Disordered eating appears to be a well-hidden epidemic in adolescents and adults, in both male and female, and is more common in athletes.
Mention eating disorders and most people think of the serious mental health conditions of anorexia nervosa and bulimia. These patients almost always require some type of healthcare to help remedy their problems. As described in the Diagnostic and Statistical Manual of Mental Disorders (DSM), eating disorders are characterized by gross disturbances in eating behavior. They include anorexia nervosa, bulimia nervosa and eating-related problems “not otherwise specified.” The American Psychiatric Association says that the “not otherwise specified” category is for eating problems that do not meet all the criteria for any specific named eating disorder. These cases, which may make up the majority, are referred to as subclinical eating disorders. While this category greatly expands the condition of disordered eating to include many more people, rightly so, it may still not be enough. The problem can be classified in a much simpler way—disordered eating.
Australia’s National Eating Disorders Collaboration states that, “Disordered eating in athletes is characterised by a wide spectrum of maladaptive eating and weight control behaviours and attitudes.” The same could be said for those not in sports, where disordered eating is also common. Where a person exists on this spectrum, if at all, is often, but not always easy to discern. Too many people with disordered eating “fall through the cracks” of the healthcare system. Of course, our society even encourages disordered eating. For many people, their problems are never recognized or are only observed when a full blown clinical diagnosis becomes obvious.
In the British Journal of Sports Medicine, DePalma (2002) writes, “It is only after following these behaviours and meeting the strict DSM-IV criteria that a person is classified as having an eating disorder. As a result of the strict DSM-IV diagnostic criteria, the number of people exhibiting dangerous pathogenic eating behaviours is actually much higher than the prevalence of diagnosed disorders.”
Eating disorders are sometimes referred to as pathogenic eating. This includes dieting, calorie restriction, reducing fat intake, fasting (not for health reasons), and the use of laxatives, diuretics and diet pills (and vomiting). This problem is more prevalent in certain sports, especially if there is a need to meet a minimum weight, although endurance athletes believe just weighing less will improve performance, which is a fallacy when health is sacrificed in the process. In some cases, one may be a pathogenic eater only during a competitive season, or only be obsessed with avoiding fat calories, while another may have ongoing unhealthy activities throughout the year. Regardless of the details, the condition creates ill health that can lead to injuries, especially stress fractures, hormone imbalance or mental problems such as depression.
A disorder means there’s some physical, chemical or mental-emotional problem, typically a combination, which needs to be addressed. Depending on the seriousness of the disorder, correcting it may be accomplished by the individual through natural means or with the help of professionals in the fields of both mental health and nutrition, although other health professionals may also be capable of successfully treating a patient with this condition. The first step, of course, is for the individual to understand that there is a genuine problem, and he or she has the desire to remedy it.
Clinical Eating Disorders
The diagnostic criteria for the two most common clinical disorders are extensive, but here is a review:
- For anorexia nervosa the criteria includes a refusal to maintain body weight at healthy levels, an abnormal fear of gaining weight or body fat, disturbed image in one’s body, and the denial of the seriousness of ones condition. In females this may also include amenorrhea (the absence of menstrual bleeding) or oligomenorrhea (a menstrual cycle between 35 and 90 days), and in younger adolescents, delayed menarche (onset of first period). These patients are classified into the food-restricting type or the binge-eating/purging type.
- The criteria for the diagnosis of bulimia nervosa include recurrent episodes of binge eating (quickly eating large amounts of food) followed by vomiting (purging), which leads to more binge eating. The classification includes the purging and non-purging type.
Subclinical Eating Disorders
As noted above, those with eating and food problems who don’t neatly fit into the criteria for named conditions are classified as having a subclinical eating disorder. This condition may exist early in life—during adolescence or even younger—with at least three possible outcomes: 1) the problem precedes a more serious well-defined clinical mental illness; 2) the condition remains a less-defined subclinical problem; or 3) the problem has been resolved.
For those people with a subclinical eating disorder, it may not be recognized as a problem. While many unhealthy attitudes about food may be considered “normal” for athletes or those on a diet, some experts still consider this condition to be a risk factor for more serious clinical eating disorders.
