Thursday, August 5, 2010

A History of Eating Disorders

The first descriptions of anorexia nervosa in the Western world date from the 12th and 13th centuries, most famously Saint Catherine of Siena (1), who denied herself food as part of a spiritual denial of self. By the sixteenth century, ascetics were considered witches and burned at the stake. There are several other clinical descriptions of "wasting disease" in the 17th-19th century, and in the early 20th century, anorexia was considered an endocrine disorder and treated with pituitary hormones. In 1973, Hilde Bruch published a book with a number of case studies, called Eating Disorders: Obesity, Anorexia Nervosa, And The Person Within. As the disorder reached public awareness in the 1970s, cases increased, spreading beyond the upper class.

Bulimia (binging and then purging via exercise, vomiting, or laxatives) is first reliably described among some of the wealthy in the Middle Ages, who would vomit during meals so they could consume more (2). (Apparently this behavior did not happen in ancient Rome despite a common conception otherwise (3)). The first clinical paper on bulimia came in 1979 - Bulimia nervosa, an ominous variant of anorexia nervosa.

Everyone agrees that the cases of anorexia and bulimia escalated in the 1970s and 1980s, and though some will say they peaked in that time, the national survey data suggests that bulimia, especially, continues to escalate. While most scholars will point to cultural pressures for thinness, increasing depression and obsessive compulsive behavior, and increased dieting behaviors as precipitants for eating disorders, it is impossible to ignore the fact that the 1970s and 80s is when the rates of obesity in the United States began to increase at an unprecedented rate, and low fat eating began its popular progression through the mainstream.

There is a third eating disorder, binge eating disorder, where periodic food binges are not compensated by restricting or purging behavior. While many obese people eat normally, binge eaters will consume up to tens of thousands of calories in a singe day, entire bags of candy, or dinner from five or six fast food restaurants, one after the other. Again this disorder has been described for centuries, but seems to have escalated only recently (4).

All eating disorders remain relatively rare. Anorexia afflicts about 0.5% of women and 0.1% of men. Bulimia around 1-3% of women (also 0.1% of men), and binge eating disorder 3.3% of women and 0.8% of men (4). Anorexia nervosa remains the most deadly of all psychiatric disorders (5), with a 5-10% death rate within 10 years of developing the symptoms, and an 18-20% death rate within 20 years. Anorexia is endemic in the fashion industry, to the point where models are now being airbrushed to add curves (6).

Eating disorders in adolescents are strongly predicted by the earlier presence of depression, bipolar disorder, and anxiety. The eating disorders also appear to be genetic (7)(8), perhaps related to inherited differences in serotonin receptors.

With the growing prevalence, genetic susceptibility, and correlation with increases in obesity and consumption of industrialized food (not to mention the zinc connection), I can't help but wonder if the eating disorders are yet one more disease of Western civilization, most strongly predicated by our poor diets. I'll keep an eye out on the literature, of course, though much of the natural progression of anorexia can be explained by disordered thinking about body image combined with the process of starvation itself. Given the speculation that a combination of massive quantities of fructose, wheat, and omega 6 fatty acids lead to inflammation, leptin and insulin resistance, and obesity, disordered thinking and restrictive or purging behaviors may be the only ways to remain "skinny" on a standard diet. The cost is high, and borne primarily by our young women.

I've found that a personalized approach, based on treating underlying depression, anxiety, nutritional deficiencies, and teaching that our bodies deserve to be nourished with proper, whole foods can be surprisingly effective. Do eating disorders exist in a population where there is no obesity? I don't know. I imagine they are vanishingly rare.


  1. I am absolutely amazed that you wrote this. I am a big fan of your blog and I was hoping to contact you in some way to speak about this very subject.

    Our family has been eating a paleo diet for quite a few years now. Our middle daughter has been diagnosed with EDNOS. She has an eating disorder that left her starving to death, without the body image issues so the Dr. decided it wasn't AN.

    I resisted the appointments with the dietician and instead loaded our girl up with even more good, grass fed meats, fats, and raw, full fat dairy. When she entered treatment, her cholesterol was atrocious due to the starvation, but today, it is totally normal and healthy (by giving her lots of fat, not decreasing it and feeding her lots of pasta as the Dr. suggested we do).

    She had her zinc tested and it was fine. So, she's not at her weight restored weight, but nothing has really changed mentally. It's like there's a film over her that prevents her from communicating, feeling, and experiencing life at the level a 13 year old should.

    Sorry, didn't want to go on, but I have to wonder what more I need to do to help her. In this case, her diet was a solid primal style diet before she developed her eating disorder. The therapist would have me believe that our "restrictive eating" is a disorder in itself (if you don't eat sugar, flour, vegetable oil, you're orthorexic or some such thing).

    Thank you for your brilliant brain and sharing bits of it with us every now and then.


