The Twitter-sphere has been discussing the difference between disordered eating and eating disorders (specifically
EDNOS ) today. I haven't responded, in part because I like to formulate a complete answer than spewing something half-baked, and also because I can't explain myself in 140 characters or less! But the more I think about it, the more I realize that I don't necessarily have all the answers, but that these are answers that are worth having.
To start forming these answers, we first need to define "disordered eating" and
EDNOS.
A Newsweek article on EDNOS, which prompted this discussion in the first place, had this quote from Susan Ice*, Medical Director at the
Renfrew Center, about
EDNOS:
" EDNOS is a hodgepodge of things that don’t necessarily belong together, except that they don’t belong anywhere else." The Newsweek article pointed out that there are plenty of insurance issues regarding
EDNOS; whereas insurance companies may grudgingly cover anorexia and bulimia treatment (if you're lucky), they frequently will not cover treatment for
EDNOS. I don't necessarily know their logic--nor even if they have any--but this strikes me as more of an insurance issue than an
EDNOS issue.
Problems with
EDNOS remain, however. It's
the most common ED diagnosis, yet differentiating
EDNOS from full-syndrome anorexia, bulimia, and binge eating disorder doesn't always yield significant results. People with
EDNOS are typically just as ill and just as impaired as those with other eating disorders. That so many people are diagnosed with something titled "not otherwise specified" is troubling, and indicates that we really don't know a whole lot about eating disorders. Leading ED researchers have noted that
the DSM criteria for eating disorders are in much need of revision. I don't advocate getting rid of the category entirely, because it is a way to account for the continuing evolution of both eating disorders and our understanding of them. That being said, we need to get a heck of a lot more clear on what's going on with eating disorders.
Then we have the issue of disordered eating. I was surprised at how difficult it was to actually find a definition of disordered eating. The most amusing was "eating that is irregular or disordered." Just file under "circular reasoning" and then hit me with the Duh Truck, why don't you.
Wikipedia equated "disordered eating" with
EDNOS, though I wouldn't call the two issues the same. The best definition I found, and one which involves way too much
hand waving for my nit-picky scientific mind, was from
Eating Disorder Expert:
"“Disordered eating” is a term used to describe eating habits or patterns that are irregular. Many different types of disordered eating habits exist, but for the most part these habits do not add up to a diagnosis of an eating disorder...Excluding whole food groups (for example, all fats or all carbohydrates), eating only at particular times of the day, eating only specific foods, eating only foods of a specific colour, eating only foods of a specific texture, not eating certain foods together in a sitting and not eating specific foods from the same plate can all be types of disordered eating." I would also place dieting and body image obsession into this category, which basically includes 95% of the American public. Research from
UNC -Chapel Hill found that
three out of four women in the US have disordered eating attitudes. It's significant. It's severe. It sucks.
It's
not an eating disorder.
Disordered eating can look like an eating disorder, especially when the eating disorder is just forming. Similarly, a full-blown alcoholic may start as a binge drinker at parties on the weekend. Neither disordered eating or binge drinking is healthy or something I would advocate. But most of those with disordered eating or binge drinking do not go on to develop eating disorders or alcoholism. This isn't to say that they aren't deserving of help and wouldn't benefit from therapy or taking a long, hard look at their behaviors. Far from it. But I have many behaviors that could stand improvement that are still far from pathological.
Right now, we don't have the diagnostic accuracy to be able to separate people into two groups: those with eating disorders and those with disordered eating. Nor do we know how to separate those with disordered eating and those without any eating issues. Disordered eating hasn't been clinically defined; for that matter, neither really has
EDNOS. As much as I hate the "less than 85% ideal body weight" and
bingeing and purging twice a week for three months criteria of the
DSM and think they're crap, it's a start. Although I can personally define disordered eating as well as Justice Homer
Stewart can define obscenity (i.e., "
I'll know it when I see it."), this isn't very useful to anyone but, you know, me.
