Stress and the Mind-Body Connection
This afternoon I sat staring at the reflection of the 40 year old woman who is me. Lines. I saw lines. Around my mouth, between my brows, across my forehead. Where did they come from? How do they seem to grow deeper by the day? When did I become so old? Botox. Maybe that’s what I need. I was covering the gray today; why not hide everything else that reveals my aging body?
The judgement stopped me. I thought of my mom. With locks of lovely spun silver. Crevices around her mouth from which laughter spills. Crinkles surrounding her eyes deep with love. Wrinkles trolling across a forehead embracing a mind of intelligence and wisdom.
I look like my mom. I look like the beauty who bore me. I am becoming the woman who never has tried to be anyone or anything else.
So it is. I can love myself this way. I WILL love myself this way. I’ll look at this image with tenderness and grace. I’ll ask gently for the preoccupations with perfection to be lifted.
I’ll practice loving you, as you are and as you will be, I said to myself and smiled.
There are moments when I feel whole, balanced, centered, and aligned. And in the very next second can emerge a fractured chaos.
“What am I doing?” I might ask.
“What is the point?”
It’s all the same. This mess of life.
The highs and the lows are the visiting teachers sent to show us how to breathe, eat, love, and feel. How to question and reflect, how to choose a way forward. How to think and how to bloom.
Our emotions are like seasons…time changes…that come and go and demand an evolution.
When I was in the dark of disordered eating, I didn’t get this. I didn’t want to die, but I didn’t know how to live.
The living could only come from feeling. Feeling everything. And feeling fully. Feeling the chaos. And believing the chaos to be a beautiful chance for awakening.
What are you experiencing now? How does it feel? Give it a language. Heavy, thick, foreboding, soft, prickly? We are not ever just one feeling. We are not ever only angry, only sad, only depressed, only anxious, only overwhelmed. We are multitudes.
Over the last decade, obesity in the United States has risen at such a rapid rate it is now being called an epidemic. According to the 2003–2004 National Center for Health Statistics (2006), in 1980 obesity was approximating 15% of the American population (Mann, Tomiyama, Westling, Lew, Samuels, & Chatman, 2007). Over the last 14 years, obesity has increased by 75% (American Heart Association, 2005 as cited in Powell, Calvin, & Calvin Jr., 2007).
More than a third of the population is categorized as obese, with over an equal proportion at risk for becoming obese (Mann, et al., 2007). Furthermore, obesity affects multiple systems within the body and contributes to such disease states as coronary heart disease, diabetes, osteoarthritis, high blood pressure and hypercholesterolemia, and asthma, just to name a few.
Other less immediately harmful conditions, such as poor sleep and gastroesophageal reflux can also result from obesity. In addition to the rising health care costs associated with obesity, the physical and emotional ramifications of obesity become increasingly debilitating with each pound of fat that is added to one’s frame. Activity becomes more difficult, motivation and interest in social endeavors often suffers, comorbid psychiatric disorders often surface (Neumark-Sztainer & Haines, 2004 ), and the problem is exacerbated with each failed attempt at weight loss. It is clearly a condition of tremendous concern.
The factors involved in obesity are many, fast food being but one key element in the equation. Its reach expands the boundaries of the United States to other countries like Great Britain, where, within a 9-year period, obesity increased at the same rate as fast food establishments were built. Importantly, however, those countries that have less access to and spend less on fast food demonstrate lower rates of obesity (Schlosser, 2001).
Environment and genetics also contribute to one’s obesity propensity, however, the external influences are far more powerful when one considers how often messages are sent through the media to promote ease and convenience (Neumark-Sztainer & Haines, 2004). The availability of energy dense food, the ubiquitous reach of food cues, and the lack of activity that is required for one to procure food means more is being consumed with an accompanying decrease in energy expenditure (Zheng, Lenard, Shin, & Berthoud, 2009). With all the external drivers within society, our fate to become the fattest nation seems sealed. However, we must consider the element of personal responsibility that comes with food consumption and health, in addition to neurochemical and biological determinants.
Researchers have been studying how appetite and food intake differ among the obese and normal weight individuals for these very reasons. What contributes to food intake outside of the growing portion sizes and dollar menu advertising? Whether fast food is inexpensive, requires little preparation, and supplies substantial energy (Henderson & Brownell, 2004), and regardless of whether more meals are consumed outside of the home, which means a substantially higher energy intake as a result of increased fat density (Schlosser, 2001), the question of why some individuals struggle to maintain a healthy weight and seem so driven to eat even in circumstances when hunger is not a variable is an important one. The nature of appetite plays a key role in the answers to these questions, and it is not limited to purely behavioral processes.
Various definitions and explanations of obesity have appeared to obscure the objectivity that would seem necessary for its management. What one researcher calls a “normal adaptive physiological response to a changed environment” (Zheng, et al., 2009, p. S9), another calls a “chronic, relapsing, stigmatized neurochemical disease” (Bray & Champagne, 2005, p. S17). One would appear to place the individual with weight problems at the mercy of hormones and biochemical and genetic processes, while the other clearly identifies the environment as an important driving factor in the creation of the obese condition. Data indicate that while genetics play a role of approximately 40-60% in weight, environmental cues, perceived rewards, emotions and mood, as well as cognitive factors are intimately connected to food choice and intake (Bongaard, 2008; Zheng, et al., 2009).