Disordered eating is common among athletes, with estimates by the National Athletic Trainers’ Association’s position statement (“Preventing, detecting, and managing disordered eating in athletes”) that range as high as 62 percent among female and 33 percent among male athletes.
Disordered eating is disordered behavior, and the problem typically reaches beyond ones diet. For example, the overtraining syndrome in both men and women are commonly associated with disordered eating. Other signs and symptoms, such as amenorrhea, fatigue, and physical injury, are typically part of the clinical picture. The need for a holistic approach is essential so all physical, chemical and mental-emotional aspects of the individual are addressed.
Unfortunately, the criteria to diagnose a clinical or subclinical eating disorder are not always easy to use in identifying a problem. I’ve seen too many patients who have gone from one health professional to another spending the time searching for the correct name for their condition when they don’t neatly fit into any one of them. This not only postpones therapy, it can cause additional undue stress.
Referring to all these problems as disordered eating makes sense—meaning the food one consumes, or avoids, impairs health and fitness, including reduced athletic performance. Once the existence of a disorder is suspected, or established, the process of recovery can begin. Regardless of where one is located on the full spectrum of disordered eating, individualizing the assessment and treatment process, whether applied by the individual in a natural way or with the help of health professionals, is a key step to improving health and fitness.
While those with a diagnosis of anorexia nervosa and bulimia are considered mentally ill, others without mental illness can still have eating disorders. In their quest to control weight, reduce body fat, become thinner, and improve athletic performance many people develop their disorder from misinformation. This can come from athletes, coaches, government pyramids, advertising hype, and the latest diet books or articles.
It would appear that most people with disordered eating have sugar addiction. Many mistakenly believe that only fatty foods add weight and body fat, but can’t consider that up to half the refined carbohydrates eaten, those most consumed by people with disordered eating, quickly convert to stored body fat.
Some may claim that any obsession is harmful. While a compulsive obsession associated with unhealthy outcomes is clearly bad for anyone, an obsession to be the best athlete and healthiest person can be a positive feature (like the notion of a positive addiction). Where one draws the line that differentiates disordered eating with just trying to be healthy and fit is not always easy, but outcome is one important differentiating factor. Eating in a way that impairs health and performance could be another part of a simple definition of disordered eating.
Is dieting associated with disordered eating? Certainly if we use the simple definition, which refers to eating in unhealthy ways or following an eating pattern that impairs athletic performance, we could answer ‘yes.’ The reason is that most approaches to dieting lead to the consumption of inadequate natural nutrients necessary for good health and performance.
Dieting may be one important risk factor for disordered eating. In a scientific paper entitled, “Aspects of disordered eating continuum in elite high-intensity sports” (Sundgot-Borgen and Torstveit, 2010), the authors state that, “In addition to dieting, personality factors, frequent weight cycling, early start of sport-specific training, overtraining, injuries, and unfortunate coaching behavior, are important risk factors.”
Stress can also be a significant factor associated with disordered eating. “Stress may indirectly contribute to disease (e.g. cardiovascular disease, cancer) by producing deleterious changes to diet” (O’Connor, 2014). Human studies have demonstrated increased preference for high sugar foods in people reporting greater stress exposure, with daily stressors associated with unhealthy snack consumption. Much of this disordered eating is linked with a negative reward pattern of behavior—the connection with sugar addiction. Of course, most people already know this, and it’s an important part of making healthy changes. More importantly, unhealthy eating patterns evenresult in an increased level of stress, which maintains a vicious cycle not easy to break.
What may often elude most people with eating disorders is the fact that there is a general consensus among most nutritional scientists and clinicians about healthy eating. This includes avoiding junk food, and the need to regularly consume fresh fruits and vegetables, and foods with quality protein and fat, while obtaining at least adequate calories and micronutrients for ones particular needs. So one can be normal weight and thin, and improve athletic performance by eating healthy foods. This understanding is a foundation of natural therapy essential for an individual to avoid disordered eating. This will be addressed further in Part 2, along with other related issues. For those interested in more information a bibliography is also provided.