I can't get more specific than this; we don't have the definitions or the research. What I can say is this:
I see eating disorders as primarily biological issues. I see disordered eating as primarily a cultural issue.
"But Carrie," you say, "what about
Anne Becker's research on the island of Fiji?" Becker, an anthropologist, found that the arrival of American TV on Fiji in the mid-90s resulted in an increase in disordered eating attitudes, dieting and self-induced vomiting. After three years of TV viewing, approximately 12% of Fijian adolescent girls admitted to self-induced vomiting, compared to 0% before the arrival of American TV. This is clearly problematic, and I regret the introduction of TV and the loss of innocence on Fiji.
Yet the study did not indicate the frequency of self-induced vomiting (not that any is good, but again, I think of the relationship between binge drinking and alcoholism. It can look the same, but it's not), nor do people comment on the rate of disordered eating attitudes before the arrival of American TV. Just over 12% of Fijian girls had a high score on the Eating Attitudes Test before TV came to the island; after three years, that number was 30%- a significant increase. The number of girls with high levels of disordered eating more than doubled in three years- it's sad and it's serious and it's a big, big problem. But that means that even without American TV and models and ads, about one in eight Fijian adolescent girls had high levels of disordered eating. Could these be the beginnings of eating disorders? Perhaps. The test doesn't distinguish between disordered eating and eating disorder. But neither were any full-syndrome eating disorders diagnosed in the first three years following the arrival of American TV.
Of course, I would never claim that anyone could split nature and nurture. Both are important. But I see dieting as a cultural phenomenon, one that is rapidly sweeping around the world. Eating disorders exist in all cultures, races, genders, socioeconomic classes, and time periods. Certainly many eating disorders start as disordered eating, but then they progress into something much more sinister and something the sufferer has much less choice over.
Both issues are important, but they are rather different. Promoting better body image and self-esteem will hopefully decrease the amount of disordered eating, and maybe result in fewer eating disorders being triggered by malnutrition in the form of dieting or "healthy eating." I'm not sure it will have much effect on eating disorders. I wasn't thinking about supermodels when I first thought about eating "better" and exercising more. I didn't obsess about freakishly skinny women until after I had started losing weight.
There is a fundamental difference between disordered eating and an eating disorder. I might not always be able to tell you exactly what it is, but I'll know it when I see it.
*Full disclosure: she was my MD when I was at Renfrew in 2001, and her last name kind of fits her. She was quite competent, but she also terrified me. Then again, she was also the one increasing my meal plan practically twice daily.
To start forming these answers, we first need to define "disordered eating" and EDNOS. A Newsweek article on EDNOS, which prompted this discussion in the first place, had this quote from Susan Ice*, Medical Director at the Renfrew Center, about EDNOS:
" EDNOS is a hodgepodge of things that don’t necessarily belong together, except that they don’t belong anywhere else."
The Newsweek article pointed out that there are plenty of insurance issues regarding EDNOS; whereas insurance companies may grudgingly cover anorexia and bulimia treatment (if you're lucky), they frequently will not cover treatment for EDNOS. I don't necessarily know their logic--nor even if they have any--but this strikes me as more of an insurance issue than an EDNOS issue.
Problems with EDNOS remain, however. It's the most common ED diagnosis, yet differentiating EDNOS from full-syndrome anorexia, bulimia, and binge eating disorder doesn't always yield significant results. People with EDNOS are typically just as ill and just as impaired as those with other eating disorders. That so many people are diagnosed with something titled "not otherwise specified" is troubling, and indicates that we really don't know a whole lot about eating disorders. Leading ED researchers have noted that the DSM criteria for eating disorders are in much need of revision. I don't advocate getting rid of the category entirely, because it is a way to account for the continuing evolution of both eating disorders and our understanding of them. That being said, we need to get a heck of a lot more clear on what's going on with eating disorders.