One could logically assume that food intake is governed in most by a balance between hunger and satiety, and evidence exists of this for normal weight individuals (Nijs, Muris, Euser, & Franken, 2010). However, among obese individuals, studies have been inconclusive at best. From a purely physiological sense, attention devoted to food is regulated by hormonal mechanisms prompting either foraging and feeding or regulation as a result of feelings of fullness (Bongaard, 2008). Researchers have speculated whether the common feeding and satiety hormones, ghrelin and leptin, respectively, are defective in the obese, leading to increased feeding. Bray and Champagne (2005) indicate that with leptin treatment, individuals with low leptin levels will return to more normal eating patterns and responses to food cues are attenuated. Others disagree, pointing to the effects of learning and reward and their impact on food attention, outside of normal leptin levels, and how higher brain functions are often overridden in the presence of environmental stimuli (Zheng, et al., 2009). Additionally, studies have shown that individuals who lack leptin have increased responsiveness within certain regions of their brains when shown pictures of food, and when treated with leptin, those responses decreased. Interestingly, however, the responses were greatest when the pictures were regarded as more appetizing (ScienceDaily, August 11, 2007). Zheng and colleagues (2009) put it well with their explanation of a “cross-talk” of metabolic and environmental stimuli.
The homeostatic mechanisms for food intake involve an intricate release of hormones, spurred initially by a drop in blood glucose (Bongaard, 2008). Normal physiological hunger is often signaled by stomach growling, or if blood sugar levels have dropped to very low levels, feelings of hypoglycemia such as faintness, headache, and lethargy may ensue. These peripheral signals, stimulated by internal mechanisms, are learned by humans, and impact subsequent eating and foraging behaviors (Benoit, Davis, & Davidson, 2010). They can be prompted with even a 10% drop in blood glucose levels (Bongaard, 2008). In order to take care of oneself, the ability to detect these changes in the body is crucial. Ghrelin plays a key role in this sequence of events.
Stimulated by hunger, ghrelin is released from the stomach, travels through the blood, and acts upon the hypothalamic region of the brain to stimulate eating. The hypothalamus closely regulates the hormonal aspects of appetite and food regulation, as well as the cognitive and emotional/reward features associated with eating. Ghrelin declines after meal consumption, but some researchers believe that this mechanism is defective in obese individuals and could be a factor in the condition (Bray, et al., 2005). Contrast this with what others explain is a dearth of evidence for any defective metabolic and hormonal machinery among the obese, but instead, a greater attunement to the stimulatory factors involved in eating (Mela, 2006). This would appear to be the more plausible explanation, as studies on obese versus normal weight control subjects indicate higher food-cue responsiveness among the obese (Nijs, et al., 2010); greater motivation to consume food (Mela, 2006); higher sensitivity to food during hunger states (Nijs, 2006); greater delay discounting, suggesting an increased drive toward immediate versus delayed gratification (Weller, Cook, Avsar, & Cox, 2008); and increased perception of reward attached to food (Mela, 2006).
When food is scarce, which is rare in today’s society, studies have shown that the environmental condition significantly impacts response to food and subsequent intake. For example, a deprivation state will impact the amount of food eaten when food is presented, subsequently creating a learned value placed on that particular food. Whether that food is broccoli or chocolate cake, if one was consistently fed broccoli following periods of significant starvation, broccoli would take on a high “incentive value”, and that value would increase according to the level of deprivation (Benoit, et al., 2010).
On the flip side of the coin, even if one is hungry and is provided with a highly palatable food, should that meal cause sickness, for example food poisoning, even if hungry in the future, it is not likely that if the food were offered, that it would be eaten. Benoit et al. (2010) call this the “deprivation-discrimination” process, and it serves to confirm the learned, behavioral responses to food and food intake. In essence, appetite relies on an additive equation of energy signal states, environmental food cues, and eating consequences (Benoit, et al., 2010), and it is the hypothalamus, brain stem, and the corticolimbic areas of the brain which serve as the control centers for the navigation of eating behaviors associated with appetite (Bongaard, 2008; Mela, 2006; Zheng, et al., 2009).
Unlike the debate that exists between genetic versus environmental causes of obesity, the hypothalamus appears to have a lock on its undeniable impact on memory, learning, emotion, and behavior as related to food and appetite. It acts in tandem with the physiological cues and states that humans experience, like hunger and thirst; it is involved in the learned associations we acquire as a result of pleasurable or aversive eating experiences; and it allows us to make decisions according to environmental stimuli (Mela, 2006). These aspects are crucial to understanding motivation for eating, as well as how they differ between normal and overweight/obese individuals. Mela (2006) explains of the misperception that exists for the primary driver of eating among the obese being taste.
