One of my favourite talks at EDIC was a sprint though the role of food in eating disorders by Professor Andrew Hill. He began by addressing the infamous cliché attached to eating disorder awareness raising – it’s not about the food – and said that he felt this was a simplistic and not entirely accurate statement. Food, he suggested, could be seen through different lenses of nutrition, health, emotion, identity and control, all of which could influence eating behaviour. During this whistlestop tour he covered everything from the Minnesota semi-starvation experiment – in which 36 healthy young men were fed 1800 calories a day for six months and developed symptoms we would usually associate with eating disorders, thus beginning research into the fact that malnutrition itself can perpetuate anorexia and bulimia independently of psychological processes – to the internal and external cues involved in feeling hungry, the expression of ones identity through channelling values and morals through food choices (e.g. becoming vegetarian), the government-sanctioned demonisation of certain food groups and so on.
The most interesting part of the talk for me was on the regulation of food intake. Professor Hill introduced this by showing an immensely detailed systems map relating to obesity, which included a staggering 108 known variables across 7 broad themes – biology, food production, food consumption, societal influences, individual psychology, individual activity and activity environment – which contributed to food intake and energy expenditure. This map really shows how complex the regulation of weight and intake is on biological, psychological and societal levels. It is not a simple issue and does not have a simple formula attached to address those who wish to influence their weight in either direction. The link to the map is here – I can’t find a version that lends itself well to zooming, but you can clearly see the seven themes and the interlocking paths which link them. The document it belongs to is this one, which is freely available online.
One influence on food intake Professor Hill particularly highlighted was the impact of actual or intended dieting/dietary restriction. This was in the “control” part of the talk, which I originally thought might refer to the fact that so many people think that eating disorders are *about* control, but was happily mistaken. What he was actually talking about was the physiology and psychology of control over food intake. He spoke of study after study which had shown how the dieting mindset actually leads to more episodes of (actual, not just perceived) over-eating, compared to non-restricted controls. This is especially true when the dieter eats food they had previously ruled as off-limits (the fuck it effect – I’ve had one biscuit so I’ll eat them all), if alcohol had been consumed, if other people around the dieter were eating high calorie foods freely or conversely if they were eating alone, if the dieter was experiencing a negative mood, and if they believed the foods they were eating were unhealthy or had a high calorie content. Professor Hill also outlined the mechanisms of cravings: dieters and restrictive eaters have both more cravings overall and more specific cravings for foods they have outlawed compared to non-dieters. When highly palatable foods are outlawed in this way they become more desirable, and if the person either finds this resistance very difficult or fails to maintain it they will often attribute the blame to a property of the food, thereby spawning hundreds of articles about the supposed addictive qualities of sugar, cake, biscuits, chocolate and so on. Hill related this to the well known mind game of trying not to think about a polar bear, and said that at least one study had taken the polar bear concept and applied it to instructing their participants not to think of chocolate – with the result that chocolate overwhelmingly became the subject of their thoughts.
This has also been researched in relation to children. Basically, findings are that children exposed to “pressuring” food rules (e.g. you must eat everything on your plate) are likely to eat less, and those exposed to “restrictive” food rules (you must not eat snacks between meals) are likely to eat more. Either way, imposing food rules either on yourself or others usually backfires in some way: either a large amount of time and energy will be required to adhere to the rules, or a restrict/binge/restrict pattern will emerge, in which a person strongly adheres to the rules for a period of time, becomes overwhelmed or exhausted and lets them slip for days/weeks/months, and after a certain further period of time will reapply the rules and begin the cycle again, ad infinitum. This pattern of behaviour in those not predisposed to anorexia usually leads to weight gain over time.
This is all really interesting in the context of both “normal” dieting, disordered eating and clinical eating disorders. Of course there are some people who, through some quirk of biology, never binge or deviate from their self-imposed rules during restrictive periods, but even this tells us something about the way they differ from the rest of the population biologically and/or psychologically. For the vast majority of the population it means simply this: diets don’t work. Formalised, rule-driven diets which prescribe a certain way of eating seem to make matters worse over time, establishing a chaotic pattern of restricting and overeating which leads to the body increasing its set point in response to deprivation, then hoarding every calorie it gets when the rules break down. From what I gather, dietary decisions made for ethical reasons are exempted from this, with the exception of when a person is fooling themselves over their reasons and actually just wants an excuse to restrict. I never craved meat in 17 years as a vegetarian and most of my ethically-driven vegetarian and vegan friends would say the same, but others I know who have stopped eating meat have struggled immensely when doing it for the “wrong” reasons.
