Blog of the UNC Center of Excellence for Eating Disorders.Blog seek to provide outstanding education and training in eating disorders detection and care to medical students and other health profession trainees at UNC.
What is body dissatisfaction? Body dissatisfaction is defined as negative perceptions, evaluation, attitudes, or feelings an individual has towards their body weight, shape, or appearance.1-3 External factors such as media images of other’s or negative feedback about one’s appearance from family and friends can influence how we evaluate our bodies.4 For example, if we believe that a thinner body is equal to beauty, it may increase the risk of developing weight and shape concerns towards our body sizes as well as body dissatisfaction.5
Body dissatisfaction is well-studied in the college student population. Previous studies showed that one out of every three college students is concerned about their weight and body shape, about 13% of female college students were dissatisfied with their body size, and female college students reported higher weight concern than male college students.6-8 In comparison with females, male college students wanted to have less body fat and desired more muscle mass.9 In addition, white female college students reported higher body dissatisfaction than Native American and Hispanic college women.10
Why might the issue of body dissatisfaction be coming up during college life? The college years represent a pivotal developmental time that students transition from teenagers to adulthood.11 In addition to facing the task of academic load and the challenge of greater personal responsibility, college students may also be exposed to group living situations such as living with roommates in dorms.12,13 This type of shared living experience may increase the risk for body dissatisfaction by body comparison and may lead to negative perceptions of one’s body image.13 College students may also use social media such as Instagram in order to establish new interpersonal relationships.14 Social media may have a negative influence on college students’ body image because students who use social media may be spending time carefully selecting the best images in order to promote themselves and to seek comments by others.14 Engaging in social media in this way may lead to increased stressors surrounding maintaining or achieving an ideal body and may lead to body dissatisfaction.15,16
Why is body dissatisfaction in college students important? College students are not only at higher risk for body dissatisfaction, but there is a significant association between body dissatisfaction and eating behavior. Body dissatisfaction has been identified as an important risk factor for disordered eating behaviors in college students, such as restrained eating, dieting, binge eating, and bulimia nervosa.17-21 Raising awareness of the link between body dissatisfaction and eating disturbances may be a first step in preventing eating disorders among college students. Health care providers can help college students change the way they see themselves by encouraging them to embrace their natural size with positive perceptions of their body images to improve physical and emotional health.
Cash, T. F. (2004). Body image: Past, present, and future. Body Image, 1(1), 1-5. doi:10.1016/s 1740-1445(03)00011-1
Jones, B. A., Haycraft, E., Murjan, S., & Arcelus, J. (2016). Body dissatisfaction and disordered eating in trans people: A systematic review of the literature. International Review of Psychiatry, 28(1), 81-94. doi:10.3109/09540261.2015.1089217
Slade, P. D. (1994). What is body image? Behaviour Research and Therapy, 32(5), 497-502.
McGuinness, S., & Taylor, J. E. (2016). Understanding body image dissatisfaction and disordered eating in midlife adults. New Zealand Journal of Psychology, 45(1), 4-12.
Legenbauer, T., Thiemann, P., & Vocks, S. (2014). Body image disturbance in children and adolescents with eating disorders. Current evidence and future directions. Z Kinder Jugendpsychiatr Psychother, 42(1), 51-59. doi:10.1024/1422-4917/a000269
Forney, K. J., & Ward, R. M. (2013). Examining the moderating role of social norms between body dissatisfaction and disordered eating in college students. Eating Behaviors, 14(1), 73-78. doi:10.1016/j.eatbeh.2012.10.017
Goswami, S., Sachdeva, S., & Sachdeva, R. (2012). Body image satisfaction among female college students. Industrial Psychiatry Journal, 21(2), 168-172. doi:10.4103/0972-6748.119653
Lipson, S. K., Jones, J. M., Taylor, C. B., Wilfley, D. E., Eichen, D. M., Fitzsimmons-Craft, E. E., & Eisenberg, D. (2017). Understanding and promoting treatment-seeking for eating disorders and body image concerns on college campuses through online screening, prevention and intervention. Eating Behaviors, 25, 68-73. doi:10.1016/j.eatbeh.2016. 03.020
Mayo, C., & George, V. (2014). Eating disorder risk and body dissatisfaction based on muscularity and body fat in male university students. Journal of American College Health, 62(6), 407-415. doi:10.1080/07448481.2014.917649
Smith, J. M., Smith, J. E., McLaughlin, E. A., Belon, K. E., Serier, K. N., Simmons, J. D., . . . Delaney, H. D. (2018). Body dissatisfaction and disordered eating in Native American, Hispanic, and White College Women. Eating and Weight Disorders. doi:10.1007/s40519 -018-0597-8
Hunt, J., & Eisenberg, D. (2010). Mental health problems and help-seeking behavior among college students. Journal of Adolescent Health, 46(1), 3-10. doi:10.1016/j.jadohealth. 2009.08.008
Pedrelli, P., Nyer, M., Yeung, A., Zulauf, C., & Wilens, T. (2015). College Students: Mental Health Problems and Treatment Considerations. Academic Psychiatry, 39(5), 503-511. doi:10.1007/s40596-014-0205-9
Venkataramani, V., & Dalal, R. S. (2007). Who helps and harms whom? Relational antecedents of interpersonal helping and harming in organizations. Journal of Applied Psychology, 92(4), 952-966. doi:10.1037/0021-9010.92.4.952
Blair, L., Aloia, C. R., Valliant, M. W., Knight, K. B., Garner, J. C., & Nahar, V. K. (2017). Association between athletic participation and the risk of eating disorder and body dissatisfaction in college students. International Journal of Health Sciences (Qassim), 11(4), 8-12.