There is an underlying assumption that obese people eat more due to the chemosensory properties of food, however, when liked foods aren’t scarce, liking what is selected and eaten occurs uniformly. In other words, where food is plenty and it all tastes good, when another food is added, it does not necessarily change the amount in terms of energy intake consumed. Furthermore, when comparing the “liking” and “wanting” of food, the former has been described as that of immediate or anticipated sensory pleasure, whereas “wanting” is a state derived from learned associations of pleasure or desire that results in motivation to eat. Neither is related to actual hunger, and neither have been assessed as different in normal versus obese individuals, however, what is discrepant is the responsiveness to the cues that prompt liking or wanting that has been shown to be much higher in obese individuals. In contrast, outside of hunger, when presented with food choices, the better liked food is eaten by normal weight and obese alike, and Mela (2006) indicates that it is not a significant change in food palatability that can explain the rise in obesity.
Responsiveness to food would appear to be related to values, some related more to immediate gratification, for example, relief of gnawing hunger, and others related to a more intrinsic and long-term reward orientation, such as health, impact on one’s children, brand awareness, monetary and budget concerns, and convenience (Mela, 2006). Obviously, there are unconscious drivers like desire based on previous experiences that we may not be attune to, as well as more conscious drivers that we are cognizant of. Unconsciously, when one eats freely, energy balance is controlled through physiological regulatory mechanisms. If at one time a much more calorically dense meal is eaten, need would dictate a decrease in consumption later.
Alternatively, should one decrease intake, the corrective response may be that the body ceases to expend as much energy and when food is available, more may be consumed. Bray et al. (2005) explain this cycle of weight stabilization, and Wardle (1988) uses similar logic to explain that it is when feeding goes from free and need-based to rule-driven and depriving, when weight regulation issues arise. Individuals who consciously make the decision to diet, and construct rigid food rules that might include forbidden foods and limitations for food intake, for example, often exhibit increased desire and responsiveness to food when it is offered. Increased binging behavior, cravings, and lack of control with stopping feeding have been shown in studies of individuals who restrict their intake (Wardle, 1988). When the food that the individual has been staying away from is eaten, significant pleasure occurs, the reward centers of the brain fire, and under these circumstances, food can become intimately connected to mood (Wardle, 1988).
This sequence also confirms Benoit et al.’s (2010) assertion of a food’s incentive value. In essence, the food most coveted by restrained eaters will be eaten in greater amounts due to its high value. Subsequently, when negative affect is experienced, even in the absence of physiological need or hunger, one will experience a conditioned response to eat to elevate mood (Wardle, 1988). Excessive eating increases among overweight people when they are anxious or depressed (Logue, 1991). In addition, induction of anxiety among obese individuals and a bad mood in dieters has been shown to cause increases in food consumption (Slochower & Kaplan, 1980). Like a negative feedback loop, eating can increase with distress, which triggers more eating, and as the person ruminates on the breakdown of his or her dietary constraints, an escalation of distress results (Heatherton, Herman, & Polivy, 1991). Described in the literature also as counter-regulation, it has been shown in various experiments to occur when a subject is given a meal, typically one of high caloric density, before being given another meal and direction to eat freely. Restrained eaters eat more as compared to normal weight controls (Wardle, 1988). As a result of perceived failure to maintain regulatory control with the first meal, they consumed more during the second, and demonstrated a cognitively mediated response.
Appetite and food intake is clearly a multifactorial issue. When natural feeding mechanisms can be overridden by environmental food cues as well emotional factors, gender, social networks and culture, habits and behavior appear to be the targets for intervention of obesity. In tandem with these behaviors a focus on recognition of responsiveness is imperative. Bringing forward unconscious signals to move toward food, as well as the seemingly automatic thoughts and behavioral processes that occur around food must be addressed in order for change to be possible. A sense of coherence, as Bongaard (2008) describes it, can give an obese individual the energy to change and develop healthier and more aware eating habits. Knowledge and education provide a substantial foothold in the way of helping others in making healthier food choices, and this needs to include education about the body’s hormones involved in regulating food intake. This cannot come at the expense, however, of cognitive and behavioral aspects of eating. Conditioned responses must be fleshed out, and recognition of restrictions and rigid patterns of behavior must be assessed, and in this case most specifically, targeting food rules or limitations that can lead to feelings of deprivation. Lastly, development of effective coping skills designed to both increase awareness and acceptance of emotions, as well as decrease negative or harmful thoughts and behaviors, must be included (Head, 2002). Clearly, a flexible, individualized approach is necessary to address and treat all of the factors related to appetite and food intake among the obese.
Benoit, S.C., Davis, J.E., & Davidson, T.L. (2010). Learned and cognitive controls of food intake. Brain Research, 1350, 71-76.
Bongaard, B. (2008, July/August). Mind over cupcake [Diet and Nutrition]. Explore, 4(4), 267-272.
Bray, G.A., & Champagne, C.M. (2005). Beyond energy balance: There is more to obesity than kilocalories. Journal of the American Dietetic Association, 105, S17-S23.
Head, S. (2002). Binge eating in obesity: Treatment and weight management issues. Healthy Weight Journal, 16(3), 24-26.
