Eating Disorders Professionals Are Challenged by Activists on Public Health Issues

Highlights of the International Conference in Salzburg

At the International Conference on Eating Disorders, held from June 9-12, in Salzburg, Austria, three plenary speakers challenged eating disorders professionals to be more active and to have a louder voice, particularly in matters of public health and eating disorders.

In a keynote address, “Coming Together without Losing Our Way,” Kelly Vitousek, PhD, Co-Director of the Center for Cognitive Behavioral Therapy and Director of the Eating Disorders program at the University of Hawaii, Honolulu, discussed the pros and cons of developing a consensus model in eating disorders. She noted that the field of eating disorders has traveled far from the days when the international conference included a narrow range of topics presented by highly restricted but immensely insightful researchers. There was a weak evidence base at the time and an orthodoxy of allowed and disallowed positions on care for patients with eating disorders, she said.

Dr. Vitousek urged eating disorders professionals of today to keep an open mind and to look outside the well-beaten diagnostic and treatment path for new clues and information on eating disorders, particularly anorexia nervosa (AN).

To establish whether there is a consensus among eating disorders professionals about AN, Dr. Vitousek monitored a number of sources, including the Academy for Eating Disorders’ Listserv, eating disorders advocacy web sites, and the literature. She found that many erroneous beliefs were identified and rebutted. In fact, she said, according to data on many professionally authored web sites, eating disorders are not about food, weight, concern about appearance, and not about control or unresolved psychological conditions, for example. Many professional sites also stated that AN was not a choice, nor the result of media pressure or family influences. She added that there are so many “nots” that eating disorders professionals have “almost debunked ourselves, ruling out nearly anything that was ever nominated as a cause for an eating disorder.” Dr. Vitousek added, “We seem to concentrate on defining the space around AN by saying what it is not, while leaving AN a shadowy disorder.” In contrast, she praised the AED position paper published last year, which was an excellent summary of the facts about eating disorders, including AN (Academy for Eating Disorders Position Paper: Eating Disorders Are Serious Mental Illnesses. Int J Eat Disord 2009; 42:97-103).

Finally, although she added that it might sound like a reversal of her comments about the need for a consensus in the eating disorders field, she said, “We need to get further away from these disorders if we want to see them more clearly.” To clarify this idea, she cited studies among scientists who are studying caloric restriction in an attempt to increase longevity. Although most studies by these groups involve middle-aged male researchers, who are studying effects on their own health, Dr. Vitousek said the eating disorders field could learn much from such studies because the scientists and patients with AN both restrict food. What might brain studies show? Interestingly, these scientists, whom Dr. Vitousek says have little awareness of AN or of eating disorders, are reporting that the restriction point for their self-studies is a body mass index of 17 or 18 kg/m2. There are parallels between these studies and patterns among patients with AN, she said, but added that the eating disorders field has stayed silent on this point. She noted that eating disorders professionals should be examining similarities and differences between these studies and patients with AN. In the process of looking at AN from a different vantage point, including studying overvalued behaviors like extreme health food fads, ultra running, competitive sports and extreme mountaineering, for example, clues might emerge that could lead to a better understanding of AN.

The true consensus among eating disorders professionals is the passion that the field shares to see that these devastating disorders are treated earlier. “It is clear that the way we characterize the eating disorders has important real-world considerations,” Dr. Vitousek said.

Taking a New Approach to Public Health Issues and Obesity

Kelly Brownell, PhD, Professor of Psychology, Epidemiology, and Public Health at Yale University School of Medicine, outlined a new approach that he calls “Strategic Science,” to deal with the public health issue of increasing obesity throughout the world.

Dr. Brownell, who also directs the Rudd Center on Food & Obesity at Yale and is a former EDR Editorial Board member, said that “Weight stigma is pervasive, powerful and unrelenting” and that research by his colleague Rebecca Puhl at Yale has shown that weight stigma rivals race, gender bias, and other stigmas in our society. Dr. Brownell said that some call weight stigma the last acceptable form of discrimination. In every important point in life, being overweight is a significant liability, he added.

How does this apply to the eating disorders field? Obviously, he said, the fear of being fat is relevant to the eating disorders. As long as weight bias is so strong, people will be fearful about being overweight and that fear and these biases help contribute to eating disorders.

Dr. Brownell told the audience that his group at the Rudd Center has developed a new approach to working on public health issues. In contrast to the traditional method used in scientific research, where a study is designed, conducted, and a paper submitted for publication, and then policies are developed, researchers using “Strategic Science” go to policy-makers first, to determine the questions they would like answered before establishing a policy. Dr. Brownell added that the “pace of science is so slow, and the results so poorly communicated, unresponsive, programmatic, and conflicted, that the world blows by before we are even relevant.” Traditional scientific approaches also use weak methods of educating and imploring the public to change. Most of these approaches have not succeeded he said, and he pointed to general failures in getting the public to exercise more or to include more fruits and vegetables in their diets.