Duarte, C., Ferreira, C., Trindade, I. A., & Pinto-Gouveia, J. (2015). Body image and college women’s quality of life: The importance of being self-compassionate. Journal of Health Psychology, 20(6), 754-764. doi:10.1177/1359105315573438
Brechan, I., & Kvalem, I. L. (2015). Relationship between body dissatisfaction and disordered eating: Mediating role of self-esteem and depression. Eating Behaviors, 17, 49-58. doi:10.1016/j.eatbeh.2014.12.008
Gordon, K. H., Holm-Denoma, J. M., Troop-Gordon, W., & Sand, E. (2012). Rumination and body dissatisfaction interact to predict concurrent binge eating. Body Image, 9(3), 352-357. doi:10.1016/j.bodyim.2012.04.001
Granner, M. L., Black, D. R., & Abood, D. A. (2002). Levels of cigarette and alcohol use related to eating-disorder attitudes. American Journal of Health Behavior, 26(1), 43-55.
Nelson, M. C., Lust, K., Story, M., & Ehlinger, E. (2009). Alcohol use, eating patterns, and weight behaviors in a university population. American Journal of Health Behavior, 33(3), 227-237. doi: 10.5993/AJHB.33.3.1
Welch, E., Miller, J. L., Ghaderi, A., & Vaillancourt, T. (2009). Does perfectionism mediate or moderate the relation between body dissatisfaction and disordered eating attitudes and behaviors? Eating Behaviors, 10(3), 168-175. doi:10.1016/j.eatbeh.2009.05.002
On May 7th, 2019, Christine Peat, PhD (NCEED Director), Jean Doak, PhD (NCEED Deputy Director) and Stephanie Zerwas, PhD (NCEED Content Expert) were able to attend the Eating Disorder Coalition’s (EDC) Advocacy Day in Washington, DC. The annual event, now in its 19th year, is an incredible opportunity to connect with other professionals, advocates, and families to educate Congress on eating disorders, their impact, and the importance of policies focused on these conditions.
North Carolina on The Hill
The focus of this year’s Advocacy Day was on improving access to medical nutrition therapy for those with Medicare—the federally-funded health insurance plan for individuals 65 or older and those younger than 65 who have a disability. Although stereotypes about eating disorders might lead some to believe that the Medicare population does not struggle with these conditions, we know that eating disorders do not discriminate based on age, ability, or any other demographic characteristic.
As you may be aware, the evidence-based treatment of eating disorders is typically a multidisciplinary approach that involves psychology, nutrition, psychiatry, and medicine. Each of these disciplines has a crucial role in providing interventions to those affected by eating disorders. Psychologists, for example, work closely with patients and their families to work on decreasing eating disorder thoughts and behaviors, while primary care providers work to monitor physical health and provide medical stabilization. These multidisciplinary efforts combine to deliver the standard of care for eating disorders, and the majority of insurance companies recognize their importance by providing coverage for each type of service.
Currently, Medicare provides coverage for all components of eating disorder treatment in the outpatient setting EXCEPT medical nutrition therapy. This inequity means that patients covered by Medicare who have eating disorders are often not receiving one of the critically important components of treatment which may limit their ability to achieve full recovery. In other cases, patients may feel their only option is to turn to the internet for information and advice on nutrition which can lead to misinformation and, even worse, an exacerbation of eating disorder symptoms given the pervasiveness of diet culture throughout online media.
Enter, the Nutrition Counseling Aiding Recovery for Eating Disorders (CARE) Act! This brand new piece of legislation was sponsored by Congresswoman Judy Chu of California (a clinical psychologist by training!) just days prior to the 2019 EDC Advocacy Day. The Nutrition CARE Act provides for 13 hours of coverage for the first year of treatment (1 60-minute initial assessment and 24 thirty-minute sessions thereafter) and 4 hours of coverage in subsequent years (8 thirty-minute sessions; and extra hours if needed). Importantly, this proposal is asking for Medicare to provide the same level of coverage currently available for those with diabetes or kidney disease—the ONLY medical conditions eligible for medical nutrition therapy in the outpatient setting under Medicare.
Focus on Access to Medical Nutrition
With this background in mind, Drs. Peat, Doak, and Zerwas were able to visit with staffers of North Carolina senators and representatives. During these meetings, they were able to educate the staffers (and, by proxy, their bosses) about how their own constituents are affected by eating disorders, the challenges patients face when they are receiving inadequate care, and how the Nutrition CARE Act would help improve access to the crucial component of medical nutrition therapy. It was a busy day of prep and training in the morning, followed by 5 consecutive meetings with congressional staffers, and a debriefing session which included remarks by Congresswoman Chu herself!
Advocacy Day was certainly an experience that will not soon be forgotten by those who were able to attend. It was incredible to see professionals, patients, families, and advocates come from all across the country to engage our elected officials in this important discussion. In fact, with 145 participants registered for the day, the 2019 Advocacy Day was the 2nd largest turnout in the EDC’s history! The passion and energy in the room was palpable, and it was an honor to be able to directly participate in our legislative process.
Eating Disorders Advocates
But there is still much work to be done! The Nutrition CARE Act is early in its progress to becoming law, so if you were unable to attend Advocacy Day but would like to stay involved, please sign up here for the EDC’s Action Alerts. And, if you are able, consider attending next year’s Advocacy Day (details forthcoming) as the event is open to anyone regardless of background or experience. The more voices we can bring to Washington, the greater the potential for us to bring about meaningful change for those affected by eating disorders!