Heatherton, T.F., Herman, C.P., & Polivy, J. (1991). Effects of physical threat and ego threat on eating. Journal of Personality and Social Psychology, 60, 138-143.
Henderson, K.E. & Brownell, K.D. (2004). The toxic environment and obesity: Contribution and cure. In Thompson, K.J. (Ed.), Handbook of eating disorders and obesity (pp. 339-348). Hoboken, NJ: John Wiley & Sons.
Hormone regulates fondness for food. (2007, August 11). ScienceDaily. Retrieved from http://www.sciencedaily.com/releases/2007/08/070809172258.htm
Logue, A. (1991). The psychology of eating and drinking: An introduction (2nd ed.). New York, NY US: W H Freeman/Times Books/ Henry Holt & Co. Retrieved from PsycINFO database.
Mann, T., Tomiyama, A., Westling, E., Lew, A., Samuels, B., & Chatman, J. (2007). Medicare’s search for effective obesity treatments: Diets are not the answer. American Psychologist, 62(3), 220-233. doi:10.1037/0003-066X.62.3.220.
Mela, D.J. (2006). Eating for pleasure or just wanting to eat? Reconsidering sensory hedonic responses as a driver of obesity. Appetite, 47, 10-17.
Neumark-Sztainer, D. & Haines, J. (2004). Psychosocial and behavioral consequences of obesity. In Thompson, K.J. (Ed.), Handbook of eating disorders and obesity (pp. 349-371). Hoboken, NJ: John Wiley & Sons.
Nijs, I.M.T., Muris, P., Euser, A.S., & Franken, I.H.A. (2010). Differences in attention to food and food intake between overweight/obese and normal weight subjects under conditions of hunger and satiety. Appetite, 54, 243-254.
Powell, L., Calvin, J., & Calvin, J. (2007). Effective obesity treatments. American Psychologist, 62(3), 234-246. doi:10.1037/0003-066X.62.3.234.
Schlosser, E. (2001). Fast food nation: The dark side of the all American meal. New York, NY: Houghton Mifflin Company.
Slochower, J. & Kaplan, S.P. (1980). Anxiety, perceived control, and eating in obese and normal weight persons. Appetite, 1, 75-83.
Wardle, J. (1988). Cognitive control of eating. Journal of Psychosomatic Research, 32(6), 607-612.
Weller, R.E., Cook, E.W., Avsar, K.B., & Cox, J.E. (2008). Obese women show greater delay discounting than healthy-weight women. Appetite, 51, 563-569.
Zheng, H., Lenard, N., Shin, A., & Berthoud, H. (2009, June). Appetite control and energy balance regulation in the modern world: Reward-driven brain overrides repletion signals. International Journal of Obesity, 33(Suppl 2), S8-S13.
Eating disorders appear to know no boundaries and touch the lives of individuals of varying ages, of numerous ethnicities, of differing genders and heritages, of those within a range of socioeconomic positions, within many countries, and across significantly varied backgrounds and family histories (Palmer, 2000 and Thompson, 2004).
Despite the wide presentation of those who are impacted; however, certain individuals may be more vulnerable. The risks incurred as a result of various psychological, social, cultural, and behavioral influences and experiences are varied but certainly not random, with much research demonstrating specific characteristics which correlate positively with disordered eating (Palmer, 2000 and Thompson, 2004). This article aims to flesh out the risk factors for developing an eating disorder, with a focus on the above areas. Additionally, to highlight the impacts that both the environment and more internally driven mechanisms may have on eating disorder development, we will address the following areas: gender and biology; society and culture; age and developmental stage; individual factors, including personality, emotion, and life events; and family history.
Risk Factors for the Development of Disordered Eating
Gender and Biology
More than any other diagnoses found in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), the eating disorders demonstrate the greatest gender gap (Smolak & Murnen, 2004). Not only are females eight to nine times more likely to develop anorexia nervosa (AN) and bulimia nervosa (BN) than males, but these differences in gender, in every American ethnic group which has been studied, have been shown as early as elementary school (Smolak & Murnen, 2004). At this age, it is not uncommon for males and females to demonstrate body dissatisfaction. Children as young as 8 years of age have shown levels of desire to change their bodies (Thompson, 2004); however, the age at which most females will present with clinically diagnosable eating disorders is commonly mid to late teens for AN and mid-twenties for BN (Palmer, 2000).
The mid to late teenage years represent a time of significant maturation, both in the physical and emotional realms, and a period when individuals are navigating independence, relationships, and are particularly sensitive to their appearances and the attention of others. Many females start menstruating in their early teens or younger, their breasts begin to mature, hormones change, which can cause conflicting emotions, and weight gain is a natural consequence of this process (Palmer, 2000). Many females may struggle with accepting these changes in their bodies, and they can be compounded by perceived pressures to look a certain way and achieve a degree of thinness believed to be most acceptable in light of the ideal shape (Wertheim, Paxton, & Blaney, 2004). These societal and cultural ideals and messages are important antecedents in the development of eating disorders and will be discussed more fully later in this paper.
