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Eating Disorders: More than skin deep


Earlier this month, Mary Cain, one of the most heralded middle distance runners of the 21st century, shared a shocking revelation. In a New York Times video op-ed, Cain detailed years of alleged abuse at the hands of Nike Oregon Project Coach Alberto Salazar. One constant aspect of this abuse was a reported fixation on Cain’s weight, with the athlete reporting that she was shamed in front of teammates for any perceived fluctuation from a specific measurement. Beyond the psychological trauma this pattern of abuse produced, Cain noted the cessation of her menstrual cycle, along with a series of bone fractures, which left her unable to compete. And while Cain’s story is certainly illuminating in what it tells us about eating disorders, it is hardly unique.

A recent study led by the Institute of Psychiatry, Psychology & Neuroscience in London, suggests that the number of people who experience these feelings is growing, and skewing younger, with children as young as eight being diagnosed with an eating disorder. The American Psychiatric Association defines eating disorders as group of illnesses, “in which the people experience severe disturbances in their eating behaviors and related thoughts and emotions. People with eating disorders typically become pre-occupied with food and their body weight.” Right now, there are an estimated 30 million people living in the United States with an eating disorder.

To learn more about this often overlooked topic, I spoke with Jena Shaw Tronieri, PhD, an assistant professor of Psychiatry and director of Clinical Services at Penn’s Center for Weight and Eating Disorders.

Q: People might assume that an eating disorder is simply eating too much or too little, but it seems more complicated than that. How do health care providers define these illnesses?

A: Broadly, we would define an eating disorder as any disturbance in eating-related behavior that is associated with significant distress, is harmful to health, or impairs functioning in other areas of life. The three eating disorders that are currently recognized by DSM-5 (Diagnostic and statistical manual of mental disorders, 5th edition) and are most typically diagnosed in adolescence or adulthood are anorexia nervosa, bulimia nervosa, and binge-eating disorder. They’re what most people think about when they hear the term ‘eating disorder.’ But, there are patients who have a difficult or unhealthy relationship with food but do not meet full diagnostic criteria for one of those specific disorders. Those patients would receive a diagnosis of, ‘other specified feeding or eating disorder.”

Q: Many people have a complicated relationship with their dinner plate. In my own life, I have tried to find a balance between indulging and traditional dieting, with some success. A common issue I have found is that it can be easy to go overboard in either direction. This then begs the question, where does healthy dieting end and a serious illness begin?

A: It is important to note that not all dietary changes are signs of an eating disorder. Many people set goals to lose weight or to change their diet/exercise routine. In most cases, changes to diet and exercise that produce weight loss can be beneficial and are associated with improvements in both health and wellbeing. To tell the difference, you would need to consider whether these behaviors were associated with distress or impairment. For example, if you would have become very distressed if you were asked to eat foods outside of your typical meal or miss a bout of exercise, or if you were exercising excessively even when sick or injured, and certainly if you began to engage in other extreme dieting behaviors like vomiting, those could be signs of an eating disorder. You also might consider whether your weight or shape had become one of the most important things to you in defining your self-worth or whether small changes in your weight or shape would have been particularly distressing for you.

Tronieri also noted that much of the suffering involved with an eating disorder is invisible. Beyond a thin or frail appearance, individuals living with an eating disorder can be prone to a thinning of the bones, drops in internal body temperature, decaying teeth, kidney and intestinal distress, along with other internal issues. Psychologically, there is a large body of evidence linking eating disorders with various forms of depression. One study from the National Institutes of Health found that among female patients with anorexia nervosa and bulimia nervosa, 43 percent met the criteria for major depression.

Q: How do we identify and support individuals living with these illnesses?

A: Well, for starters, it’s important to avoid insensitive statements like “just eat a sandwich.” Those kinds of statements both miss the mark and greatly oversimplify the conditions. The etiology (causes) of eating disorders are complex and include genetic, biological, and environmental/relational factors. Further, the behaviors involved in these disorders have both physical and psychological consequences that can make it very difficult to change once the pattern has started. In fact, even if an individual wanted to make certain changes, their illness may prohibit them from doing so. For example, for a patient with anorexia, very low energy intake is associated with physical changes that can make increasing food intake feel physically uncomfortable and with deficits in cognitive flexibility (that would help with behavior/perspective change), in addition to the psychological factors that make eating very challenging.

To support those living with eating disorders, Tronieri says it’s important to be both compassionate and understanding. Generally, providing encouragement and support are most helpful for individuals with eating disorders, as well as many other psychological disorders. Recognizing and praising the affected individual when they make an effort to change, even if it's small, can go a long way.

Ultimately, it takes a team approach between clinicians and those close to the individual to properly address an eating disorder. Research shows that many individuals will relapse into these behaviors at some point. That’s why it’s important to acknowledge that just like our own relationships with food can be at times, there is far more complexity to this issue than meets the eye.

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