Improving Relationship with Food and Eating
This article is intended for people who wish to learn about evidence-based strategies to adopt normal attitudes and behaviors towards food.
We will start off talking about the continuum model of eating disorders, which forms the foundation for the evidence-based strategies. Thereafter we shall take up intervention strategies to target disordered attitudes and cultivate normal eating and also target disordered behaviors.
The continuum model of eating disorders: It’s essentially a model that describes how eating behavior lies on a continuum or lies on a spectrum, ranging from normal eating to a full blown clinical or clinically significant eating disorder.
Therefore, this article will describe Continuum Model, which includes:
- Normal eating
- Disordered eating
- Eating disorders
Isolated intervention strategies to target disordered attitudes and cultivate normal eating: Isolated intervention strategies are designed to cultivate normal eating, so designed to really induce it or help a person get from disordered level or eating disorder level towards more normalcy and there are various techniques.
- Weekly weighing
- Gratitude journals
- Nutrition education
- Functionality appreciation
- Beliefs testing
Isolated intervention strategies to target disordered behaviours: The two strategies that we will discuss stand in contrast to each other. They both serve different purposes but are useful.
- Intuitive eating
- Structured, flexible eating
Brief introduction to normal eating, disordered eating and eating disorders
“Normal” eating: Healthy relationship with food, eating, exercise and body image that has no noticeable impact on functioning and quality of life.
“Disordered” eating: Pattern of maladaptive attitudes and behaviours towards food, eating, body image and exercise that is beginning to have broader impacts on mood, social functioning, physical health and quality of life.
“Eating Disorder”: A class of behaviours that are sufficient in frequency and intensity to warrant criteria of a clinically significant eating disorder, like anorexia nervosa, bulimia nervosa and binge-eating disorder. Warrants immediate attention and intervention due to its devastating effects.
The Eating Disorder Continuum Model
Distinguishing normal eating from disordered eating and eating disorders:
There is actually no accepted or agreed upon definition of what normal eating actually constitutes. But we have some idea of the characteristics that resemble normal eating, so we can define, even though there’s no standardized definition, by aggregating literature together, normal eating seems to reflect a healthy relationship with food, eating, exercise, and body image that has no discernible impact on a particular person’s functioning or quality of life.
Again, there is no universally agreed upon definition of disordered eating. But if we are to aggregate the literature together, it seems to reflect a pattern of maladaptive attitudes and behaviors towards food eating, body image, and exercise that has broader impacts on mood, social functioning, physical health and quality of life.
So disordered eating is beginning to show signs of those particular problem eating behaviors or attitudes that we’ve seen. And it’s also impacting broader aspects of someone’s life. So, when that’s the case, it’s kind of indicative that it’s starting to become disordered, but it does not necessarily mean that the person has an eating disorder. I think it’s very important to distinguish between the two because someone can exhibit episodes of disordered eating but not have an eating disorder. But someone who has an eating disorder by definition, must experience episodes of disordered eating or attitudes of disordered eating.
Broadly speaking, an eating disorder is a class of behaviors or attitudes, but mainly behaviors that are sufficient in frequency and intensity to warrant criteria of a clinically significant eating disorder that we typically hear about such as anorexia nervosa, bulimia nervosa, and binge eating disorder.
And someone who has a clinically significant eating disorder usually shows marked impairments in quality of life and psychological or social functioning that warrants immediate and sufficient clinical attention because of the profound effects that it has.
There is no standardized, accepted definition in the literature as of yet, However, we do have some idea of the characteristics that might resemble normal eating. Following are the characteristics of normal eating:
- Starting a meal relatively hungry and eating until feeling content (not overly full)
- Incorporating a wide variety of foods in your diet that serve many different important functions
- Allowing yourself to eat because you feel happy, sad, or lonely
- Eating enough food regularly throughout the day so that your body can function at optimal capacity
- Not rushing to finish off a packet of sweets because you know you’ll let yourself have some again at a later time
- Is overeating on some days and undereating on other days
- Flexible and adapted to the situation at hand
- Hard work – it can take up a lot of your time, effort and energy
Normal eating is really being guided by internal cues because your body knows best. Your body will know when it needs to eat and when it can finish or stop eating, or when it’s had enough. So, getting towards normalcy of eating when feeling hungry and stopping when feeling full is actually considered an aspect or a characteristic of normal eating.