If during this time a young female is provided with less than nurturing and supportive messages, she may well be on her way toward “psychobiological regression” (Palmer, 2000, p. 58). Arthur Crisp, a leading researcher in disordered eating, described how through eating restraint and significant loss of weight, as occurs with AN, the normal biological processes are halted (Palmer, 2000). A female who may be stressed with the process of growing up may take pleasure in her body remaining less mature (Palmer, 2000).
Society and Culture
This is quite an interesting concept, when as consumers the images portrayed are those of voluptuous, curvy women. But consider how often these curvaceous females have only breasts that are large, and their other body parts remain relatively small- hips and thighs for example, which for many women are the areas where they may carry the most fat, and fat that is biologically more imperative for child-rearing.
Males are not immune from risk during this time, however. An estimated one third of males express a desire to be thinner, and an equal number would like to be more muscular (McCabe & Ricciardelli, 2004). Quite the opposite of the female ideal, one that is much thinner than the average woman, the males portrayed in the media, for example, in magazines, movies, modeling competitions, and even action figures, are portrayed quite differently than average also, carrying a lot more muscle (McCabe and Ricciardelli, 2004). While diet and exercise for weight loss is the focus for many women, 44% and 68%, respectively, approximately 15% and 52% of males engage in the same (McCabe and Ricciardelli, 2004). Those who have weight concerns have shown high exercise dependence as opposed to dietary restriction as is seen with many females, and steroid use with the purpose of building muscle has been shown in 1-12% of males (McCabe and Ricciardelli, 2004).
Society and the perceived ideal body weight and shape significantly influences how one may feel about his/her body. One’s self-esteem is impacted, which can lead to meanings being associated with food, weight, and one’s body. Low self- esteem can be both a risk factor for developing an eating disorder, but also a consequence of having an eating disorder (Palmer, 2000). Many theories have been outlined to explain how society’s focus on slimness is a primary risk factor in eating disorder development, some with a heavy focus on feminist perspective detailing how women’s upward mobility and independence has created a stereotypical bent toward adopting a more male-like figure to emerge as more socially powerful creatures (Palmer, 2000).
Women’s roles have certainly changed over the years, with more women waiting to have children, working outside of the home, and acquiring positions of substantial power that may historically have been male dominated. Additionally, a greater number of women are earning larger incomes and taking on greater responsibilities in their fields. With higher power positions comes the additional pressure of being in a more prominent role and perhaps more on display (Smolak & Murnen, 2004). Objectification theory explains that this feeling of being on display has been shown to lead to increased dieting due to body shame, as historically, men’s bodies have been regarded as acting and performing and female’s bodies evaluated (Smolak & Murnen, 2004). Situations such as this can create significant stress, and depending on one’s ability to manage that stress, in the context of one’s personality characteristics, cultural background, occupation, as well as family variables, eating restraint is often initiated.
Eating restraint cannot be addressed without a discussion first; however, of culture’s impact on disordered eating behavior. The power of one’s surroundings, whether people or places, is significant. For example, within the gay culture, 42% of men, over a 15 year period, were treated for BN (Anderson-Fye & Becker, 2004). Moreover, consider the effect of socioeconomic status on the increased risk of eating disorders. African Americans, Asians, Native Americans, and Latinos have all demonstrated an increase in disordered eating as a result of increased upward mobility (i.e. social status) (Anderson-Fye & Becker, 2004).
Social roles, food access, and perceptions of normative body weights are often influenced by an increase in social status. Elevated social status affords greater access to technology. People in westernized nations, as a result of technological advancement, are bombarded with images portraying unrealistic body ideals (Anderson-Fye & Becker, 2004). This phenomenon is confirmed by the significantly higher prevalence of eating disorders in urban areas as compared to rural (Anderson-Fye & Becker, 2004), and as individuals from other countries immerse themselves in the surrounding culture, stress increases with the pressures to adopt the behaviors and bodies of that culture (Anderson-Fye & Becker, 2004).
An example of acculturative stress is demonstrated by the Fijians, who have historically been substantial eaters with more robust body sizes, but of late have adopted behaviors like those found in more westernized societies. Cultures which have been examined for the body ideals they most emulate, showed less risk of disordered eating when those ideals were larger (Anderson-Fye & Becker, 2004). In effect, acceptance of higher body weights is protective against eating disorders (Anderson-Fye & Becker, 2004). Not surprising, it is those cultures that put more stock into caring for their bodies in terms of health rather than appearance that show less disordered eating tendencies.
Obviously, multiple and comingling elements are involved in the development of disordered eating. However, one factor in particular, eating restraint, is the most common link between those diagnosed with eating disorders. Eating restraint often has as its antecedent, weight loss and the desire to change one’s body shape and size (Palmer, 2000). The purposeful limiting of the amount of food consumed, restrained eating results in eating less than one’s hunger would normally direct. It is perpetuated by beliefs and attitudes about food and body weight, the behaviors of others, and the consequences of either maintaining a body weight that is higher than the norm or losing weight and receiving positive reinforcement for such behavior (Palmer, 2000).
