins? Is our entire society whacked? Why? Can we escape it? How?

Ultimately, the survey found that two out of three women have some form of disordered eating. While these aren't full-blown eating disorders, things like chronic dieting, compulsive exercise, and eating in secret can all take a toll on a person's health and well-being. But this survey also found that an additional ten percent of women had full-blown eating disorders. This means that only one in four women has a healthy relationship with food.

There's a book called "The Rules of 'Normal' Eating." I know the author meant normal eating as eating when you're hungry, stopping when you're full. But this isn't normal. It's abnormal. Perhaps we need a different rule book, because our society doesn't have rules I think I want to play by.

*I took identifying information, as well as height and weight out because the exact numbers really don't matter.

**I bet some of you are pissed, though, that I didn't include it. Am I right?

I'm in a day program at my local hospital, both for anorexia and depression. I do a twice-weekly therapeutic meal with one of the staff dieticians. The usual one is very knowledgeable and perky almost to a fault. She eats people food.

I ate with one of the contingent dieticians today since the usual one took the day off. It was painfully obvious that this woman had never worked with eating disorders before. I sat down with my burgers, fries, and ice cream while the dietician sat down with vegetables on a tortilla and a Dannon Light 'N Fit yogurt.

Say what? This woman is supposed to be teaching ME how to eat???! I could have fed her tray to a freaking rabbit! My cat eats more than that!

Well screw you very much.

I ate the burger and fries. So there.

I'm supposed to be learning a concept called "nomal eating." Who the hell eats "normal"? My coworkers compete in a fun event officially known as Weight Watchers at Work. The competition is basically who can cheese me off the fastest discussing which food has the least points. I have yet to point out that they can save lots of money on WW by just picking my brain, but I figure why ruin their fun. So if a dietician eats like a rabbit, what am I to do?

I don't think the diet industry causes eating disorders. It's far more complicated than that. But it makes it much harder to justify and substantiate recovery when everyone is telling us that calories are evil beings.

Burgers, fries, drama. Lovely.