Focus on other purposes of food
Normal is instead of allowing someone not only to incorporate a broad range of food, but also for many different purposes, not only for health-related reasons, but also for social related reasons, personal related reasons, for taste related reason. Focusing just on the pure physical health effects and on the calories and the macro nutrients of specific food types is only half the picture. We also need to focus on what other purposes food brings us. Food brings us joy. It brings us together socially.
Eating to feel better is a normal process
Normal eating is also allowing yourself to eat because you feel happy, sad, lonely, or any other different emotions. If you are ignoring your emotions and you’re stifling them and stuffing them down and not using food as kind of a way to help, soothe, this could actually be considered part of an abnormal process. I would argue that emotional eating is only problematic if you feel worse, after you’ve eaten out of emotion. So, if eating out of emotion is not actually fixing the emotional distress that you’re experiencing, then that is an issue and it’s something that needs to be changed. But if you feel much better or significantly better after eating something when you are experiencing a certain emotion and you actually soothe yourself and calm yourself down, then that is actually a normal process.
Consuming enough energy to perform a wide variety of tasks for a sustained period of time
Normal eating is also eating enough food regularly, throughout the day so that your body can function at optimal capacity. People who exhibit disordered eating tendencies tend to restrict themselves, they tend to display abnormal signs of eating, like fasting, skipping meals and things like that. And the consequence of that is their body isn’t functioning to an optimum capacity. So, normal eating actually entails making sure that you get enough, you’re consuming enough energy so that you can perform a wide variety of tasks for a sustained period of time. I think that’s a crucial component of normal eating and something that you want to instil in. Prolonged energy restriction can be very problematic in a number of different domains.
It is acceptable to eat in moderation something that one feels one shouldn’t eat
Normal eating is also not rushing to finish up a packet of sweets because you know you will allow yourself to have them again at a later time. The classical behaviour of someone with an eating disorder is that when they have consumed something they feel like they shouldn’t have, like a couple of cookies or something. Then they are frantically trying to finish off those cookies so that it is not therefore present for the next day, so they don’t have that temptation again. That is seriously abnormal type of behaviour and cognition that we need to eliminate. So, what we should be striving for is a safe environment where someone has things in moderation and is OK and is acceptable with that because they know at a later date that they can then have that thing again, also in moderation.
What ultimately matters is the long term trends in patterns
Also, overeating on some days and undereating on other days is normal eating. We are not machines; we are not designed to consume the exact same number of calories per day and the exact same macronutrient split each day. If you ate more on one day, that is fine. The next day you ate a little bit less, that is also fine. Because what ultimately matters is the long term trends in patterns. Day-to-day fluctuations do not matter. It’s more so over a prolonged period of time. It’s more so over the weeks over the months and even the years that matter. These minor fluctuations are not a big deal. It is considered a component of normal eating.
Normal eating is showing skills of adaptation or flexibility
Normal eating is also a flat, very flexible and adapted to the situation at hand. This brings me back to my earlier point that we are not machines, we are not drilled to operate in a certain way, every single day. We need to adapt to the ever-growing demands of our personal circumstances, so we need to be able to be on our toes, and on our feet if something comes up, we need to adapt accordingly. So, normal eating is showing skills of adaptation or flexibility but still not have a profound impact on day-to-day functioning.
Normal eating is hard work
And the final characteristic of normal eating is that it is a very hard work. Some people feel that moving from disordered eating to normal eating is easy and will happen suddenly and that they will not have to bother for food anymore. No, that is a common misconception. It is important to be able to think about food regularly. It does take a lot of time. It does take a lot of energy and it does take a lot of effort, but ultimately at the end of the day, if someone can get a normal relationship with food, with eating, with their body image, then that will go a long way to improving multiple aspects of their functioning or their day-to-day life.
Moving along the continuum: Disordered eating
Again, there is not really an accepted or agreed-upon definition of disordered eating.
- Reflects problem patterns of behaviour or attitudes towards food or eating that show associations with functional impairment
- Present in people with and without an eating disorder. What is disordered for one may not be disordered for another.
- If the behaviour/attitudes do not result in some sort of impairment, then, conceptually speaking, this does not resemble disordered patterns. Very rare for this to be the case.
- People are usually not very good at predicting or identifying these impairments
- Common domains that are impaired include:
- Rapid weight gain/loss
- Social exclusion/isolation
- Mood shifts
- Health complications
A common feature of disordered eating is that people’s social relationships tend to suffer markedly. Classical example is someone who is going on a very strict and regimented diet avoiding going out to parties or celebrations in fear of what type of food will be presented at those settings.