“Start spreading the news: Education, dissemination & the science of eating disorders” was the theme of this year’s International Conference on Eating Disorders (ICED) in New York, March 14-16, 2019. I was fortune to receive the Student/Early Career Travel Fellowship from the Academy for Eating Disorders (AED) to attend this year’s ICED and to present my research “Weight stigma, binge eating, and acculturation among Asian Americans with overweight and obesity” as a poster.
Dr. Ya-Ke (Grace) Wu receives AED Early Career Fellowship
This year was my first time attending the ICED! I was impressed with the many opportunities I had for networking with others in the field—this conference is unique in creating a lot of formal and informal networking opportunities for clinicians and researchers. The fellowship that I received not only supported my registration and travel to ICED, but also provided me with educational training and networking opportunities with other clinicians, educators, and researchers. For example, I was able to attend a Research Training Day—an entire day devoted to research grant development and research methods for doctoral students and early career investigators. From this opportunity, I learned so much about writing grant proposals and applying the statistical methodology of network analysis to eating disorder research. I also had the chance to discuss future NIH grant proposals with Dr. Mark Chavez, a Program Chief of the National Institute of Mental Health Eating Disorders Research Program. All fellowship recipients were also invited to attend the Annual Mentor-Mentee Breakfast. During the breakfast, students and early career attendees were paired with senior AED members to discuss issues relevant to the students and early career attendees’ research or career plan. This opportunity was unique because it not only helped a young researcher like myself to identify experts in the field of binge eating but also took the pressure off of having to introduce myself to those experts. These types of networking opportunities are essential for an early career investigator like me to establish possible research collaborations with experts in the area of eating disorders and to find future mentors for my research career.
One goal I had for the conference was to absorb the current knowledge related to my specific research interests of binge eating in bariatric surgery. I attended the Special Interest Group Annual Meeting of Bariatric Surgery, and another educational session titled “Towards understanding disordered eating following bariatric surgery”. Both emphasized the importance of understanding and treating disordered eating post-surgery to prevent poor outcomes following bariatric surgery. During the educational session, I learned about the current progress of binge eating assessment measures for post-surgery patients. These experiences will be helpful for my future research plans.
I had a great experience presenting my poster on the first day of the conference. I showed a study that examined the associations among self-reported weight stigma, binge eating severity, and acculturation in a minority population of Asian Americans. The findings of my research showed that participants with obesity reported more weight stigma and binge eating than participants with overweight. Also, weight stigma was significantly associated with binge eating severity, and the level of acculturation did not significantly influence the relationship between weight stigma and binge eating. I exchanged my research experiences with other scholars who also conducted weight stigma research during the poster presentation.
Attending the ICED, was a great learning experience for me. I greatly appreciated all the people from the AED that organized the conference and my postdoc advisor Dr. Jessica Baker who encouraged me to attend this fantastic conference. The experts that I met during the conference not only presented their scientific knowledge, but also demonstrated a humble attitude toward the living world, and they will forever be my role models for my research career.
I was recently reading a fascinating article by Dr. Guido Frank in the journal Physiology and Behavior. The article is Open Access, so you can download it here, but I asked Dr. Frank if he would mind being interviewed about the article and the thinking behind his model. He said, “Yes!”
Dr. Guido Frank
Bulik: Dr. Frank, you recently published a fascinating article in the journal Physiology and Behavior called “Motivation to eat and not to eat – The psycho-biological conflict in anorexia nervosa. I thought our blog readers might be interested in hearing your theory only translated a bit for us non-neuroscientists. You start your article out by presenting the “core conflict” in anorexia nervosa which you claim that all individuals with anorexia nervosa (AN) have in common “a discrepancy between their conscious motivation for how much they want to eat – or rather restrict food intake – versus the body’s need to stay at a healthy and sustainable body weight.” Let me start out with a simple question, your theory is primarily about traditional low weight AN, correct?
Frank: Yes, that is correct. The model revolves around the changes in the body that happen during weight loss and that in most of us would trigger eating. However, in anorexia nervosa those changes are ineffective in promoting eating and rather drive the vicious cycle of food restriction.
Bulik: At the root of your model and the origins of AN in a person is the desire to lose weight. How does that start?
Frank: The desire to lose weight can start for many reasons, just wanting to better in sports, wanting to eat healthier, or after for instance abuse experience not wanting to feel the body. This is what I call the conscious motivation to change eating. This change in eating may or may not be accompanied by the wish to lose weight. However, cutting out certain high calorie foods together with more exercise typically leads to weight loss.
Bulik: So, lots of people have a desire to lose weight, but people with AN seem to get stuck in this weight loss trap. I understand how the drive to lose weight can start, but what makes it continue?
Frank: Weight loss is then associated with the desired change in eating behavior and becomes an obvious sign of “success”, which reinforces the original goal of changing eating habits. People who develop anorexia nervosa typically are very hard working and have the desire to do things right. Those traits together with the fear of losing this accomplishment, reinforces (encourages) continuing to cut out foods.
Bulik: Dr. Frank, you know that we at UNC do a lot of work on the genetics of eating disorders. How do genes play a role in your theory?
Frank: Genes, I believe, play a central role in the transition from the desire to eat healthier or lose some weight to developing anorexia nervosa. Genetic predisposition including having a temperament that is more on the anxious side and striving for perfectionism, may mediate the transition to anorexia nervosa, to the extreme drive for thinness and body dissatisfaction, and eventually body image distortion.