With the Strategic Science approach, Dr. Brownell explained, “We try to do more research that is strategic rather than programmatic, and the audience is not fellow scientists but senators, attorneys general, and governmental agencies. The question is, What piece of science would help your agency make a policy? The approach is to think in advance about what the impact of the study will be, rather than to perform a study, and then to first try to apply its findings.” Once this is established, small and efficient studies can be done, usually at much lower cost than traditional clinical and research studies. As an example, he described a short study his group conducted that cost about $50 to perform, and that tested sugar-free and low-sugar breakfast cereals among children. The food industry position is that children need sugar in cereals to get them to eat breakfast. The results were that children ate 100% of the sugar-free cereal, and added plenty of milk and fruit to their cereal. On their own they ate the correct portions; in contrast, children who ate the sugary cereals ate twice as much cereal.

Dr. Brownell pointed to several areas where the eating disorders field and public health officials can collaborate, and urged eating disorders professionals to have a louder voice in public health issues such as obesity. Federal agencies and agencies at all levels are poised to take action, he said because traditional approaches have failed.

In contrast with the one-on-one basis of the traditional medical approach, Strategic Science is a new model in which agencies or cities change conditions in order to help individuals make healthier decisions, Dr. Brownell said. And, the eating disorders field should be involved, he said; right now it has no voice in public health matters. The stakes are very high, he added, noting that for every person successfully treated for obesity, millions are developing the problem. The case is the same for eating disorders—as other conference speakers had stressed, relatively few are being treated, while millions are developing the problem.

Regulatory defaults, such as listing calories on menus, which is still a controversial topic, can help individuals make healthier decisions, Dr. Brownell said. He outlined several areas that seem ideal for input from the eating disorders field, including reducing weight stigma, developing viable and compelling information about food and addiction, using animal and brain imaging, labeling and marketing issues. One of the major battlefields concerns restricting food marketing of unhealthy foods to children. He noted that a major supporter of restricting unhealthy marketing to children is the Robert Wood Johnson Foundation, which has donated $100 million to this campaign; in contrast, the food marketing industry spends this much by January 4 each year.

If the eating disorders field joined in such public health efforts against obesity, the team would be bigger and stronger, he said, and such a team needs passionate professionals with a conscience. “I hope we can join hands to improve public policy,” Dr. Brownell said.

Shame: ‘The Elephant in the Room’

Philippa Hay, MD, PhD, Professor of Mental Health at the University of Western Sydney, Australia, and her colleagues hope to find more effective methods for public health intervention for bulimic eating disorders. With the help of an ARC Discovery Project grant, the researchers are working to better understand stigma and mental health literacy among bulimic patients.

During a plenary session, Dr. Hay described the results of several studies that reinforced the idea that stigma, guilt or personal shame about disordered eating play a large role in lack of detection of such disorders . “Shame is the elephant in the room,” she said.

In their recent study of attitudes about the nature and treatment of bulimia nervosa (BN), Dr. Hay and colleagues compared three groups of young adult women: those at low risk for an eating disorder, those at high risk for an eating disorder, and those already showing symptoms of an eating disorder. After the women completed a self-report questionnaire, they were given a vignette of a fictional person with BN, followed by a series of questions addressing the nature and treatment of the problem.

Dr. Hay reported that she and her colleagues found that high-risk and symptomatic participants were more likely than low-risk participants to report they would not approach anyone for advice or help if they had BN or a similar eating disorder. The main reason for this was that they were ashamed and would not want anyone to know about their disorder. Those with symptoms were more likely to believe that someone with BN would be discriminated against more commonly than did low-risk participants. The conclusion was that specific attitudes and beliefs may need to be addressed in prevention and early intervention programs.

In another study of 87 young community women with common eating disorders (68% with EDNOS), eating disorder psychopathology remained high and the women continued to be highly symptomatic and to have poorer quality of life. One disturbing finding was that often half of those with disordered eating were not detected during visits to their general physicians. In some cases, according to the women, their general practitioner seemed to “brush off” the patient’s concern about disordered eating, particularly when the patient’s weight fell in a normal range. Other patients with AN reported that their mothers didn’t want them to leave the house for fear the neighbors would see them. Another common theme that emerged was that the eating problem was not thought to be a serious problem.

Dr. Hay noted there are no simple answers, but community literacy approaches may be helpful. One area that could be improved is the substitution of empathy, for sympathy, from general practitioners; another is gaining familiarity with the disorders through such efforts as television programs featuring stories about patients with eating disorders. Dr. Hay told the audience that most patients with undetected eating disorders in Australia are first seen first by general practitioners, and once the diagnosis is made, at least in Australia, most patients are treated by psychologists, not psychiatrists.

“Kids can also be agents of change,” she noted. In New South Wales, eating disorders are included in the core school curriculum and all students are taught about eating disorders. While this is a good thing, no one is currently studying what the outcome may be. In addition, some of the best-intentioned public health programs are not based on empirical evidence. She cited an example of an idea that all schoolgirls should be weighed, without considering the negative effects of being weighed in front of the entire class.

“Better advocacy and making our voices heard throughout the psychiatric world will also help,” she said. Areas that that badly need changing are stigma about eating disorders in the community and the erroneous concept that they are not really serious disorders. For example, one patient said that, despite her symptoms of bingeing and purging, her physician told her, “You can’t have an eating disorder because you are of normal weight.”