Composed: Feb 28, 2023
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Challenging Diet Culture: Examining Atypical Anorexia
February 26, 2023, is the start of Eating Disorder Awareness Week. As part of Eating Disorder Awareness Week, I wanted to talk about anorexia. Anorexia is a lot more prevalent in our society than you might think.
What is Anorexia?
According to the National Institute of Health (NIH): Anorexia nervosa is a condition where people avoid food, severely restrict food, or eat very small quantities of only certain foods. People with anorexia also may weigh themselves repeatedly. Even when dangerously underweight, they may see themselves as overweight.
The NIH further breaks this down into two categories:
- In the restrictive subtype of anorexia nervosa, people severely limit the amount and type of food they consume.
- In the binge-purge subtype of anorexia nervosa, people also greatly restrict the amount and type of food they consume. In addition, they may have binge-eating and purging episodes—eating large amounts of food in a short time followed by vomiting or using laxatives or diuretics to get rid of what was consumed.
What is Atypical Anorexia?
Most often, we associate anorexia with people who are underweight. The Eating Recovery Center discusses something called "Atypical Anorexia":
"Atypical anorexia is an eating disorder that is nearly identical to anorexia. The difference? While people with anorexia are at significantly low body weights, people with atypical anorexia weigh in the "normal" range or live in larger bodies. Classified as an Other Specified Feeding or Eating Disorder (OSFED), atypical anorexia is also known as subthreshold anorexia. People of all genders, shapes and sizes can suffer serious, and even fatal, complications from atypical anorexia. And the number of people diagnosed with atypical anorexia is growing. A recent study found that between 25-40% of patients in inpatient eating disorder treatment centers have atypical anorexia.
There are few differences in how anorexia and atypical anorexia affect people. The primary difference is that people with anorexia have a lower body weight to height ratio than people with atypical anorexia. While the two eating disorders are similar, since people with atypical anorexia do not appear underweight, they are less likely to receive eating disorder treatment compared to individuals with anorexia who look underweight."
How "Eat Less, Move More" Contributes
The "Eat Less, Move More" idea insinuates that anyone who is not in top physical condition is overeating. Because that's the only reason a person could possibly be overweight, right? It's all about calories, right? Calories in, calories out…the calorie is king! No, this is not true. Read on to learn why.
@autumnallyear.us Eat less, move more doesn’t work long term. It just damaged your metabolism. #cico #calories #starvation #metabolism #metabolicdamage #eatenoughcalories #maybeeatmore ♬ Lo-fi hip hop - NAO-K
Do you know what a calorie is? Do you know how the caloric makeup of a food is calculated?
Originally, calories in food were measured by burning the food:
"Food labels contain the number of calories per serving. But how is this number determined? The answer is surprisingly simple: The food is burned. A sample of the food is placed in an insulated, oxygen-filled chamber that is surrounded by water. This chamber is called a bomb calorimeter. The sample is burned completely. The heat from the burning increases the temperature of the water, which is measured and which indicates the number of calories in the food. For example, if water temperature increases by 20 degrees, the food contains 20 calories. This method of measuring calories is called direct calorimetry."
I'm not entirely convinced that was ever an effective means of determining the usable energy contained within a food. However, today, that method is no longer used. Instead, something called the Atwater system is used.
"The Atwater system uses the average values of 4 Kcal/g for protein, 4 Kcal/g for carbohydrate, and 9 Kcal/g for fat. Alcohol is calculated at 7 Kcal/g. (These numbers were originally determined by burning and then averaging.) Thus the label on an energy bar that contains 10 g of protein, 20 g of carbohydrate and 9 g of fat would read 201 kcals or Calories."
So, now we've gotten even less accurate. We're using averages. So, the total caloric makeup of any food that you see on a nutritional label is not entirely accurate. It is an estimation calculated based upon the assumption that the average of the caloric makeup of the component parts (carbs, protein, and fat) is applicable to the food you're consuming. How many calories are going in? You don't know that with the degree of accuracy you may have thought.
The Calorie is Not King!