I share Professor Hill’s outlook on this issue: that our society and government have worsened this problem by constantly harping on about certain foods or macronutrients (fats, carbs) being unhealthy, or even somehow immoral. For goodness sake, I feel like I’m committing an act of rebellion every time I eat cake in public. Not that it really affects me beyond finding it vaguely entertaining when people remark on my ability to eat cake and not gain a million pounds (I feel this is related to the fact that I actually allow myself cake, rather than freaking out about it and eating twenty cakes in a spurt of panic as I did as a teenager), but what about all the people who are too ashamed to eat anything but celery in public, only to go home and eat the entire contents of their fridge? Stigmatising various foods, inaccurately labelling them with good/bad judgements and even worse, attempting to shame larger people into losing weight just isn’t going to do a damn thing to help.
It is for this reason that from January 2010 I’ve been steadily learning about and applying to my own life the principles of Health At Every Size and intuitive eating. To begin with I found Health At Every Size a bit of an unfortunate name – after all, I hadn’t been healthy at my lowest weight so I couldn’t quite see the logic – but then I realised I hadn’t understood it correctly. What HAES actually means “is an approach to health that does not pursue the goal of a particular body weight, but rather concentrates on what health benefits and improvements can practically be achieved for individuals” (from the HAES UK FAQ, acronym heaven!). I would really recommend that anyone interested, either from the point of view of wanting to find out more for their own benefit OR because they are sceptical/unsure how it works, reads the first two sections in the FAQ linked: the basics and the justifications. HAES has a growing body of evidence behind it, not just established by the leading experts who have a vested interest in the subject (Linda Bacon is the woman in the know), but also gradually by other interested parties who want to test alternative approaches to weight issues as it becomes clear that dieting just makes things worse.
It’s no secret that I would really encourage people to look into intuitive eating in later stages of their recovery. I started teaching myself this way of eating and maintaining a healthy weight in February 2010, after a year of gaining weight and a month or so at my target. I could have micromanaged my weight forever, adjusting my calorie intake up or down depending on whether the number was trending up or down in general, but I was thoroughly sick of counting calories and obsessing over numbers, and wanted to at least try something different. I started slowly because eating disorders can rob bodies of sensitivity to hunger cues, and I couldn’t reliably identify feelings of hunger or fullness after twelve years of eating disorder. I believe I began by sticking to my general meal plan structure – breakfast, snack, lunch, snack, dinner, snack – and still aiming for the same sort of amounts at each, but without either weighing portions or counting the exact calorie totals. I was sure my weight would rocket (come on, I was a recovering anorexic, we’re all sure our weight will rocket!), but it didn’t, and so I extended my experiment for another week, and another. It held steady, and I have maintained my weight within six pounds (which is what constitutes one BMI point for me) without consciously trying to for the last two years now. I still have to break away from this approach slightly and make an effort to keep my intake up if I’m particularly stressed or ill, but otherwise I eat what I want, when I want, in the amounts I want, and those cues from my body mean I maintain a healthy weight.
One last question to Professor Hill from a lady in the middle of the auditorium: if there are so many different variables which influence our food intakes, from advertising to clock watching to biology gone wrong to stress, how can intuitive eating be a practical solution? Surely our bodies and minds are too confused to work out what they want? I can’t remember his answer fully because by that point I’d put my notebook away in anticipation of the dash for the complimentary cups of tea before the masses started queuing, but I vaguely remember it having a similar feel to my own thoughts on the matter. My answer, had the question been directed at me, would have been that once I was healthy I approached the problem on two fronts: by eating mindfully and retraining myself to be more sensitive to my internal cues, and by educating myself about HAES, intuitive eating and the like, slowly giving up my rules and revising my way of seeing food through the value-driven prisms of good/bad, right/wrong, healthy/unhealthy. It worked for me, and while I respect that different things will work for different people, it’s not just me and it’s not just people in recovery from anorexia. This approach is especially healing for people who have had problems with bingeing, chronic overeating or bulimia, and I would love for more people to give it a chance rather than immediately dismissing the idea on the basis that it can’t possibly work, that people need more rather than less control over their food intake, and/or that it’s too damn scary to contemplate. Actually, it gave me the most genuine and wonderful sense of control and freedom over my life, my body and my food intake, and it has taken all the fear out of eating.
I kind of wanted to kiss Professor Hill after his talk for being so well informed and making so much sense – but I wanted that cup of tea more 😉