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About the Food

“It’s not about the food.”

This phrase, used widely in eating disorder recovery, is misleading and potentially harmful.

Here’s the truth – anorexia nervosa (AN) is not “about” anything other than being born with a certain neurobiological predisposition to this particular brain disorder, which lays dormant until activated by insufficient nutrition. Given that food restriction has a calming and mood-elevating effect in people with this type of brain chemistry, anorexics may restrict their food intake (either consciously or unconsciously) as a way of coping with uncomfortable feelings or stressful events.

So it isn’t JUST about the food; it’s about feelings and circumstances as well. People with AN must learn healthy ways to regulate their emotions. Most of them will require psychotherapy to help them tackle anxiety and perfectionism, build healthy relationships, challenge their distorted thoughts and beliefs, or treat coexisting conditions such as depression or OCD. But it is the disturbance in eating behavior and weight, rather than feelings or events per se, which cause immense physical and psychological damage.

An initial period of low nutrition sets the disorder in motion. Continued low nutrition and low body weight perpetuate the symptoms. Sustained full nutrition and weight restoration are essential for mental and physical recovery. Continued good nutrition and maintenance of a healthy body weight for life protect patients against relapse. At every step of the process, nutrition (or lack thereof) plays a functional role.

The relationship between food and AN is analogous to the relationship between alcohol and alcoholism. To state that AN “isn’t about the food” is like stating that alcoholism “isn’t about drinking.” A person may be born with a predisposition to developing alcoholism due to her genetic makeup and her particular brain chemistry. However, if that person never takes a sip of alcohol, the disease will never be activated in the first place. Similarly, a person predisposed to AN will not develop the disorder in the absence of a nutritional deficit.

I like to think about the development of eating disorders in terms of the “four P’s:”

Predisposing factors
Recent research indicates that 50-80% of the risk of developing AN is genetic. Individuals with AN have a certain genetically-transmitted neurobiological predisposition. Personality traits which make an individual more susceptible to developing AN include anxiety, perfectionism, obsessiveness, behavioral inhibition, and cognitive rigidity. Most patients with AN have exhibited one or more of these traits since early childhood, long before the development of an eating disorder. These traits tend to be exacerbated during bouts of malnutrition and persist long after recovery, albeit to a lesser degree.

Precipitating factors
Anorexia nervosa is always precipitated by a period of low nutrition. The precursor to the low nutrition will vary from person to person. In modern American culture, where most girls and young women experience a drive for thinness, dieting is the most common pathway to AN.

Not every episode of AN is triggered by dieting, however. A simple desire to “eat healthy,” participation in sports without appropriate caloric compensation, a bout with the stomach flu, or simply loss of appetite during a period of stress – any one of these unintentional, seemingly benign periods of low nutrition can trigger AN in a vulnerable child.

Weight and shape concerns are culturally mediated phenomenon and are not necessarily part of the symptom picture for all anorexics. In medieval times, fasting for religious purposes triggered what we now call anorexia nervosa. AN is seen in cultures as diverse as China, where sufferers report loss of appetite or physical complaints, and Ghana, where sufferers view their self-starvation in terms of religion and self-control.

Puberty, which involves dramatic hormonal, neurological, and physical changes coupled with new social and academic demands, is often a precipitating factor for AN. Neurobiological researchers have hypothesized that puberty-related hormonal changes may exacerbate serotonin dysregulation, explaining why AN usually begins in adolescence.

Perpetuating factors
Continued malnutrition is largely responsible for the self-perpetuating cycle of eating disorder symptoms. A starved brain is a sick brain, and people who are undernourished for any reason display many of the symptoms commonly associated with AN: preoccupation with food, unusual food rituals, social withdrawal, irritability, and depression.

In addition to these symptoms of starvation, body dysmorphia, drive for thinness, and fear of weight gain serve as perpetuating factors. Individuals with AN are unable to recognize how thin they are and may perceive themselves as normal or fat, despite emaciation. They are terrified of eating and morbidly afraid of gaining weight. They cope with these fears by continuing to restrict their diet and remaining underweight, which of course perpetuates the symptoms of starvation. It is a vicious cycle.

Psychological problems such as depression, anxiety, post-traumatic stress, ADHD, and bipolar disorder may also serve as perpetuating factors. Food restriction and compulsive exercise act as a “drug” for certain individuals, providing them with temporary relief from anxiety and negative moods. An anorexic who is suffering from other psychological problems may use her eating disorder symptoms in attempt to alleviate her intolerable emotions. This makes re-feeding and recovery excruciatingly difficult, as the anorexic is required to face extremely painful thoughts and feelings as she endures the two things she fears most: eating more and gaining weight.

Prognostic factors
Research indicates that full nutrition and prompt weight restoration as soon as possible after AN diagnosis is a predictor of good outcome. Likewise, prolonged periods of time spent at a sub-optimal weight are associated with a protracted course of illness and increased risk of irreparable damage such as infertility, osteoporosis, and suicide.

A recent study of inpatients with AN found that the best predictors of weight maintenance during the first year post-discharge were the level of weight restoration at the conclusion of acute treatment and the avoidance of weight loss immediately following intensive treatment. Another study found that nutrient density and variety (eating a wide range of foods, including those that are high-calorie and high-fat) were significant predictors of positive long-term outcome in weight-restored anorexics.

All of the available data suggest that eating a complete, well-balanced diet and maintaining ideal body weight are of utmost importance in recovery from AN and in preventing relapse. Full nutrition and weight restoration alone will not cure AN, but full recovery cannot occur without these essential components.

In sum, nutrition plays a functional role in all stages of AN, from the initial onset and maintenance of symptoms to physical and mental recovery to relapse prevention.