The other (and larger) issue with the "Calories In, Calories Out" method is that it assumes that calories out is a stable number. And that couldn't be further from the truth. The less we eat, the more our metabolic rate slows down. The slower our metabolic rate, the less energy we burn. The less we burn, the less calories we have going out. And this becomes a vicious cycle. You eat less, your metabolism drops, weight loss plateaus and/or you begin to regain, so you eat even less, and this cycle repeats. Eat Less, Move More and Calories In, Calories Out was never a good strategy.
If you're stuck in this cycle, the only way out is to stop. A reverse diet can be useful to help reverse this and bring you back to eating a healthy amount of food that will sustain a healthy metabolism and promote a healthy lifestyle.
There are people who are "overweight" who are eating less than 1000 calories per day (which is a starvation diet) and are struggling to lose weight. So, how helpful is it for a medical professional (or anyone, for that matter) to tell someone to eat less? Eat less than what? Eat less than a starvation diet of 1000 calories per day? Eat less than their Basal Metabolic Rate?
The implication, of course, is that you're only overweight because you're overeating. So, you must eat less than you're currently eating. But, if you're already undereating? You can see how dangerous this advice might be.
Add to that, the advice to "move more" without finding out how much a person is already moving. Many people suffering from Atypical Anorexia are already over-exercising (in addition to undereating). So, advising them to move more is dangerous and irresponsible advice, to say the least. Move more than what?
Studies have shown that we burn as many calories as more active hunter-gatherer societies.
"While we've always assumed that humans' ancient ancestors must have been more active than today's modern Westerners — with our office jobs, our cars and our TV sets to keep us sedentary — new measurements of actual energy expenditure are surprising. They show that people in traditional foraging societies do indeed participate in more physical activity, but that their total energy output is almost identical to that of today's pudgy Westerners. This counterintuitive finding is explained by the foragers' lower basal metabolic rate: they expend less energy while at rest, even when we compare people of the same size and age."
- Time Magazine
Yes, you read that right. People who move more have a lower basal metabolic rate. So, how much good is all that "move more" stuff really doing us anyway?
How Diet Culture Contributes
What is Diet Culture?
"Diet culture is more than just being on a diet all the time. It's an environment of cultural messages about food and bodies that has led to a set of beliefs: that thinness equals health, worth, and overall wellness, goodness, and morality. People who engage in diet culture pursue unrealistic body ideals at the expense of their health and wellness.
These beliefs are prevalent in the marketing of food, beauty products, and programs that promise to help users achieve "body goals."
Some examples of how diet culture invades our day to day life include magazines touting celebrity eating plans or cleanses, food marketing that labels products as "guilt-free", weight loss programs that make you track your food as points.
The practice of viewing food as "good" or "bad" instead of through a lens of nutrition and nourishment can be harmful."
Myths Prevalent in Diet Culture:
- Myth: Health is determined by size - Fact: you cannot tell someone's state of health by looking at them. There are plenty of thin people with type 2 diabetes. There are plenty of overweight people with normal blood pressure. There are plenty of people who you might think appear underweight who have normal health markers and who eat a healthy amount of food. There are plenty of people in larger bodies who are suffering from atypical anorexia. You cannot tell someone's state of health by looking at them.
- Myth: There are "good" and "bad" foods - Fact: foods do not possess morality. What you eat doesn't make you a more or less virtuous or moral person. We know some foods do not contribute to a healthy lifestyle, but they are not immoral. You do not lack virtue or morality if you eat them. Attaching morality to inanimate objects is one of many silly stories we tell ourselves as part of our attachment to diet culture.
- Myth: Once I lose weight I'll be happy - Fact: this is WRONG! This is right up there with other silly stories we tell ourselves like "once I'm thin people will love me (or love me more)" or "I'll travel more" or "I'll want to work out"...the list goes on. Smaller bodies don't bring instant happiness. You don't need to be thin to be deserving of or to receive love. Exercise can be good for many reasons. There is no requirement to be a certain weight to exercise. There are no more benefits gained when a person in a smaller body exercises. There are no more benefits gained when a person in a larger body exercises. Simply losing weight will not ensure happiness.
Your Body is Not Broken
If you have struggled to lose weight despite your best efforts, your body is not broken. You have just fallen victim to the same ideas about eating less, moving more, counting calories, and reducing dietary fat intake that many of us have. It damaged your metabolism and that makes it harder for you to successfully lose body fat.