Bulik: OK so you have someone with a desire to lose weight, and they feel rewarded by successful weight loss, and they might have a genetic predisposition to anxiety or perfectionism, but doesn’t their body feel terrible when they are in a starvation state?
Frank: Exactly, and that will be part of a vicious cycle to lose control over weight loss. The body responds to weight loss with sensitizing hormones and neurotransmitters receptors to stimulate eating. This physical component I would call the unconscious motivation to eat and gain weight. The person then experiences this body-driven motivation to eat, which goes against the original conscious motivation to “eat healthy” which has by now been associated with weight loss, which triggers anxiety and reinforces the cognitive control over eating.
Bulik: OK so we’re back to anxiety again. If I am understanding you correctly, the first desire to lose weight can come from all kinds of reasons, then maybe a genetic predisposition to anxiety or perfectionism might contribute to the transition to anorexia nervosa from dieting, and now you are talking (almost psychodynamically) about a conflict between an unconscious (physically driven) desire to eat with the conscious desire to lose weight or remain thin. Am I summarizing this correctly?
Frank: Yes, in fact when I developed this neurobiological model, I was chuckling to myself as I was indeed reminded of the classic Freudian conflict that leads to dysfunctional behavior. Back to the biology, when we eat but suddenly the proverbial tiger stands in front of us, we have to suppress the eating drive and stop eating quickly and run to preserve our life. This circuitry is set in motion by fear, directed from a brain region called the ventral striatum (a dopamine rich area) to the hypothalamus, and it involves dopamine, a brain neurotransmitter. The fear of weight gain, we believe, triggers this mechanism and suppresses eating. However, more control over eating and food restriction further drive the body to stimulate eating, which further triggers anxiety and further stimulates food avoidance, and now you are stuck in a vicious cycle.
Bulik: So how do you break out of this vicious cycle?
Frank: There are several key goals to accomplish to successfully treat anorexia nervosa. First, I think it is important to help patients and their families understand that this is a complex illness with a distinct biology behind it. This helps get this out of the realm of the mysterious to a more understandable problem that can be treated. Second, weight gain is key including learning to eat again and maintaining a healthy body weight. This can be a long and difficult process. Third, it is important that folks learn to live their life and replace the focus on anorexia nervosa with truly positive directions so that the anorexia nervosa “voice” becomes less and less important. Lastly, we are working on developing medications to make psychotherapy more successful and recovery from anorexia nervosa easier.
Bulik: So, this is all about low weight AN. As you know atypical AN is in the news a lot lately. Although I don’t love the name, it refers to individuals who have all of the symptoms of AN (the psychological and behavioral symptoms) and their bodies are essentially starved, but they are not at low weight. Does your model apply to them?
Frank: Our research data suggest that the brain responds differently in underweight anorexia nervosa compared to individuals who are diagnosed with the “other specified eating and feeding disorder of the anorexia nervosa type” without underweight. So far it seems that the brain gradually changes with weight loss, making the underweight group the most difficult to recover. The psychological and behavioral symptoms without low weight can still be severe and interfering with life, of course. In those individuals the body feedback may be less of a factor, although we are currently studying whether for instance the amount weight lost also changes the body and brain, even without being underweight by our typical criteria. I am hoping that the next few months will bring us some clarity for this question.
Bulik: Anything else you would like to add to help the readers of Exchanges to understand your model?
Frank: I just would like to emphasize that while anorexia nervosa is difficult to treat and recover from, it is possible to recover. I would like to encourage everyone with anorexia nervosa not to give up. Every person is different and needs individualized treatment plans, but our increasing understanding of the illness will eventually help develop more effective treatments. I also would like to mention that the term “illness” does not imply in my mind that medication will be the only answer to treatment. I rather belief that the combination of meal support and psychotherapy, facilitated and catalyzed by specific medication, will be the most effective treatment as long as we have not identified biological or genetic “switches” that we can turn off to stop anorexia nervosa from developing.
Bulik: Thank you Dr. Guido Frank of the Departments of Psychiatry and Neuroscience of the University of Colorado.
Electronic cigarettes, or e-cigarettes, are nicotine delivery devices that produce aerosol for inhalation through the combustion of flavored nicotine-containing liquids known as e-liquids (Glasser et al., 2017). As smoking traditional cigarettes is declining (Jamal et al., 2018), the use of e-cigarettes, or vaping, is increasing, especially among young people (Kasza et al., 2017; U.S. Department of Health and Human Services, 2016). Adults aged 18-24 years reported significantly more vaping in the past 30 days than adults over age 25 (13% vs. 6%, respectively; Kasza et al., 2017). Young adulthood is a high risk period for several behaviors that can influence health long term, and they often co-occur. Young adults are also most at risk for the development of eating disorders; the mean age of onset for eating disorders ranges from 18-21 years (Hudson, Hiripi, Pope, & Kessler, 2007; Volpe et al., 2016). Additionally, women with eating disorders—particularly bulimia nervosa and binge-eating disorder—report a higher prevalence of traditional cigarette smoking and greater nicotine dependence than healthy controls (Anzengruber et al., 2006). A logical next question is whether there is an association between vaping and eating disorders.