  2. Sorry, she IS at her weight restored weight. Should have proofread that a little better.

  3. Hi Tara. It's terrific that her normal weight is restored. If you look at the graphs on pages 13-17 or so of my reference number 4 above, you'll see that anorexia is striking us at younger and younger ages. I've ignored or given minimal attention in my blog to some of the psychological issues with eating disorders - mostly because they have been written about extensively. But there is always that issue of control. I'm a reductionist - the psychology of anxiety, obsessiveness, and eating disorders and addiction all fall into the same category in my mind - affect phobia. Meaning fear of feeling. We will do all sorts of nutty (sometimes also productive) things to keep from feeling sadness, joy, anger, and grief especially. There is too much to explain for a blog comment, but treating affect phobia is all about learning self-love, mindfulness (ability to attain serenity and a mind-body connection), and ultimately feeling and using our driving, powerful emotions to lead us forward in our lives. I took all these ideas from people brighter than I - I'll see if I can't dig up some references later. Good luck. She'll figure it out

  4. I can't find any references that aren't heavy psychoanalytic tomes. The concept itself is very simple, though, and the first stage of therapy treatment is always support and teaching self-love (we are born needing tons of reassurance from Mom and Dad and we carry our wubbies around with us - somewhere along the way we let go of the wubby - attachment and other psychology theories suggest that we "internalize" our teddy bears - if everything develops properly, we know deep in our hearts that we are worthy, decent, and loved. Many people, for many reasons, temperament, or neglect and abuse for example, do not properly internalize the teddy bears, and feel empty, anxious, and scared. Sometimes teenagers are in the process of internalizing, and it gets derailed by everything else that's going on in their lives. So what I mean by "supportive" treatment is helping the person feel worthy and loved - not always as easy as it sounds, but the concept is simple) along with the behavioral pieces to reduce eating-disordered behaviors.

  5. Thank you so much for your response. My hubby is in his final year of medical residency so he's been combing through everything he can find on this, I leave the science stuff up to his genius-mind, but what you say really resonates with me.

    Your statement about internalizing our teddy bears brought tears to my eyes (yes, I'm a sucker). Really, that is our girl. She just does not feel. I mean, of course she does somewhere, but I don't know where that is and I believe her when she tells me that she feels "worried because everybody keeps telling me I'm burying my feelings and they seem frustrated with me, but I really don't, I really just feel fine all the time". She says she's happy while tears run down her cheeks.

    We're a very close, demonstrative family. Her two sisters are always throwing their arms around me or wrapping themselves around us in some fashion. I don't understand why there is such a difference. Quietly, I ponder if it's because I was a vegan when I was pregnant with her. Lord only knows what type of damage I did to that baby girl's brain. Sorry, I didn't know better.

    I wonder if her her therapist is at her limits in being able to help. Is there a certain type of program that you think would be effective? We're doing Maudsley, family based therapy right now.

    Sorry, I know this is not an online consultation, I just respect what you're doing and your opinion.

    All the best,

  6. Sounds like you have a good team. As a parent, you never want to worry alone. You accomplished the first part, and the most important for immediate health - regaining normal weight, and supplying her with nourishing foods. The "learning to feel" part takes a long time (it did for all of us, even if everything proceeds as planned), and of course no one can do it for her. I can't give more specific advice than what I could say about general treatment for eating disorders - but having a good team is key.

  7. Emily, great post and comments. Your broad perspective on eating disorders is appreciated, and your take on affect phobia is very astute (though, maybe it's because that's how I see it, too). As a psychologist-in-training who wants to specialize in eating "problems" (full spectrum from anorexia through bulimia through compulsive overeating/binge eating), I find the neglect of the physiological aspects of these conditions problematic. But, on the flip side, simply addressing the eating and biological factors is also not the whole picture. I, also, find the sociocultural factors really significant (i.e. emphasis on thinness, perfection, and objectification of women). Thanks for having this blog -- it's excellent. And, as a student, I totally appreciate the scientific references!

    Tara, thanks for sharing; I hope all continues to go well on your daughter's healing journey.

  8. Primal - Leigh McCullough was one of my teachers during residency - she has a research team and a type of therapy that is very interesting :

    She videotaped thousands of hours of therapy and tracked which patients got better, and trained students to view the tapes of therapy and track the type of intervention (cognitive or supportive or behavioral, for example). All very solid evidence basis, very impressive. She was also formerly married to George Valliant, who pioneered the studies of defenses, most famously - he was also one of my teachers in residency. Anyway - that's how I come upon my respect for affect phobia.