You don't need to lose "weight"
Let's reframe the "weight loss" mantra. You don't want just to lose weight. If we're aiming to lose weight but not being clear with ourselves about what we are aiming to lose, we may employ some strategies that cause us to lose things we need. We need bone mass. We need muscle. We need connective tissue. We need a certain amount of body fat. We need all of these things in order to be healthy. And aiming to lose weight alone is not a healthy goal. Put the scale away! It is not your friend.
Medically Induced Caloric Restriction - Bariatric Surgery
If you've had gastric bypass or other weight loss surgery, you've done something to help your body be more healthy. You did so, most likely, because your doctor told you that would be the best path for you. And I'm not going to try and tell you that was right or that was wrong. I don't know if it was right or wrong for you and it's not my job or my place to judge you.
Bariatric surgery is a medically induced caloric restriction diet. The problem with bariatric surgery is that it relies upon the notion that caloric restriction is the only path to weight loss. You do not have an excess of space in your stomach. You do not have an excessively long digestive tract. Having a band placed around your stomach or having sections of your digestive tract removed facilitates the sort of weight loss that can cause muscle loss, bone mass loss, and nutritional deficiencies.
A study from the NIH revealed that obese patients may regain many of the pounds they initially shed within 5 years following their weight loss surgery.
"The first year after surgery is usually a honeymoon period that should be used for coining new habits, and the ones that don't do that regain weight," Keidar, a researcher at Tel Aviv University, said by email. "Don't take surgery as a panacea - beware of bad eating habits."
Of course, not everyone regains body fat lost after bypass surgery. But many people do.
Imagine if doctors worked with patients to gain new habits that didn't involve starvation and/or the use of gastrointestinal surgery. It seems that they're so close to understanding where they've gone wrong but just don't quite see it. It can be hard to see when we were wrong...and it can be even harder to admit.
Things we sometimes say that are not helpful
- Telling someone they look "skinny", commenting that they have "lost weight", or telling them they "look healthier" isn't the compliment you may think it is. Sometimes, it is actually very hurtful.
Weight does not determine how good someone looks and telling them that they look great after having lost weight can send the unintended message that they didn't look good before they lost weight.
- Commenting on other's eating habits.
What someone else eats is none of your business. And mentioning things like how many calories are in a food, how much fat a food contains, or the overall volume of how much someone else is eating can cause HUGE amounts of shame and feelings of self-consciousness and self-loathing. Remember, you cannot tell if someone has an eating disorder just by looking at them. Keep your eyes on your own plate and don't offer advice that is not solicited.
- Using words like "gross", "disgusting", "hate", etc. to describe your own (or someone else's) body.
When you describe your own (or someone else's) body in this way, consider the fact that people are social creatures. We are impressionable. We learn how to treat ourselves from those around us. It is particularly damaging to describe your own body in this way around your children, but adults are also impressionable, social creatures.
Anorexia is not a disorder that only affects people who are very thin. Eating under your Basal Metabolic Rate is a starvation diet. If you are afraid to eat because you might gain weight, you may have anorexia (even if you're not thin). If you use terminology like "hate", "disgusting", "gross", etc. to describe your own body, you have a disordered relationship with your own body image. If you exercise for hours a day or in spite of being very sore in an effort to try to lose weight, you might have an eating disorder.
If you think you have an eating disorder, the National Eating Disorder Association has a hotline you can call or text (800) 931-2237, an online chat, and a short, confidential screening tool you can fill out online to help you determine if it's time to seek help.
They also have a Crisis Text Line. If you are in a crisis and need help immediately, text "NEDA" to 741741 to be connected with a trained volunteer.
The Crisis Text Line provides free, 24/7 support via text message to individuals who are struggling with mental health, including eating disorders, and are experiencing crisis situations.
Please, if you think you're suffering from an eating disorder, seek help. Whether it is from the NEDA or elsewhere.
I say much of this from a place of experience and compassion. I have exercised despite being VERY sore in an effort to lose weight. Never did I think that was unhealthy because it is a very prevalent concept in our society. "No pain no gain", right? Wrong. Ignoring pain is not healthy. And deconstructing that thought process was hard.