Disordered Eating: Behaviours and Attitudes
|Disordered behaviours||Disordered attitudes|
|• Fasting/skipping meals||• Obsessive thoughts around what, when, and how much to eat|
|• Excluding certain foods or food groups out of fear of weight gain||• Black-and-white view of food, eating and dieting|
|• Self-induced vomiting||• Overvaluation with weight/shape|
|• Use of laxatives or diet pills||• Feeling fat irrespective of BMI|
|• Compulsive exercise||• Unhealthy fears of weight gain|
|• Binge/loss of control eating||• Fears of eating out|
|• Cigarette smoking to reduce appetite||• Lack of insight towards the nature of their disordered behaviours|
|• Yo-Yo dieting||• Inflexible food rules/beliefs|
|• Eating in secret out of shame/guilt|
|• Obsessive calorie counting|
|• Repetitive/obsessive weight/shape checking|
Moving along the continuum: Eating disorders
Eating disorders have a very specific and clear definition. It refers to a class of psychiatric conditions that reflect severely disrupted patterns of eating that have a marked impact on psychological functioning and that’s according to the APA (American Psychiatric Association) or the DSM (Diagnostic and Statistical Manual of Mental Disorders).
- Very specific criteria needs to be met in order to be classified with an eating disorder
- Bulimia Nervosa
- Recurrent episodes of binge eating (once per week, average) in combination with inappropriate compensatory behaviours and an overvaluation with weight shape.
- Binge-Eating Disorder
- Recurrent episodes of binge eating in the absence of any recurrent extreme weight control behaviours. It is very similar to bulimia nervosa, but the only difference is that there’s an absence of extreme weight control behaviours like self-induced vomiting or compulsive exercise, laxative use, et cetera.
- Anorexia Nervosa
- Anorexia nervosa is the more common eating disorder we tend to think about defined or characterized by an extremely low body weight and that low body weight is due to persistent and chronic energy restriction, and there’s usually some degree or heightened degree of body image distortions. That is expressed through an intense fear of weight gain or feeling facts. So, this is where we see that, that person or that young girl or even boy who is very, very emaciated and they’ve got very, very little body fat and they weigh quite little. And that is the most devastating life-threatening eating disorder we have. It’s the eating disorder, it’s the psychiatric condition that’s associated with the highest mortality rates.
- OSFED stands for ‘other specified feeding or eating disorder’. Those who resemble the symptoms for one of the three eating disorders above, but who just fall short on specific criteria required.
We usually see that people who exhibit an eating disorder are much more worse off than people who exhibit more milder symptoms or patterns of disordered eating. But in order to have an eating disorder, you need to be able to meet a bunch of very specific criteria, and if you don’t meet those criteria, then you don’t meet classification for a particular eating disorder.
Cultivating normal eating patterns
Evidence-based intervention approaches help clients move from disordered eating/eating disorders to normal eating. Strategies for cultivating normal eating patterns are designed to target either the behaviour or the attitude, but what we usually find is an effect on both of them.
- Evidence-based intervention strategies designed to target the cognitive or behavioural features of disordered eating/eating disorders
- The ultimate aim is to help people move further to the left of the continuum, wherever they currently stand
- The safety and effectiveness of certain strategies will depend on how far along the continuum the person is
- Example: Intuitive eating strategies are not appropriate for those with eating disorders, but are for people who exhibit milder signs of disordered eating.
- The usefulness of the particular strategy will also depend on your goals, motivations, temperament etc.
- These strategies usually form part of a full program that contains many different elements that work in tandem
Strategies to target disordered attitudes
Supervised Weight Checking
- Description – once per week weight checking with health professional to help interpret the longer-term trends in body weight changes.
- Health professional must education client on factors that influence moment-to-moment fluctuations and why interpreting short-term fluctuations is harmful
- Intervention target – reduces the frequency and intensity of shape/weight concerns and an overvaluation with weight and shape
- Hence has a flow on effect to other behavioural symptoms
- Target population – very helpful for people with a clinically significant ED (regardless of the subtype)
- Unclear about whether this strategy is useful for the general population with milder shape/weight concerns. Perhaps weight avoidance more appropriate?
- Description – an exercise where you take a moment to write down on paper 10 things, you are currently thankful for in your life
- Might sound a little “corny”, but there is a strong body of literature highlighting the mental health benefits of gratitude exercises
- Intervention target – targets immediate obsessions and preoccupations with food, eating, and body image because it forces clients to redirect their attention towards things that are independent of these domains
- Target population – general population of people who exhibit body image concerns and dysfunctional eating attitudes.
