Last week, the American Medical Association released a policy statement about Photoshopping models and eating disorder prevention.

The statement:

Advertisers commonly alter photographs to enhance the appearance of models' bodies, and such alterations can contribute to unrealistic expectations of appropriate body image – especially among impressionable children and adolescents. A large body of literature links exposure to media-propagated images of unrealistic body image to eating disorders and other child and adolescent health problems.


The AMA adopted new policy to encourage advertising associations to work with public and private sector organizations concerned with child and adolescent health to develop guidelines for advertisements, especially those appearing in teen-oriented publications, that would discourage the altering of photographs in a manner that could promote unrealistic expectations of appropriate body image.


"The appearance of advertisements with extremely altered models can create unrealistic expectations of appropriate body image. In one image, a model's waist was slimmed so severely, her head appeared to be wider than her waist," said Dr. McAneny. "We must stop exposing impressionable children and teenagers to advertisements portraying models with body types only attainable with the help of photo editing software."

And if the AMA had left out the mention of "eating disorders" at the end of the first paragraph, I wouldn't have had anything to say except to nod my head in agreement.  Because the alteration of images is appalling and imappropriate and, indeed, harmful.  The problem is the link to eating disorders.  The AMA said there was a "large body of research" linking media exposure to eating disorders.

So I went looking to see if I could find this large body of research.  I went to PubMed and searched for "eating disorders media" and indeed, I pulled up 264 studies on the subject.  But if you read the studies more closely, you'll see that there's lots of links between "disordered eating" and "eating pathology" and "body image dissatisfaction" and media exposure, but there's very little mention of linkage to outright, diagnosable eating disorders as spelled out by the DSM-IV.  One study did actually say that "media contributes to the development of eating disorders," but when I looked at the studies cited, all I saw were examples that linked media exposure to disordered eating.

A lot of the media coverage of the story has said that Photoshopped images "promote anorexia."  I'm not entirely sure I understand what that means.  I think I know what they're getting at--that looking at these images make you more likely to develop anorexia--but there's no actual evidence that this is true (at least, none that I could find).  We don't think ads for disinfectant somehow promote OCD.  We also don't think that those Bluetooth headsets promote schizophrenia because it looks like you're talking to yourself.

I think the big difference is that people don't think they know what it's like to have schizophrenia because they've been paranoid at one time or another, or that they've had a rather animated conversation with themselves.  But people do think they know what it's like to have an eating disorder because they've dieted and asked their husbands if these jeans make their butts look big. 

It's a common mistake, confusing disordered eating and eating disorders.  Many men and women are unhappy with their bodies and are on a diet.  People with eating disorders also often express extreme body dysmorphia and restrict their food intake.  They do look alike on the outside, but the internal experience is very different.  Dr. Sarah Ravin summarizes the difference between disordered eating and eating disorders as follows:

Disordered eating is very widespread in our country, especially among women. I define disordered eating as a persistent pattern of unhealthy or overly rigid eating behavior – chronic dieting, yo-yo dieting, binge-restrict cycles, eliminating essential nutrients such as fat or carbohydrates, obsession with organic or “healthy” eating – coupled with a preoccupation with food, weight, or body shape.


By this definition, I think well over half of the women in America (and many men as well) are disordered eaters.


The way I see it, disordered eating “comes from the outside” whereas eating disorders “come from the inside.” What I mean is this: environment plays a huge role in the onset of disordered eating, such that the majority of people who live in our disordered culture (where thinness is overvalued, dieting is the norm, portion sizes are huge, etc) will develop some degree of disordered eating, regardless of their underlying biology or psychopathology.


In contrast, the development of an eating disorder is influenced very heavily by genetics, neurobiology, individual personality traits, and co-morbid disorders. Environment clearly plays a role in the development of eating disorders, but environment alone is not sufficient to cause them. The majority of American women will develop disordered eating at some point, but less than 1% will fall into anorexia nervosa and 3% into bulimia nervosa.

I think it's great that the AMA is trying to protect children and adolescents from companies that would turn actual women into bobblehead models (the woman in the Ralph Lauren ad looks a bit like a bobblehead since her head is so disproportionately large compared to her body).  Our ideas of what "normal" and "healthy" look like are disorted and it is harmful.  On that subject, the research is clear.