Limited studies have examined the association
between these two traits. Among individuals who use e-cigarettes, vaping to control appetite has been positively
associated with body concern among college students (Napolitano, Lynch, and
Stanton, 2018). Adults who reported vaping for weight loss or weight control
purposes were more likely to use e-cigarettes frequently, be overweight, and
restrict their calories than those who use e-cigarettes for purposes other than
weight loss or weight control (Morean and Wedel, 2017). Further, e-cigarette
users who reported having a current eating disorder were more likely to vape on
a daily basis, to do so to lose or control weight, and to experience more
relief from negative emotions as a consequence of vaping than e-cigarette users
who did not report having a current eating disorder (Morean and L’insalata,
2017). Finally, Bennett and Pokhrel (2018) reported a significant association
between weight concerns and current vaping frequency, such that increased
weight concerns were associated with a higher frequency of e-cigarette use. However,
other research has found no association between risk of eating disorders and
e-cigarette use (Tavolacci et al., 2016).
Although e-cigarettes are generally
viewed as less harmful than traditional cigarettes (Glasser et al., 2017), this
might not be accurate. E-liquids may negatively affect human cell viability (Sassano
et al., 2018) and 58.2% of e-cigarette users report experiencing at least one
adverse symptom, such as cough, dry/irritated mouth or throat,
dizziness/lightheadedness, and headache/migraine (King et al., 2019). Due to
the novelty of e-cigarettes, the long-term consequences of vaping are unknown;
however, e-cigarette aerosols cause tissue and DNA damage that could plausibly
promote disease in long-term users (Helen & Eaton, 2018). As the potential harms
of e-cigarettes and vaping continue to emerge, further researching the
association between e-cigarette use and eating disorders could provide
information useful for clinicians treating these conditions.
Bennett, B. L., & Pokhrel,
P. (2018). Weight Concerns and Use of Cigarettes and E-Cigarettes among Young
Adults. International Journal of Environmental Research and Public Health,
A. M., Katz, L., Pearson, J. L., Abudayyeh, H., Niaura, R. S., Abrams, D. B.,
& Villanti, A. C. (2017). Overview of Electronic Nicotine Delivery Systems:
A Systematic Review. American Journal of Preventive Medicine, 52(2),
Hudson, J. I., Hiripi, E., Pope,
Jr., H. G., & Kessler, R. C. (2007). The prevalence and correlates of
eating disorders in the national comorbidity survey replication. Biological Psychiatry, 61, 348-358. doi:
K. A., Ambrose, B. K., Conway, K. P., Borek, N., Taylor, K., Goniewicz, M. L.,
… Hyland, A. J. (2017). Tobacco-Product Use by Adults and Youths in the United
States in 2013 and 2014. The New England Journal of Medicine, 376(4),
King, J. L., Reboussin, B. A.,
Wiseman, K. D., Ribisl, K. M., Seidenberg, A. B., Wagoner, K. G., … Sutfin, E.
L. (2019). Adverse symptoms users
attribute to e-cigarettes: Results from a national survey of US adults. Drug
and Alcohol Dependence. https://doi.org/10.1016/j.drugalcdep.2018.11.030
Lanza, H. I., Pittman, P., &
Batshoun, J. (2017). Obesity and Cigarette Smoking: Extending the Link to E
cigarette/Vaping Use. American Journal of Health Behavior, 41(3),
Morean, M. E., & L’Insalata,
A. (2018). Electronic cigarette use among individuals with a self-reported
eating disorder diagnosis. The International Journal of Eating Disorders,
51(1), 77–81. https://doi.org/10.1002/eat.22793
Napolitano, M. A., Lynch, S. B.,
& Stanton, C. A. (2018). Young adult e-cigarette users: Perceptions of
stress, body image, and weight control. Eating and Weight Disorders.
Sassano, M. F., Davis, E. S.,
Keating, J. E., Zorn, B. T., Tavleen, K., Wolfgang, M. C., … & Tarran, R.
(2018). Evaluation of e-liquid toxicity using an open-source high-throughout
screening assay. PLoS Biology, 16(3),
Tavolacci, M-P., Vasiliu, A.,
Romo, L., Kotbagi, G., Kern, L., & Ladner, J. (2016). Patterns of
electronic cigarette use in current and ever users among college students in
France: A cross-sectional study. BMJ Open, 6, e011344.
Binge eating disorder (BED) is the most common eating disorder and affects approximately 6-8 million people in the United States. However, BED remains under-recognized and under-treated among U.S. adults.1 A large national study showed that, among adult individuals who met criteria for BED, only 3.2% reported ever being diagnosed with BED by a healthcare provider.2 Left untreated, BED increases risk for poor mental and physical health as well as work impairment.3,4
The criteria for diagnosing BED are found in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the standard classification of mental disorders used by mental health professionals in the U.S.5 One of the diagnostic criteria of BED is binge eating defined as recurrent episodes (i.e., occurring on average at least once a week for >3 months) of eating an unusually large amount of food in a short period time with an associated loss of control over eating during the episode.5
BED research illustrates many reasons why patients with BED often do not receive proper care:
Limited knowledge and awareness of BED
The general population has limited knowledge and awareness of BED and individuals may not recognize their binge eating as a problem behavior unless they are directly asked about the symptoms of BED by a health care provider.6 Also, individuals may believe that their binge eating is not severe enough to warrant treatment, leading them not to seek help for their BED.7
Shame or embarrassment
Some individuals may be reluctant to discuss binge eating with their healthcare provider because they feel embarrassed about the behavior.8 Backer and colleagues conducted a qualitative study to identify patients’ perspectives on social barriers to receiving eating disorder treatment. They found that adults with eating disorders were hesitant to discuss symptoms with healthcare providers out of fear that their binge eating would be viewed as a “weakness” or a “character flaw.” 8 Further, individuals BED often fear stigma, judgement, or being labelled as having a mental illness by healthcare providers.
