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.

15 Replies to “About the Food”

  1. That was very interesting to read. I did not like to read about the need for “high calorie/fat” foods though. I made a face to that one, but that’s probably pretty predictable.

  2. Sadly though, these prognostic factors still don’t seem to be 100% protective against relapse. I know girls who I met THREE YEARS AGO in intensive day treatment and they did well — completely compliant with the program, 1 year intensive follow-up, stable for a year after and just now are beginning to relapse again.

    What explains these relapses AFTER the hallowed “1 year” mark? Especially after such a long period of stability (above target weight, healthy behaviours, etc.)

    I don’t know if recovery is ever possible. Perhaps one can just hope for a remission that lasts as long as possible.


  3. I hear ya, A. I don’t feel like I’ll ever be able to eat like a normal person. I can’t even fathom being able to. I don’t even know what eating normally is anymore.

  4. A:),

    You’re right, these factors aren’t 100% protective against relapse. In fact, nothing is 100% protective against relapse. There is some debate within the field about whether anorexia nervosa is a chronic illness with periods of remission and exacerbation.

    Many people do relapse – that fact is undeniable. In fact, relapse seems to be the rule rather than the exception. Sometimes we can identify the reasons for the relapse, and other times it is a mystery. I do know for a fact that it is possible to recover and stay recovered forever. I believe that full recovery is possible, but the underlying predisposition will always be there.

    I do know that early intervention (before age 18, within 3 years after the illness begins) and achieving full weight restoration (not just some arbitrary minimum weight) are the best predictors of full recovery. Adults have a much harder time recovering, although it is certainly possible for adults to recover as well.

    Sadly, there is still so much we don’t know about this illness.

  5. I know I’ve said this before, but the “Adults have a much harder time recovering” comment is not too promising…especially when you’re an adult who’s had an ED (though not a bad one) for 18 years.

  6. There’s a ton of mind-body research that I know nothing about that I find completely intriguing. The physiological basis to “healthy living” in mind, body, and spirit.

    The human body is amazing in all its parts and systems. Amazing!

  7. How long have we all been debating this, A:) and PTC?

    You can recover. You need the right help, and you deserve the right help. I’ll set you a challenge: get yourself into care that brings your eating back to normal and you attain your healthy brain state and then see how you feel about all these issues. I really think one’s logic and thinking on these issues depends on whether you are fully well or not.

  8. I have to say to Laura, if A is the A I think she is, she IS in treatment and is virtually weight restored, so the challenge is unnecessary. I do agree that thoughts on recovery change depending on how well one is, and I would add that this doesn’t end at weight restoration. When I first got to a healthy weight after 12/13 years of eating disorder (so it IS possible to recover after being ill for a very long time!) I was a complete wreck emotionally – my mood was all over the place and I was still very anxious and obsessive. I’ve been weight restored for a little over a year now and my mood has calmed down, my anxiety is far more manageable, and my eating disordered thoughts are virtually non-existent. I would add to Dr Ravin’s thoughts that people in recovery who relapse may do so due to the same precipitating factors which trigger the illness in the first place. A period of stress, illness or deliberate restriction for some reason causes the same biological/neurochemical changes which leads to relapse. So I would totally agree that recovery is possible, but the predisposition will always be there. I think I will have to be vigilant against biological triggers like getting stomach viruses for the rest of my life, but that doesn’t mean that the eating disorder is part of my life on a daily basis. If that makes sense!

  9. Timeless info. I can’t tell you how often we discuss topics like this in group. If drunks are seekers why are they so lost. And if they are just hiding, why do they always get found.

  10. We just discussed this last night in group. Everytime someone relapses, which is all to frequently, we have to go over what happened and devise tactics to defeat it next time. Sometimes that means re-visiting the basics and sometimes it gets a lot more complicated. Anyway, thanks for sharing.

  11. I just found your blog in August. My daughter is anorexic. How I wish we were closer to you! It is near impossible to find effective treatment where we live in rural Michigan. We have had our share of therapists who actually did far, far more harm than good (telling our daughter is was our fault, she could move out when she was 17, etc.). Please continue to keep your thoughts coming – they’re extremely helpful especially to parents who do not have great professional support. Thank you!!!

  12. To help with the negative mind thoughts (guilt, worry, etc.), I’m planning to add an ACT or DBT therapist for my daughter. Would you recommend one over the other? Also, is it necessary for the therapists to have training in how to apply these to anorexia or is it not necessary? Thanks so much!

  13. Laura,

    Great questions! It’s good that you are seeking evidence-based treatment for your daughter’s psychological issues.

    ACT, DBT, and CBT can all be helpful in treating the psychological symptoms of anorexia once the patient has been weight-restored and is eating normally. There is no evidence that ANY type of psychological therapy is effective with anorexics who are underweight or malnourished.

    It is very important to find a therapsit who has experience treating anorexia as well as training in one of these evidence-based treatments.

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