I love the blog F*ck Feelings. It always provides a great perspective and very useful advice for dealing with what the authors call "the shit sandwiches of life" (their advice: ask for ketchup). They've never really addressed eating disorders, and I was always curious to see how they handled the subject. One of the most recent blog posts gave me my answer.

A woman had written in about being very dissatisfied with her weight, and asking why she was having these problems if she was already on the thin side.

Dr. Lastname ("because doctors always go by their last names") had this to say:

Most people aren’t happy with the way they look or how much they weigh, and all people spend at least a little time each day being unhappy, but many still manage to live normal, albeit slight chubby/grumpy lives.

As to the source of your insecurities, your guess is as good as mine and the many other scientists, clinicians, and desperate-for-a-topic writers who explain this phenomenon. It could be your ex, or it could reading too much Cosmo.

These experts assume, for the most part, that you wouldn’t be so self-critical if you didn’t listen to magazines, celebrities, or your critical-yet-well-meaning grandmother, and just believed in your self. They tell you that self-esteem will conquer all. Of course, they’re wrong.
There’s lots of evidence that self-hating body thoughts can happen to people with perfectly good self-esteem, nice families, and normal bodies. Instead of obsessing about why you feel this way the same way you obsess over calorie counts, stop and ask yourself, first, whether these thoughts are doing you much harm.

I know they’re causing you pain, but ask yourself whether they’re affecting your health or relationships. Right or wrong, you can think you need to lose a few without hiding major parts of your personalities and or being a bad friend or parent.

If you think your body-hate isn’t doing too much harm, try ignoring it. Certain kinds of psychotherapy may help, but watch out if you find yourself becoming more self-obsessed and blaming yourself for not getting better. The mark of good psychotherapy, like good coaching, is that it gives you ideas and motivation for managing a problem without increasing your expectations of control.

If body-hate is hurting your health or relationships—if you purge, have become anemic, or acquired any number of the dire symptoms that come with an eating disorder—assemble a treatment team, including a primary care physician, a psychiatrist and dietitian, and don’t hesitate to put yourself into an around-the-clock “eat-your-food” camp if it’s necessary. It can save your life.

In any case, don’t pin your hopes and self-esteem on self-control, or self-hating thoughts will just get worse. If you make it your job to keep trying and regard the illness as you would the weather, it can’t touch your sense of who you are.

You need never see yourself as a food nut or anorectic; you’re simply a person with eating issues, which puts you in the same camp as 90% of the population. You might feel like shit, but you are truly not alone.

Aside from their perspective on intensive treatment (an around-the-clock "eat your food camp" is an apropos enough descriptor), their benchmarks for determining the difference between disordered eating and eating disorder is pretty darn accurate. Because so many people are obsessed with food and weight, it's often hard to determine where this cultural obsession leaves off and where an eating disorder begins. If your obsessing about food, weight, exercise, etc, are causing any health problems (purging, anemia, marked/unhealthy weight loss) OR if these obsessions are hindering other areas of your life, then you've got a serious psychological problem. Not that you can't or shouldn't address disordered eating, but feeling like crap after reading Cosmo is not, in and of itself, an eating disorder.

It should, however, be a really big sign to stop reading magazines that make you feel like crap.

What do you think of "Dr. Lastname's" assessment of eating disorders in general and this woman in particular? Share away in the comments!

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.

I got invited to join a Facebook group of this name late last night, and I spent part of the day contemplating my response. I hesitated in writing for several reasons, not the least of which were that I don't have time right now to be responding to a lot of potentially irritated people, and also because I wanted to frame my thoughts properly. After a while, I figured what the hell- I'll bite. I decided to blog my thoughts here and post a link to the group so I didn't have to check two places for comments.

I searched through my blog archives and was astonished to discover that I had never answered this question head-on, in its own post. So, here it is.

To me, the question of "Does media play a role in eating disorders?" is usually asked in a sense of "Does media play a role in causing eating disorders?" And that answer, I would have to say, is pretty minimal. Media provides lots of context, and more than enough triggers, but to say that people with eating disorders are "dying to be thin" minimizes the seriousness of the illness and does everyone a disservice.