  9. I have to disagree with primal... i undoubtedly believe anorexia(which i suffer from) is hereditary. I have been in and out of inpatient for 6 years. i developed my ED in college after gaining the freshmen like 30lbs... i have always been incredibly sensitive, obsessive worrier and people pleaser. nothing in the 'industry' caused my anorexia. i felt shitty about myself and i was fat. i dieted down to 88lbs standing almost 5'8.
    conventional treatment did not work nor help. nothing in my family life cause anorexia. no one persuaded it. my childhood was incredibly good and normal. my dad has anger and panic issues, as i believe my inherited chemical imbalance is via him. we both 'think alike' however i took it upon myself to study endocrinology, metabolism, starvation and nutrition on my own. i bought 3946851934 books and read and read. i ended up at paleo food, primal dieting. i took recovery into my own hands. i got some good advice from an outsider(my mama) who said 'it is not ED is only as real as you let it be'....and with that i took primal eating and FLOURISHED. everytime i was stuck i reminded myself that my desk chair is real, my anorexia is fake. over and ovr again. it's not easy. i live on my own, i have no support team. but i now weigh 120lbs and am 5'7 now(osteopenia took an inch).
    It took about 4 months for me to put on 20lbs to where i am now. i ate copious amounts of meat, eggs, organs, coconut milk, dairy(until recently), veggies, butter, coconut oil/butter, pretty much everything primal i cold get my hands on and afford. it aint no joke when you eat real food gaiing weight is flippin hard. i went through over 5000 calories a day for a few weeks.
    now, i feel GREAT, i am strong! i am happy! i realize it is all fake, it is a aftereffect of starvation and nutritional deifcencies. it doesnt get any easier until those deficiencies are restored. you cant start recovering until you accept everything recovery come with. this was HUGE for me. i was 'recovering' for years not getting anywhere until i accepted i am REALLY recovering and everything it entails(weight gain, stress, crying, bloating, diarehha, constipation, sweating etc etc). when i accepted that is was all jut fine, i could recover.

    i LOVE LOVE LOVE this blog and the information you provide, so i am hoping my incredibly short version of an 8 yr struggle will help someone.

    and to Tara, just feed her. feed her primal food and a lot of it. teach her about nutrition and WHY it will work. teach her about starvation and WHY she is feeling and going thru what she is. you have to SHOW her so she trusts you and recovery. ask her if she accepts recovery b/c if she doesnt you will be hard pressed to get her to 'speak up'.

  10. Emily, thank you so much for the link.... I will definitely check it out (sorry for the tardy response -- I was out of town for a while).

    malpaz, I'm glad you have found what works for you. While I agree there are biological/genetic components to eating disorders (depression, anxiety, addiction), everyone's story is different. My childhood was not happy (rejected by my father and grandmother; barked at, spit on, and mocked constantly about many aspects of my appearance by kids at school; other abuses and traumas; etc.). In addition to the dietary improvements I've made -- which have been beneficial -- talk therapy and meditation have been/are also helping me make improvements in my very broken self-esteem and self-confidence.

  11. Thank you for this very interesting and inspiring post! Especially for this part of it:

    "I can't help but wonder if the eating disorders are yet one more disease of Western civilization, most strongly predicated by our poor diets. I'll keep an eye out on the literature, of course, though much of the natural progression of anorexia can be explained by disordered thinking about body image combined with the process of starvation itself. Given the speculation that a combination of massive quantities of fructose, wheat, and omega 6 fatty acids lead to inflammation, leptin and insulin resistance, and obesity, disordered thinking and restrictive or purging behaviors may be the only ways to remain "skinny" on a standard diet."

    I truly believe (due to personal experiences, in great part) that eating disorders aren't just mental issues, but also have a physiological component that should not be neglected. If you look at what people eat when they overeat, or avoid when they undereat, it's mainly food that consists of simple carbohydrates, combined with fat. I believe this food has some kind of addictive effect on the brain, and since the standard diet consists of a great proportion of carbohydrates, I think it fosters overeating in many people by annulling the regulating mechanisms of hunger and satiety. With undereating, it may be just a different reaction to the same problem, i.e., an afford to avoid those foods that make you overeat and gain weight.

    It makes me angry that the standard treatments of eating disorders still insist on reintegrating those problematic or "forbidden" foods into the daily diet. It's like telling an alcoholic to have a drink every night, but then not to drink anything more. And if the patients fail, they are told it was due to their lack of will power.

    But couldn't it be the case that eating disorders are substance addictions like alcoholism and drug addictions, and the addictive substance is carbohydrates (especially in combination with fat)? You wouldn't treat an alcohol or drug addict by putting him on a low or medium drug dose and expect from him to maintain that level, but put him on detoxification. So perhaps with eating disorder patients, it should be done accordingly, and the appropriate treatment (next to treating the cognitive and emotional aspects of the disorder) was to put them on a diet that is low in carbohydrates, i.e., a Paleo-style diet.

  12. Great blog. I had bulimia for years, believe now it was due to addiction to gluten and carbs (certainly not weight in my case). Anorexia used to be diagnosed as consumption, a disease which it often led to. Tryptophan and glutamine are needed to make niacinamide which has anti-TB activity (isoniazid is the drug analogue of niacinamide).

  13. I followed the links you provide (eventually arriving at regarding the claim that Romans did not purge after overeating and found that the claim at the links is only that they did not have special rooms for the purging. The historians who make that clarification do mention, however, that there are "descriptions in Roman authors of excessive eating and purging [Suetonius, Seneca]".


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