The act of restraining eating can cause obsessions about food, lead to frequent urges to eat, may lead to binging, and influence food rules (Palmer, 2000). An individual who does not exhibit disordered eating behaviors may be dieting and perhaps overeat at a meal without accompanying guilt, fear, or a feeling of low self-worth. On the other hand, one who is restraining to lose weight and breaks a rule of meal size might subsequently eat more than she typically would. In essence, this individual may think, “I already screwed up, so I might as well eat a ton more…” This concept of “counterregulation” (Palmer, 2000, p. 43), exemplifies the beliefs that can become skewed in one with disordered eating. These beliefs are impacted by one’s individual personality characteristics.
Aside from personality, eating restraint may be perceived as a necessary part of one’s occupation as well. Ballet dancers, for example, may feel pressure to achieve and maintain a certain body weight in order to perform optimally or even to meet industry standards. Jockeys, gymnasts, and other athletes such as wrestlers, skaters, and rowers, who are subject to regular weigh-ins, are at an increased risk of developing disordered eating just as a function of being required to maintain a body weight that perhaps has been perceived as critical to peak performance (Anderson-Fye & Becker, 2004). Those individuals who are involved in sports or weight-emphasized activities at a young age and are subjected to body scrutinization, for example, models, receive messages early on about the importance of body size and shape. These messages, again in tandem with personality, can severely impact one’s risk of developing an eating disorder.
Personality Variables, Life Events, and Family History
Personality variables include the interaction of cognitions and emotions. The cognitions commonly experienced by those with AN or BN, as well as the emotions found to be consistent among those with eating disorders can be both inciting factors and consequences of the disordered eating behavior. Common among the majority of those who present to treatment are low self-esteem and perfectionism (Palmer, 2000). Body image disturbance and rigid thinking demonstrated by one’s subjective reality not matching with what is evidential are also demonstrated frequently (Palmer, 2000).
Of a more severe nature is the emotionally reactive behavior, mimicking that of Borderline Personality Disorder, exhibited by many individuals with BN (Palmer, 2000). Dramatic and erratic behavior is common, as well as a lack of emotional regulation and coping skills (Palmer, 2000). On the other hand, those with AN exhibit more anxious and fearful personalities accompanied by obsessional tendencies. Obsessive compulsive disorder appears to be a major risk among these individuals (Palmer, 2000). Social phobia and anxiety symptoms are common within both of these disorders, and approximately half of those diagnosed with BN demonstrate comorbid depression (Palmer, 2000). With low skill in identification and regulation of emotion, those with AN and BN often react to events or situations in a fixed and inflexible manner in an attempt to exert control (Palmer, 2000). Much has been written about eating disorder sufferers’ necessity to control food when feeling out of control in other areas of life. Without effective coping skills, food may be used to avoid events experienced as tumultuous (Palmer, 2000).
Reactions such as these are considered to be innate in some cases (Palmer, 2000), but often learned within family environments. Affective disorders, for example, are known to run in families, with BN having the strongest familial etiology. First degree relatives of AN and BN sufferers demonstrate an excess of eating disorder cases, and mood disorders are higher in families of those with AN and BN (Palmer, 2000). Interaction patterns within families can contribute significantly to the risk of developing disordered eating as well. AN and BN sufferers often recollect adverse conditions including low contact and unreasonably high expectations within their families as compared to individuals with other psychological disorders (Palmer, 2000). Importantly, eating attitudes often run in families, and the messages that one’s parents give about food, body weight, and body size contribute significantly to how an individual’s self-esteem will develop, how social roles will be adopted, and how internal conflicts will be managed (Palmer, 2000). Often talked about more in the sphere of ‘emotional eating’, one’s behaviors toward food may be influenced by experiences like being comforted or punished with food or being told to clean one’s plate and being rewarded with dessert, for example. In these cases, one might attach an emotion to food. As such, beliefs about food and its meaning can become skewed.
More offensive risk factors include sexual abuse or emotional abuse, which present situations of tremendous loss of control. In fact, childhood sexual abuse is quite prevalent among individuals with BN and AN with the binge component (Palmer, 2000 and Thompson & Wonderlich, 2004). Sexual abuse may cause a girl to reject her own body as it was the vessel used by another to commit the act, the binge behavior used to avoid uncomfortable emotions. Moreover, dietary restraint, binge eating, and emotional eating have been attributed to “loss of voice” (Smolak & Murnen, 2004, p. 595) in adult women. Described in the literature as a consequence of abusiveness by a partner that is tolerated in conjunction with one’s personal needs being ignored, loss of voice is another example of what can feel like a loss of control (Smolak & Murnen, 2004). Clearly, treatment by others and the environment in which one is raised and matures bear significant roles in the development of disordered eating.