I was flipping through a copy of The Handbook of Treatment for Eating Disorders and I stumbled across an article that looked at the Three Ps of eating disorder onset: Predisposing factors (ie, genetics and other neurobiological factors), Precipitating factors (ie, culture, dieting, "healthy eating," etc), and Perpetuating factors (ie, what keeps the illness going). The role of the media certainly fits in the category of "precipitating factors," but although these factors are important, they seem more incidental than causative. Predisposing factors are largely homogeneous; precipitating factors can vary widely.

Finding yourself afraid to eat is a rather bizarre phenomenon. Our brains need to explain it somehow--so we turn to the vocabulary we know. I did blog about this almost two years ago now, rather briefly, and I think I shall plagiarize myself a bit:

Could eating disorders be women and men trying to be perfect? To live up to society's expectations? To look like models? I doubt it. That's part of it. It's the cultural context of the illness. In the Middle Ages, women (most of the recorded cases were in females) who starved themselves were considered saints. They fasted to get closer to God. Some, like Catherine of Siena, got hooked. It felt good. Her explanation was of faith. Ask a sufferer today, and a lot of it seems to be 'healthy eating' and images of supermodels and the idea that you can Have It All. It's no more a reason than faith. But it is a context. It does explain the triggers, the psychological environment from which an eating disorder develops.

One of my OCD fears was that I was going to catch AIDS from someone, or that I already had AIDS and was going to give it to someone else. Regardless, it was OCD. But if I was about 15 years older (the OCD AIDS stuff started in about 1993-1994, when I was 13-14), AIDS wouldn't have been on the radar. It might have been another disease. It might have been something else entirely. A person with schizophrenia would not have feared the CIA listening in on phone calls 100 years ago. First off, they probably wouldn't have had a phone, nor would there have been wire taps, and lastly- there was no CIA. Diseases have a context. But that doesn't mean that AIDS fear mongering caused my OCD, nor that the CIA causes schizophrenia.

Or, for that matter, that the media caused my eating disorder.

Much of the debate about media and eating disorders boils down to this: do eating disorders exist along a continuum with more normalized eating (that is, are eating disorders an extreme version of a diet and common body image issues?), or are eating disorders a separate entity. The answers aren't all in, and I won't pretend to understand all the answers that we do have (but I'll pretend enough to do a more in-depth blog tomorrow- stay tuned!), but I believe that eating disorders are a distinct entity separate but similar to our obsession with dieting and thinness.

Let's compare eating disorders to depression. Saying eating disorders are just a really whacked out diet is like saying depression is just a really bad mood. Most people with depression are in a really bad mood--that's kind of the definition of depression, really. And many people with eating disorders appear to be dieting and have body image distortion. But depression isn't a really bad mood that won't go away. When the weather sucks or the store is out of eggs or the car won't start, people will often say, "Ugh- I'm so depressed!" Not really. You're pissed off, sad, annoyed, whatever, but that's not depression. Both eating disorders and depression frequently pass through stages of seeming like just another diet or a really bad mood that lasts for-freaking-ever, but they then take on a life of their own. They stop becoming a choice and become an illness.

I thought for a long time that the thinness ideal had a lot to do with eating disorders, and I've since changed my mind, especially in light of the emerging research that suggests that up to 82% of eating disorder risk is genetic.* Eating disorders existed long before supermodels and they'll probably exist long after. And I think we are missing so many opportunities for prevention and education by focusing on the media aspect and leaving so many other areas out in the cold.

*A, this wasn't the study that I was referring to in a previous post (the study is too new), but it does confirm the numbers in the talk that I scribbled down.

I think I've blogged on this before, but the recent uptick in "-orexia" terms in the news have me more than a little annoyed.

"Brideorexia" is defined by the Urban Dictionary as "When a bride goes overboard trying to get skinny for her wedding day." The dictionary uses the term in a sentence as: Damn, How did she get so f*cking skinny?!?! She came down with a case of brideorexia!

I get that the Urban Dictionary isn't the Oxford English Dictionary, but would it be too much to ask for a hint of accuracy and classiness? A woman isn't absolved of an eating disorder when a ring is slipped on her finger and she does shopping for the Pretty White Dress. Nor does the Pretty White Dress provide immunity from developing an eating disorder. It might be more expensive than almost any item of clothing she has bought before, but it's still just a dress.