Previous negative experiences
Individuals with BED may have had negative experiences and unhelpful advice from providers when they attempted to discuss their BED symptoms in the past.9 It is possible when discussing their BED with providers, providers focused more on the need for weight loss rather than helping them get their eating under control.10 In short, they did not feel “heard” and opted to remain silent about their eating problems.
Limited resources for BED treatment
Individuals with BED may not live near a specialist eating disorders service and may lack the time or resources to travel for treatment.11 Patients with Medicare or Medicaid may be ineligible to receive treatment at many clinics without paying out of pocket.9 Regardless of health insurance status, individuals may be unable to afford the cost of eating disorder treatment.12
Health care providers can use simple screens to encourage their patients to discuss eating concerns. The Binge Eating Disorder Screener-7 (BEDS-7)13* can be used to screen for binge-eating behavior and to guide a conversation with the patient about eating concerns. A simple screener like the BED-7 can be especially helpful for clinicians who feel ill-equipped to ask sensitive questions related to BED symptoms or lack time for more extensive interviews about eating behaviors.14 A positive screen can help a provider gauge how severe the BED is and guide the specialist referral process. If you think you might have BED yourself, you can take the screener at home, and bring it with you when you talk to your healthcare provider. This can increase your confidence in speaking with your provider about BED.
Raising awareness of BED is important to help more people get the treatment they deserve. Effective treatments for BED exist, but they can only work if someone can access treatment.
*Note: The BED-7 was developed by Shire US Inc. (a pharmaceutical company), but is a free resource that is available for use by anyone.
Kornstein, S. G. (2017). Epidemiology and recognition of binge-eating disorder in psychiatry and primary care. Journal of Clinical Psychiatry, 78 (Suppl 1), 3-8. doi:10.4088/JCP.sh1 6003su1c.01
Cossrow, N., Pawaskar, M., Witt, E. A., Ming, E. E., Victor, T. W., Herman, B. K., . . . Erder, M. H. (2016). Estimating the prevalence of binge eating disorder in a community sample from the United States: Comparing DSM-IV-TR and DSM-5 criteria. Journal of Clinical Psychiatry, 77(8), e968-974. doi:10.4088/JCP.15m10059
Ling, Y. L., Rascati, K. L., & Pawaskar, M. (2017). Direct and indirect costs among patients with binge-eating disorder in the United States. International Journal of Eating Disorders, 50 (5), 523-532. doi:10.1002/eat.22631
Pawaskar, M., Witt, E. A., Supina, D., Herman, B. K., & Wadden, T. A. (2017). Impact of binge eating disorder on functional impairment and work productivity in an adult community sample in the United States. International Journal of Clinical Practice, 71(7). doi:10. 1111/ijcp.12970
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Association.
Kornstein, S. G., Kunovac, J. L., Herman, B. K., & Culpepper, L. (2016). Recognizing binge-eating disorder in the clinical setting: A Review of the literature. prim care companion The Primary Care Companion for CNS Disorders, 18 (3). doi:10.4088/PCC.15r01905
Cachelin, F. M., & Striegel-Moore, R. H. (2006). Help seeking and barriers to treatment in a community sample of Mexican American and European American women with eating disorders. International Journal of Eating Disorders, 39(2), 154-161. doi:10.1002/eat. 20213
Becker, A. E., Hadley Arrindell, A., Perloe, A., Fay, K., & Striegel-Moore, R. H. (2010). A qualitative study of perceived social barriers to care for eating disorders: Perspectives from ethnically diverse health care consumers. International Journal of Eating Disorders, 43(7), 633-647. doi:10.1002/eat.20755
Innes, N. T., Clough, B. A., & Casey, L. M. (2017). Assessing treatment barriers in eating disorders: A systematic review. Eating Disorders, 25 (1), 1-21. doi:10.1080/10640266. 2016.1207455
Citrome, L. (2017). Binge-eating disorder and comorbid conditions: Differential diagnosis and implications for treatment. Journal of Clinical Psychiatry, 78 (Suppl 1), 9-13. doi:10.4088/JCP.sh16003su1c.02
Dearden, A., & Mulgrew, K. E. (2013). Service provision for men with eating issues in Australia: An analysis of organisations’, practitioners’, and men’s experiences. Australian Social Work, 66(4), 590-606. doi:10.1080/0312407X.2013.778306
Hepworth, N., & Paxton, S. J. (2007). Pathways to help-seeking in bulimia nervosa and binge eating problems: A concept mapping approach. International Journal of Eating Disorders, 40(6), 493-504. doi:10.1002/eat.20402
Herman, B.K., Deal, L.S., DiBenedetti, D.B., Nelson, L., Fehnel, S.E., Brown, T.M. (2016) Development of the 7-Item Binge-Eating Disorder Screener (BEDS-7). Primary Care Companion CNS Disorders, 18(2). doi: 10.4088/PCC.15m01896.
Supina, D., Herman, B. K., Frye, C. B., & Shillington, A. C. (2016). Knowledge of binge eating disorder: A cross-sectional survey of physicians in the United States. Postgraduate Medicine, 128 (3), 311-316. doi:10.1080/00325481.2016.1157441
The Academy for Eating Disorders (AED) recently held its 25th annual International Conference on Eating Disorders (ICED) in New York, New York from March 14th-16th. The theme of this year’s conference was “Start Spreading the News: Education, Dissemination, and the Science of Eating Disorders,” and the content was aimed at disseminating the clinical and research science of eating disorders more broadly. The conference kicked off with a stimulating keynote address from one of the foremost researchers on suicide, Thomas Joiner, PhD (Florida State University) during which he discussed current epidemiological findings on death by suicide, as well as anecdotal, clinical, and scientific evidence that evaluates a new theory of suicidal behavior. This year’s keynote address was particularly salient as those with eating disorders have a disproportionately high risk for suicide, and thus had direct implications for the clinicians and researchers in attendance.