Maybe it is about the food after all.

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A Dangerous Precedent

Earlier this week, a federal judge ordered the Pittsburgh Public Schools to pay $55,000 to settle a lawsuit filed by a mother, who claimed her adolescent daughter was bullied into anorexia.

According to the lawsuit, the plaintiff’s daughter, now 15, was bullied relentlessly at school in 6th and 7th grades. A group of boys taunted her and made degrading remarks of a sexual nature, insinuating that she was fat and ugly. The girl stopped eating lunch at school in attempt to avoid being teased by these boys, who ridiculed her for eating and being fat. Although the girl’s teacher, principal, and guidance counselor were aware of the bullying, they did nothing to intervene. The girl began losing weight, and by the middle of her 7th grade year, her weight was dangerously low and she was diagnosed with anorexia nervosa, for which she was treated at an inpatient psychiatric clinic. The plaintiff, whose daughter now attends private school, sued the school district, her daughter’s middle school, and her principal, claiming that her daughter developed anorexia as a result of their inaction.

I disagree with this ruling, and I think it sets a dangerous precedent.

Before I state my points of contention, I will make several points very clear:
• Bullying has the potential to cause extreme distress. It is cruel, harmful, and absolutely inexcusable.
• All schools should have clear, written policies about bullying and sexual harassment. All students, parents, and faculty must be aware of these policies. School faculty and administrators must enforce these policies to the best of their abilities.
• School faculty and administrators have a responsibility to provide a safe learning environment for all students, and have a duty to intervene at the first sign of bullying.
• Students who engage in bullying behavior should be punished appropriately. If the bullying continues, they should be expelled.

In this particular case, the bullies did some terrible things; they must be held responsible for their actions and punished appropriately. The school faculty and administration were certainly negligent; they must be held accountable for their inaction and punished appropriately. The school district was remiss not to have a bullying policy, and they should be compelled to create one. The victim suffered horribly as a result, and she deserves to heal from this trauma and to attend school in a safe environment. And the buck stops here. I do not believe that the bullies or the negligent school personnel are responsible for this child’s mental illness.

To create a legal precedent in which school officials are held legally or financially liable for a child’s mental illness is dangerous on several levels:
• It implies that the actions of children can cause another child to develop a mental illness.
• It implies that the actions or inactions of adults can cause a child to develop a mental illness.
• It implies that anorexia nervosa is (or can be) the result of teasing or bullying.
• It reinforces the popular but antiquated and unsupported notion that anorexia nervosa is the result of some deep-seated trauma.
• It implies that this child would not have developed anorexia nervosa if she had not been bullied.
• It neglects the horrific experiences of tens of thousands of other children who have been bullied and have suffered silently, but have not developed anorexia nervosa.
• It invalidates the experiences of the tens of thousands of children and adults who have never been bullied or traumatized in any way, but nonetheless have developed anorexia nervosa.

Imagine being a prepubescent boy and being held responsible for causing a classmate’s severe mental illness. Don’t get me wrong – I am in no way defending the behavior of these bullies. They did cruel things and they must be punished. But they did not make this girl develop a life-threatening brain disorder. They couldn’t have, even if they wanted to! Similarly, the school faculty and administrators were obviously negligent and made some terrible mistakes, but they did not cause this child to develop a mental illness.

The most recent scientific evidence strongly suggests that anorexia nervosa is a biologically-based, genetically transmitted brain disorder which is triggered by malnutrition and then becomes self-perpetuating. Children with anorexia come from all walks of life. Some are popular, confident, social, happy, and well-adjusted before their illness begins. Others are depressed, anxious, introverted, teased, or unstable before they develop anorexia. Some children develop anorexia after a stressful event, which could be as benign as a starting middle school or as serious as rape. For many children, the onset of anorexia nervosa does not coincide with a major stressor, but rather spirals out of control during an attempt to “eat healthy,” get in shape for sports, or lose a few pounds for prom.

My point is that some children are simply “wired” for anorexia nervosa, which can be triggered by relatively minor stressors or relatively benign bouts of under-nutrition. It doesn’t make sense to “sue the trigger” when it is just that – a trigger. If we can sue a school district – and win tens of thousands of dollars – for allowing a child to be bullied into anorexia, where does it end? If a child develops an eating disorder after reading a book on nutrition, do we sue the publisher? If an 18-year-old becomes anorexic while struggling to adapt to the social and academic challenges of college life, do we sue the university?

If a teenager develops and eating disorder after being raped, the rapist should be tried and convicted and incarcerated. But the eating disorder, in my opinion, is irrelevant to the outcome of the trial. The rapist should be incarcerated for the same length of time (for life, in my opinion) regardless of whether the victim develops any mental illness afterwards, because he committed a violent crime. The crime is no more or less heinous based upon the particular pre-existing neurological makeup of his victim.

It is well-known amongst mental health professionals that a psychotic break can be triggered by “high expressed emotion,” such as bullying or family conflict, in a person who has the underlying neurobiological predisposition. Do we then sue the school for allowing a child to be “bullied into schizophrenia?” Do we sue the parents for arguing too much and thus causing their son’s psychosis?

I have the deepest sympathy for this plaintiff, and especially for her daughter. No doubt, they have both suffered horribly. This mother is only doing what she believes is best for her dear child, and I’m sure she believes she is helping other children in the process. The judge who approved of this settlement is, likewise, only trying to ensure that justice is served. He or she probably has no intimate knowledge of the etiology of anorexia nervosa, and probably has no idea what some of the negative ramifications of his ruling could be.

If the lawsuit had been simply about protecting children from bullying, I would have supported it 100%. I cannot, however, support a lawsuit which enshrines bullying as a legally valid cause of anorexia.