"Drunkorexia" means that a person restricts their food all day to "save up" for the calories consumed during a night of alcohol consumption. Now, the comorbidity of eating disorders and alcoholism is well known and sadly rather common. But drunkorexia isn't the lone purview of sorority girls and frat boys at a kegger. Alcoholism and eating disorders can and do exist side by side. But this isn't particularly novel, and certainly not a "new" disorder. The struggle of those who deal with both EDs and substance abuse shouldn't be minimized by some cutsey name.

"Stressorexia" typically occurs when working moms get too stressed or busy to eat, and begin the cycle of weight loss and disordered eating. Stress is a big trigger for eating disorders, and I certainly see how stress and loss of appetite can lead to the beginnings of an eating disorder. But unlike several publications have observed, stressorexia isn't a "new" eating disorder. It might be a new cadre of excuses why you can't eat or don't have time to eat or why you've lost weight. It might be a new background against which eating disorders are expressed. But seriously? The stress/eating disorders link is hardly a new disorder, nor is it separate from any other eating disorder.

I'm not against publicizing a surge in eating disorders amongst working mothers, and certainly those women who will strive the hardest to be the "perfect" mom and employee will be the most likely to fall victim to an eating disorder. And there's a big difference between using stress as a reason to skip lunch and lose a few, and an eating disorder that may result.

We also have pregorexia, where a pregnant woman is afraid to gain the necessary weight for her and her unborn baby. It's described as "the pregnant woman's eating disorder," as if it's something to covet. A pregnant woman with an eating disorder is precisely that: a pregnant woman with an eating disorder. And women with eating disorders are not refusing to gain pregnancy weight out of desire to be like some thin celebrity; they're afraid to gain weight because of a life-threatening eating disorder. Someone who wants to stay thin during pregnancy might have issues, but it's different than an eating disorder.

There's manorexia, which is a man who is anorexic. Other than the presence of a Y chromosome, it's still anorexia. A male's experience of an eating disorder would be different than a female's, but that doesn't mean it's a different disorder. A 12-year-old girl's experience of anorexia is different than mine, someone who is nearly 30, but no one would diagnose her with "girlorexia."

Would they?

The Twitter-sphere has been discussing the difference between disordered eating and eating disorders (specifically EDNOS) today. I haven't responded, in part because I like to formulate a complete answer than spewing something half-baked, and also because I can't explain myself in 140 characters or less! But the more I think about it, the more I realize that I don't necessarily have all the answers, but that these are answers that are worth having.

To start forming these answers, we first need to define "disordered eating" and EDNOS. A Newsweek article on EDNOS, which prompted this discussion in the first place, had this quote from Susan Ice*, Medical Director at the Renfrew Center, about EDNOS:

"EDNOS is a hodgepodge of things that don’t necessarily belong together, except that they don’t belong anywhere else."

The Newsweek article pointed out that there are plenty of insurance issues regarding EDNOS; whereas insurance companies may grudgingly cover anorexia and bulimia treatment (if you're lucky), they frequently will not cover treatment for EDNOS. I don't necessarily know their logic--nor even if they have any--but this strikes me as more of an insurance issue than an EDNOS issue.

Problems with EDNOS remain, however. It's the most common ED diagnosis, yet differentiating EDNOS from full-syndrome anorexia, bulimia, and binge eating disorder doesn't always yield significant results. People with EDNOS are typically just as ill and just as impaired as those with other eating disorders. That so many people are diagnosed with something titled "not otherwise specified" is troubling, and indicates that we really don't know a whole lot about eating disorders. Leading ED researchers have noted that the DSM criteria for eating disorders are in much need of revision. I don't advocate getting rid of the category entirely, because it is a way to account for the continuing evolution of both eating disorders and our understanding of them. That being said, we need to get a heck of a lot more clear on what's going on with eating disorders.