In keeping with the larger theme of the conference, there were several plenary sessions that were geared toward expanding the reach and/or scope of eating disorders research and clinical interventions. The first plenary session centered around examining the evidence regarding optimal duration for eating disorders treatment. Speakers including Michael Barkham, PhD, Glenn Waller, DPhil, and Ivan Eisler, PhD presented data on brief interventions for eating disorders, and the discussant, Tracey Wade, PhD, helped attendees think through the utility of these interventions and how they might be made available to a greater proportion of the population. Subsequent treatment-focused plenaries highlighted complicated ethical issues involved in compulsory treatment (including a poignant perspective by someone with lived experience compulsory treatment for an eating disorder), as well as an examination of leading-edge therapeutic approaches that leverage novel findings in neuroscience and neurobiology.
NCEED Team ICED 2019
This year’s ICED also provided an avenue for the National Center of Excellence for Eating Disorders (NCEED; based here at UNC) to be introduced to the larger field. With the official launch occurring during National Eating Disorders Awareness Week, the NCEED team took advantage of the growing momentum to exhibit at ICED and promote the Phase I launch.
NCEED also had the opportunity to meet with thought leaders in the eating disorders field by hosting a meeting to seek feedback and guidance on the mission and vision of the program. The meeting brought together leading researchers, clinicians, and advocates so gather a wide range of perspectives. Attendees provided the necessary collective wisdom that will allow NCEED to flourish as a sustainable resource for the larger healthcare field.
NCEED meeting with thought leaders in the field
Throughout the conference, ICED attendees were exposed to many opportunities to educate themselves and also to network with a community of peers. In addition to the keynote and plenaries, daily workshops and paper/poster sessions offered participants in-depth knowledge on clinical interventions, innovative scientific investigations, and efforts to close the research-practice gap. At times, conversations about the direction of our field in terms of diversity, equity, and inclusion were challenging, but they were an important part of the dialogue and vital to the growth of the organization (i.e., the Academy for Eating Disorders) and the field as a whole. In sum, ICED 2019 was an interactive opportunity to learn, engage in dialogue, and advance the study and treatment of eating disorders. ICED 2020 will take place in Sydney Australia!
For decades, the arrival of spring has also meant the
proliferation of headlines offering tips and tricks to women for achieving a
“Bikini Body.” In recent years, however, many women and publications are pushing
back against that notion. In 2015, Women’s
Health magazine vowed to stop using the phrase on covers based on its
negative and shaming connotation that only some bodies deserve to be in bikinis
(Laird, 2015). Other publications have emphasized, “Every body is a bikini
body,” which has become a common refrain following the popularization of body
positivity in recent years (Brickell, 2018).
Body positivity encompasses many ideas. A simple
interpretation of body positivity is the act of loving your body as it is
instead of always striving to lose weight, tone, or change the size, shape, or
even color to achieve some ideal. Although a wonderful idea at its core, some
have urged caution that individuals who may have many body-related insecurities
or even deeper problems with their self-image may find the pressure to be body
positive yet another “should” imposed on them by the environment (Royse, 2019; Schreiber
& Hausenblas, 2016). When speaking with Glamour,
Claire Mysko, the CEO of the National Eating Disorder Association, suggested
that the guilt felt when someone is unable to maintain consistent body
positivity can worsen negative self and body image (Royse, 2019).
A flexible and gracious interpretation of body positivity encourages
accepting that your body and the changes it goes through during life are
separate from your self-worth as a person (Schreiber & Hausenblas, 2016). This
perspective has also been forwarded as working toward separating your
body-esteem from your self-esteem (Bulik, 2011). Another approach is to examine
messages about body image you have been exposed to in the media and culture in
general and how they diverge from an approach of accepting your body and
recognizing its unique and varying needs (Schreiber & Hausenblas, 2016).
Body positivity should never feel like a pressure. In fact,
it should feel the opposite—more like a liberation or freeing from “should”
about physical appearance. Working toward your own personal definition of body
positivity could put you on a path to a truly body positive future—one where you
recognize that your body does not determine your self-worth; that your feelings
about your body may fluctuate occasionally; and that it is wonderful to accept
and appreciate your body for the hard and amazing work that it does for you.
Eating and weight concerns can take a toll on your health and well-being. They can also affect your relationships. Partners often don’t know what to say or do or how to support their loved one who is having problems with eating.
Drs. Cynthia Bulik, Donald Baucom, and Jennifer Kirby are currently conducting a study at the University of North Carolina examining two different treatments for binge-eating disorder (BED). Individuals with BED find themselves eating large amounts of food and feeling out of control. Or, they feel like once they start eating, it is sometimes hard to stop. The study consists of 16 weeks of evidence-based treatment at NO COST. Participants also receive payment for participating in assessments.
If you are an adult, have been in a committed relationship for at least 6 months, and are currently dealing with BED or have a partner who currently has BED, you may be eligible.