The question of who is at risk for eating disorders is a complicated one to answer. No one factor is demonstrative of how an individual will move from a healthy desire to lose weight to a significant fear of weight gain with accompanying body image disturbance. Various pathways exist to explain the process of moving into and beyond eating restraint and into adopting dysfunctional behaviors that approach the criteria necessary for an eating disorder diagnosis. The psychological mechanisms elucidated above can stem from one’s family environment, as well as cultural and societal influences. In addition, the interaction between these and one’s uniquely individual personality characteristics can mean rigid ideas generated as a result of comments made about weight, conflict between parents, and negative peer group interactions. While there does appear to be a widely variable presentation among those with eating disorders, the evidence that does exist regarding the factors that most often prove influential may guide a clinician’s assessment and treatment strategy. Understanding that the elements involved can take on a variety of appearances, a clinician can be better equipped to evaluate both the antecedents of the disordered eating behavior, as well as those that may be involved in their maintenance.
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Recidivism among dieters has prompted major revisions in treatment methodology as researchers discover the significant contributions of genetics, psychology, and environmental factors to eating behavior. More than 85% of Americans have dieted during their lifetimes, yet the majority of diets offer little flexibility to accommodate the biopsychosocial components of the dieter’s life. Weight regain is virtually inevitable under these circumstances as self-regulation and emotional management deteriorate. No longer can the traditional focus of nutrition from the calories in versus calories out approach; exercise; and cognitive behavioral therapy (CBT) be considered the gold standard intervention trifecta. Studies report a 98% relapse (weight regain) rate following weight loss. Approximately 50% is gained back after three years and the rest gained back after five years. While discouraging, we can learn a lot from the two percent who are successful maintainers. What do they do? How do they think? Where do they differ in regards to behavior? Research accessing the lived experiences of successful and unsuccessful maintainers offer rich details that those of us who are actively engaged in the weight loss process and preparing to embark into maintenance can begin applying.
1. Be constantly vigilant: The dedication you implement during weight loss must continue during maintenance. The effort you put toward your health cannot stop once you have reached your goal weight. Ask what you are doing now that you are willing to continue with when you achieve your goal. Defensive pessimism, a concept described in the weight loss literature, explains the adoption of an approach with a foothold in reality. Successful maintainers anticipate threats that may occur, know that there will be times they struggle, and plan ahead accordingly. Any goal that is met with commitment is one we will work toward with a “no matter what” attitude. Relying on motivation for goal achievement will lead to disappointment—we will often “not feel like it” or “not want to” do something, but those who keep on keeping on understand the fleeting nature of feelings. With practice, they can more easily move past them and onto how happy and encouraged they will feel if they follow through with what they know is in their best interest. Self-determination theory classifies these types of goals as intrinsic. Weaved into the fabric of our lives, intrinsic goals parallel our core values.
2. Develop a support system: Not only is support the number one factor contributing to well-being and resilience, it is a primary element in maintaining commitment to weight maintenance related behaviors. While research shows that responsibilities in other contexts, such as familial, relationship, career, etc. can create tension that can lead to goal-compromising behaviors, having a support network minimizes the negative effects of goal threats.
3. Challenge your ingrained beliefs and behaviors: Most individuals who have been on and off of diets for most of their lives acknowledge the entrenched beliefs and meanings around food often created in childhood. Food as comfort, food as love, and food as a stress reliever are three of the most commonly held attachments to food. Many of us grew up hearing “clean your plate” or “you can have dessert when you finish your dinner.” Throwing away food was unacceptable. On the other hand, many are brought up in households of abundance. Food was always available and access unconnected to hunger. In essence, it was used as a pacifier when negative emotion was experienced (i.e. getting a cookie from during a time of upset). Successful maintainers become conscious of their motivations to eat and begin rewriting their narratives about food and the relationship they want to have with it.
4. Self-monitor: The National Weight Control Registry is a wealth of information from over 10,000 individuals who have lost and maintained their weight for significant periods of time. Self-monitoring is one behavior you will hear them mention repeatedly as critical to their weight maintenance success. Practical aspects of monitoring include consistent weight tracking, monitoring of portions, engaging in regular exercise, and setting boundaries around eating practices. Emotional monitoring to avoid engaging in stress eating or eating for reasons unrelated to hunger include practicing awareness and management of stress, choosing more effective methods of dealing with negative
emotion, but also being flexible and compassionate with one’s self when setbacks occur.
5. Adopt a growth mindset: Carol Dweck, a researcher from Stanford University, has studied the difference between a growth versus a fixed mindset and its impact on goal achievement. Individuals who take steps toward their goals with a growth mindset focus on discovery and exploration and believe that through learning they can develop skills and enhanced knowledge and proficiencies. It encourages persistence and expectations of failure for the purpose of greater success. We learned to walk by falling! A fixed mindset, on the other hand, encourages one to give up easily and reduces the likelihood that grit will be extended toward mastering something new. The concept of neuroplasticity and the manner in which we can be active participants through adulthood in changing our brains should provide ample evidence and motivation to continue learning! The growth mindset spurs individuals to be on the lookout for opportunities, and expansion of one’s biases and normal ways of behaving increases gray matter in the areas that matter most too. Your prefrontal cortex will thank you! Finally, successful maintainers adopt a non-perfectionistic approach. While they may not like failure, they embrace it and give themselves permission to experience it; they allow versus avoid painful emotions and disappointment, thus positioning themselves toward greater pleasure; and they are grateful for their successes.