Then we have the issue of disordered eating. I was surprised at how difficult it was to actually find a definition of disordered eating. The most amusing was "eating that is irregular or disordered." Just file under "circular reasoning" and then hit me with the Duh Truck, why don't you. Wikipedia equated "disordered eating" with EDNOS, though I wouldn't call the two issues the same. The best definition I found, and one which involves way too much hand waving for my nit-picky scientific mind, was from Eating Disorder Expert:

"“Disordered eating” is a term used to describe eating habits or patterns that are irregular. Many different types of disordered eating habits exist, but for the most part these habits do not add up to a diagnosis of an eating disorder...Excluding whole food groups (for example, all fats or all carbohydrates), eating only at particular times of the day, eating only specific foods, eating only foods of a specific colour, eating only foods of a specific texture, not eating certain foods together in a sitting and not eating specific foods from the same plate can all be types of disordered eating."

I would also place dieting and body image obsession into this category, which basically includes 95% of the American public. Research from UNC-Chapel Hill found that three out of four women in the US have disordered eating attitudes. It's significant. It's severe. It sucks.

It's not an eating disorder.

Disordered eating can look like an eating disorder, especially when the eating disorder is just forming. Similarly, a full-blown alcoholic may start as a binge drinker at parties on the weekend. Neither disordered eating or binge drinking is healthy or something I would advocate. But most of those with disordered eating or binge drinking do not go on to develop eating disorders or alcoholism. This isn't to say that they aren't deserving of help and wouldn't benefit from therapy or taking a long, hard look at their behaviors. Far from it. But I have many behaviors that could stand improvement that are still far from pathological.

Right now, we don't have the diagnostic accuracy to be able to separate people into two groups: those with eating disorders and those with disordered eating. Nor do we know how to separate those with disordered eating and those without any eating issues. Disordered eating hasn't been clinically defined; for that matter, neither really has EDNOS. As much as I hate the "less than 85% ideal body weight" and bingeing and purging twice a week for three months criteria of the DSM and think they're crap, it's a start. Although I can personally define disordered eating as well as Justice Homer Stewart can define obscenity (i.e., "I'll know it when I see it."), this isn't very useful to anyone but, you know, me.

I can't get more specific than this; we don't have the definitions or the research. What I can say is this:

I see eating disorders as primarily biological issues. I see disordered eating as primarily a cultural issue.

"But Carrie," you say, "what about Anne Becker's research on the island of Fiji?" Becker, an anthropologist, found that the arrival of American TV on Fiji in the mid-90s resulted in an increase in disordered eating attitudes, dieting and self-induced vomiting. After three years of TV viewing, approximately 12% of Fijian adolescent girls admitted to self-induced vomiting, compared to 0% before the arrival of American TV. This is clearly problematic, and I regret the introduction of TV and the loss of innocence on Fiji.

Yet the study did not indicate the frequency of self-induced vomiting (not that any is good, but again, I think of the relationship between binge drinking and alcoholism. It can look the same, but it's not), nor do people comment on the rate of disordered eating attitudes before the arrival of American TV. Just over 12% of Fijian girls had a high score on the Eating Attitudes Test before TV came to the island; after three years, that number was 30%- a significant increase. The number of girls with high levels of disordered eating more than doubled in three years- it's sad and it's serious and it's a big, big problem. But that means that even without American TV and models and ads, about one in eight Fijian adolescent girls had high levels of disordered eating. Could these be the beginnings of eating disorders? Perhaps. The test doesn't distinguish between disordered eating and eating disorder. But neither were any full-syndrome eating disorders diagnosed in the first three years following the arrival of American TV.

Of course, I would never claim that anyone could split nature and nurture. Both are important. But I see dieting as a cultural phenomenon, one that is rapidly sweeping around the world. Eating disorders exist in all cultures, races, genders, socioeconomic classes, and time periods. Certainly many eating disorders start as disordered eating, but then they progress into something much more sinister and something the sufferer has much less choice over.

Both issues are important, but they are rather different. Promoting better body image and self-esteem will hopefully decrease the amount of disordered eating, and maybe result in fewer eating disorders being triggered by malnutrition in the form of dieting or "healthy eating." I'm not sure it will have much effect on eating disorders. I wasn't thinking about supermodels when I first thought about eating "better" and exercising more. I didn't obsess about freakishly skinny women until after I had started losing weight.

There is a fundamental difference between disordered eating and an eating disorder. I might not always be able to tell you exactly what it is, but I'll know it when I see it.

*Full disclosure: she was my MD when I was at Renfrew in 2001, and her last name kind of fits her. She was quite competent, but she also terrified me. Then again, she was also the one increasing my meal plan practically twice daily.