How do you know if you or your partner might have BED? Here are some signs:
Eating feels out of control (for example, once you start eating you can’t seem to stop)
Eating large amounts of food when not feeling physically hungry
Feeling guilty, ashamed, or distressed after eating
Eating in secret
Eating large quantities of food in a short period of time
If you would like to learn more about the study, please contact the Research Coordinator, Rachel Guerra, via email (UNITE@unc.edu) or phone (984) 974-3802.
This is Part 3 of a 3-part series on posttraumatic stress disorder (PTSD) and eating disorders by Dr. Mary Hill. To access the first post describing the co-occurrence of eating disorders and PTSD click here. To access the second post on evidence-based treatments for PTSD, click here.
At some point in their lives, many individuals experience or witness a traumatic event, such as a physical or sexual assault, serious car accident, natural disaster, or combat;1 however, most of us know little about common reactions to trauma. Misconceptions about trauma and individuals’ reactions to trauma can unintentionally promote stigma, shame, and misplaced blame, and the most commonly reported reason individuals do not report a trauma or seek treatment is because of fear of stigma, shame, and social rejection.2 Therefore, it is critically important to address these misconceptions. The following are truths about trauma and trauma reactions and helpful information about how and why these reactions occur.
The inability to recall key features of the trauma or having difficulty remembering aspects of the trauma are genuine symptoms of posttraumatic stress disorder (PTSD).
Inability to recall key features of the trauma is a common experience and is a symptom of PTSD.3 Trauma survivors’ memories of the trauma are also often disorganized. During a traumatic event, one’s distress level increases, and the body’s fight, flight, freeze/numb response kicks in to help an individual survive. Several mechanisms that promote self-preservation also interfere with the processing of information that is encoded during times of intense distress.4 This reaction likely serves as a protective response initially but can be prolonged in unhelpful ways due to avoidance of trauma memories and reminders.
Difficulty remembering key features of the event is often distressing and can lead to beliefs like, “I can’t trust myself,” or “I’m going crazy.” Through exposure-based trauma therapies, like prolonged exposure (PE; for more information about PE and other treatments, see link to PTSD treatment blog), fragmentation of memories can be reduced and organization of memory increased.4 This does not mean that survivors are making things up, rather that they are able to gradually approach the memories safely and process them.
Experiencing dissociative symptoms, like depersonalization and derealization, during and/or after a trauma are common and can be very distressing.
Depersonalization is the “persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).” Derealization is “persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).” Many people report feeling “out of it” or “in a daze” during and even after the trauma. Both depersonalization and derealization can occur in response to a trauma, and for individuals who experience these symptoms recurrently, they may meet criteria for the diagnosis PTSD with dissociative symptoms.3
Although dissociative symptoms are often distressing, they are common, automatic, and protective responses. They can be reduced through interventions that promote awareness of triggers and use grounding techniques in addition to addressing the trauma directly. Distress tolerance skills, emotional awareness and acceptance, and other mindfulness and grounding skills can be incorporated into trauma-focused treatments for individuals with dissociative symptoms.
Trauma survivors are not to blame for the trauma happening.
Survivors’ self-blame is another frequently experienced reaction to trauma and is a common symptom of PTSD.3 Self-blame functions as an attempt to control what has happened to the individual. It feels uncomfortable to realize that we do not have full control over a situation, so we can trick ourselves into believing that we had control when we really did not. For example, one might think, “If only I had made decision B instead of decision A, then this wouldn’t have happened.” Believing one has control over the situation is more comfortable than acknowledging vulnerability and uncertainty; however, it leads to unwarranted guilt, shame, and self-blame. Also, because of hindsight bias (when people think “I knew that would happen,” or “I should have seen it coming,” because they believe that an event is more predictable after it has already occurred and the outcome is known),5 individuals often think they should have known what would happen and could or should have done something to avoid or escape the situation.
Similarly, when others blame the victim, they reduce their own feelings of vulnerability and uncertainty. We like to think “bad things happen to bad people, and good things happen to good people.” So when bad things happen, we assume it must be for a reason. This belief promotes a comforting, albeit inaccurate, assumption that we should be able to avoid all bad things happening to us. Problematic blame by self and others is also addressed in trauma-focused therapies and can help survivors and loved ones more accurately understand what happened and what was within their power to control. It is important to also address inaccurate blame among healthcare professionals and law enforcement, as many survivors report being blamed or dismissed when disclosing trauma to members of law enforcement, physicians, and therapists.6
Reluctance to report a trauma, like a sexual assault, doesn’t mean it wasn’t horrible.
Trauma survivors’ reluctance to come forward may be attributed to difficulty processing what happened, self-blame, and systematic problems with how trauma survivors are often treated when they disclose trauma. Many fear that a) they won’t be believed, b) people will see them differently (i.e., “damaged”), c) they may be blamed or ridiculed, or d) that gaps in their memory will be scrutinized and interpreted as lying.
Misconceptions about trauma and trauma reactions add to survivors’ distress levels and interfere with their willingness to seek help and experience benefits of support. Ongoing efforts to decrease stigma and provide accurate information about trauma and common reactions to trauma may help reduce distress among survivors. In addition, it can reduce negative outcomes experienced when trauma survivors do seek support from law enforcement, hospital emergency departments, mental health professionals, and loved ones.
Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. Journal of Traumatic Stress, 26, 537-47. doi: 1002/jts.21848
Kantor, V., Knefel, M., and Lueger-Schuster, B. (2016). Perceived barriers and facilitators of mental health service utilization in adult trauma survivors: A systematic review. Clinical Psychology Review, 52, 52-68. doi: 10.1016/j.cpr.2016.12.001
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences. New York, NY: Oxford University Press.