6. Be structurally flexible: Successful maintainers understand how rigid food rules and depriving themselves of their favorite foods creates more cravings, more urges, and the propensity to binge. They realize that they can’t eat whatever, whenever, but they plan for indulgences in moderation. Structured flexibility gives them a sense of control without the belief that willpower will carry them through the tougher situations. They learn to ask questions of their cravings and check in with themselves to understand what might be driving their urge to eat. They practice recognition of black and white/all or nothing thinking as well as distorted thinking that propels them toward mindless or emotional eating. For example, the use of “I choose not to” versus “I can’t eat that” feels empowering and more intrinsically motivating. Being structured but flexible means having high expectations in combination with the understanding that uncertainty is inevitable and will require reflexivity and responsiveness rather than impulsivity.
7. Develop a toolbox of strategies: Different contexts demand different strategies. What is effective in one situation may not be appropriate for another. But successful maintainers know that they have the choice to change their environments or change the way in which they respond to them. In some contexts, an “if__________, then____________” approach can work well. This is called an implementation intention. For example, “If Don asks me if I want some dessert, then I will say ‘no thank you’ and excuse myself.” In other contexts a more flexible, responsive approach is needed. This could mean drinking more water when a cravings is felt; pausing to really assess physiological hunger; repeating a motivational, empowering mantra; asking a question to increase awareness; and/or slowing down during a meal to fully experience satisfaction and reduce overeating. In essence, successful maintainers create rituals—new patterns of behavior that help to create lasting, meaningful change.
8. Master mindfulness: Successful maintainers describe how they’ve acquired a new sense of themselves—about their bodies, about their minds, and about their lives and what is important to them. As they have practiced opening up to new experiences, objectively assessing their circumstances, and observing their behavior less judgmentally, they see their lives through new lenses. They practice being present, more compassionate, paying attention, deepening their awareness, avoiding avoidance, and intentionality. Through such practices, a successful maintainer can recognize that different identities sit down to eat sometimes – identities based on prior learning, on comparisons of self to others, and ideas about what others believe.
Don’t miss out on the discussion! Tell us about your emotional triggers and the biggest difficulties you’ve had as you move toward your goal of weight loss OR if you’re working on keeping it off! What bogs you down and gets in your way?
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Ask yourself: Am I confident?
Got an answer?
I anticipate a few different responses:
- “Hell yeah, baby! I’ve got it going on!”
- “Um, I guess. It kinda depends on the situation.”
- “I wish I was more confident. I struggle with having pretty low self-esteem.”
Obviously the answers can vary tremendously, but I’d say that like most aspects of behavior, your answer for your level of confidence will operate on a continuum.
You’re likely thinking that you should be able to answer the question with something close to #1, yet avoiding what would be construed as arrogance and pretentiousness.
Research indicates that lack of confidence is actually healthy. It’s a driver for assessing your weaknesses and learning more in order to better yourself. Don’t confuse this please with a lack of self-efficacy and learned-helplessness. No, you weren’t born with your intelligence being genetically determined. Genes are important, yes. They provide the foundation for what makes us, well, us. However, it’s the environment and how we think and what we do and the activities that we engage in that unlock our genes and govern their expression.
Experience changes our brains in substantial ways. Mindful awareness exercises produce noticeable increases, for example, in brain matter density in the areas responsible for attention and emotion regulation. Why? Because with effort put toward this behavior and our attention being directed in this intentional manner, we increase blood flow to those areas. More blood flow means more nutrients and capillaries growing in those regions.
But back to confidence– if your confidence tank was always topped off how often would you be motivated to try something new, read a book, ask questions, meet people, engage in a challenging conversation, or take lessons to strengthen your skill in a particular area?
In his book, Confidence: Overcoming Low Self-Esteem, Insecurity, and Self-Doubt, Dr. Tomas Chamorro-Premuzic explains how when you look past confidence, what you find is an underlying desire to be competent. We often confuse the two concepts. In essence, when you say, “I lack confidence”, what you’re really expressing doubt about is your competence level in a certain area.
Competence is actually a key factor in our level of motivation and the determination we implement toward a goal. One of our basic psychological needs, it represents our felt sense of mastery and skill. If we hear ourselves saying, “I doubt I can do this” or “I’m not confident I can succeed with this” perhaps this isn’t negative at all, as many people would think it is. I’ve heard plenty of people comment in reply to statements like this, “Have faith!” or “Have confidence! It’ll happen!” Is it important to be positive? Sure. There’s plenty of research that shows a positive attitude changes the biochemistry in our bodies, results in improved health and immunity, and even changes the outlooks of those around us. But let’s not be unrealistically optimistic. “I doubt I can do this” gives us impetus to ask the next question, “What do I need to consider as I move forward?” and “Are there obstacles that I might encounter along the way, and how might I prepare for them?” Anticipating in this manner creates an environment that leads us in the direction of greater competence, and confidence will follow!
Happiness huh? How can you be more happy? New podcast on TheDietDoc! http://ow.ly/p10JZ
Happiness huh? How can you be more happy? New podcast on TheDietDoc! http://ow.ly/p10JZ