- Not appropriate for people with eating disorders.
- Safety and efficacy has yet to be established, not even within a broad suite of intervention strategies
Basic Nutritional Education
- Description – health professionals provide basic, easy-to-understand nutritional information to their clients to prevent the onset of new disordered eating attitudes
- The role of different macro and micronutrients
- Energy consumption and weight gain
- Calories retained after methods of purging
- Differences between gaining fat versus gaining body weight
- Intervention target – inflexible food rules and diet beliefs that put people at risk for disorders of recurrent binge eating
- Target population– at all stages of the continuum
- Usually sufficient as a stand-alone universal prevention strategy, (i.e. for those who don’t yet resemble any risk/symptoms) but also often embedded in the psychoeducational component of existing CBT for ED treatments
Functionality appreciation exercise
- Description – reflective and writing exercise; clients are asked to write down the importance of their most valued body functions. Probe clients to answer the following:
- Why are those functions important to you?
- How would your life change if a certain function was taken away?
- Could you live a meaningful life if you couldn’t perform all of these identified functions?
- Intervention target – enhances positive aspects of body image (e.g. functionality appreciation, body appreciation, appearance satisfaction) and exercise (e.g. exercise for health-related reasons), but is also effective at addressing body objectification & dissatisfaction
- Target population – only for non-clinical samples who display signs of mild body concerns
- Avoid using for people with an eating disorder – no evidence, as of yet, in clinical populations
Belief Testing Experimental Exercises
- Description – Exposure exercise that you should practice over the course of months
- Generate list of feared, forbidden foods and classify them into three groups: Red traffic light (most feared); yellow traffic light (moderately feared); green traffic light (feared, but could eat if forced)
- Start off introducing one green traffic light food once per day for a week
- Documents belief you are testing
- Come up with an expected & alternative hypothesis on what’s going to happen by re-introducing this food
- Record the outcome after 1 week
- Re-rate initial belief
- Belief usually changes and consequently fear ceases
- Intervention target – irrational beliefs about different food types & groups and inflexible dietary restraint (see Fairburn 2008 for a full description)
- Target population – usually people with clinical EDs, but can also be used early as a prevention approach for people starting to restrict their food through obscure rules
Strategies to target disordered behaviors
- Description – Eating based on internal hunger/satiety cues
- Self-monitoring of eating behaviour
- Ratings of perceived hunger before, during and after meals
- Understanding the difference between physical & emotional hunger
- Mindful eating micro-exercises during meal times
- Slow chewing, fork down, no distractions, seated at all times etc.
- Intervention target – directly addresses dietary restriction practices, disinhibited eating, and loss of control eating
- Target population – useful as a public health approach or an element of ED prevention
- Professional opinion – avoid using this in people with an eating disorder
- Evidence is very over exaggerated
Structured, flexible eating
- Description – Pre-planned eating schedule that “mandates” 3 meals and 3 snacks per day, no more than 4 hours apart
- The contents of the meals/snacks are not important initially
- Central focus is to regain control in the initial stages
- Intervention target – targets severe disordered eating behaviours, including fasting/skipping meals, undereating, and binge or loss of control eating
- Arguably the most important element of CBT for eating disorders
- Introduced in the second session and is largely responsible for the well-known rapid response
- Target Audience – every ED subtype; beneficial at all different ED presentations
- No reason why structured eating in this way wouldn’t be beneficial for the general population
- Numerous benefits other than reductions in binge eating & extreme restriction
- The nature of eating problems lies on a spectrum
- Normal eating => Disordered eating => Eating disorders
- Isolated intervention strategies designed to target specific disordered eating features, help bringing people back to “normal”
- Key intervention strategies that are more commonly used to heal your relationship with food
- Weekly weighing
- Gratitude journals
- Nutrition education
- Functionality appreciation
- Beliefs testing
- Intuitive eating
- Structured eating
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Abhinav Malhotra is an award-winning personal trainer, coach and sports nutritionist in Dubai, UAE. He also offers online services to clients around the world. A personal trainer par excellence, Abhi has worked with the world’s leading fitness chains, supplement brands and founded his own fitness academy in India. He has achieved successes for many clients from all backgrounds and has trained the Indian Army Rugby Team. He is the first International Kettlebell Sport athlete from India.