Then we have the issue of disordered eating. I was surprised at how difficult it was to actually find a definition of disordered eating. The most amusing was "eating that is irregular or disordered." Just file under "circular reasoning" and then hit me with the Duh Truck, why don't you. Wikipedia equated "disordered eating" with EDNOS, though I wouldn't call the two issues the same. The best definition I found, and one which involves way too much hand waving for my nit-picky scientific mind, was from Eating Disorder Expert:
"“Disordered eating” is a term used to describe eating habits or patterns that are irregular. Many different types of disordered eating habits exist, but for the most part these habits do not add up to a diagnosis of an eating disorder...Excluding whole food groups (for example, all fats or all carbohydrates), eating only at particular times of the day, eating only specific foods, eating only foods of a specific colour, eating only foods of a specific texture, not eating certain foods together in a sitting and not eating specific foods from the same plate can all be types of disordered eating."
I would also place dieting and body image obsession into this category, which basically includes 95% of the American public. Research from UNC -Chapel Hill found that three out of four women in the US have disordered eating attitudes. It's significant. It's severe. It sucks.
It's not an eating disorder.
Disordered eating can look like an eating disorder, especially when the eating disorder is just forming. Similarly, a full-blown alcoholic may start as a binge drinker at parties on the weekend. Neither disordered eating or binge drinking is healthy or something I would advocate. But most of those with disordered eating or binge drinking do not go on to develop eating disorders or alcoholism. This isn't to say that they aren't deserving of help and wouldn't benefit from therapy or taking a long, hard look at their behaviors. Far from it. But I have many behaviors that could stand improvement that are still far from pathological.
Right now, we don't have the diagnostic accuracy to be able to separate people into two groups: those with eating disorders and those with disordered eating. Nor do we know how to separate those with disordered eating and those without any eating issues. Disordered eating hasn't been clinically defined; for that matter, neither really has EDNOS. As much as I hate the "less than 85% ideal body weight" and bingeing and purging twice a week for three months criteria of the DSM and think they're crap, it's a start. Although I can personally define disordered eating as well as Justice Homer Stewart can define obscenity (i.e., " I'll know it when I see it."), this isn't very useful to anyone but, you know, me.
I can't get more specific than this; we don't have the definitions or the research. What I can say is this:
I see eating disorders as primarily biological issues. I see disordered eating as primarily a cultural issue.
"But Carrie," you say, "what about Anne Becker's research on the island of Fiji?" Becker, an anthropologist, found that the arrival of American TV on Fiji in the mid-90s resulted in an increase in disordered eating attitudes, dieting and self-induced vomiting. After three years of TV viewing, approximately 12% of Fijian adolescent girls admitted to self-induced vomiting, compared to 0% before the arrival of American TV. This is clearly problematic, and I regret the introduction of TV and the loss of innocence on Fiji.
Yet the study did not indicate the frequency of self-induced vomiting (not that any is good, but again, I think of the relationship between binge drinking and alcoholism. It can look the same, but it's not), nor do people comment on the rate of disordered eating attitudes before the arrival of American TV. Just over 12% of Fijian girls had a high score on the Eating Attitudes Test before TV came to the island; after three years, that number was 30%- a significant increase. The number of girls with high levels of disordered eating more than doubled in three years- it's sad and it's serious and it's a big, big problem. But that means that even without American TV and models and ads, about one in eight Fijian adolescent girls had high levels of disordered eating. Could these be the beginnings of eating disorders? Perhaps. The test doesn't distinguish between disordered eating and eating disorder. But neither were any full-syndrome eating disorders diagnosed in the first three years following the arrival of American TV.
Of course, I would never claim that anyone could split nature and nurture. Both are important. But I see dieting as a cultural phenomenon, one that is rapidly sweeping around the world. Eating disorders exist in all cultures, races, genders, socioeconomic classes, and time periods. Certainly many eating disorders start as disordered eating, but then they progress into something much more sinister and something the sufferer has much less choice over.
Both issues are important, but they are rather different. Promoting better body image and self-esteem will hopefully decrease the amount of disordered eating, and maybe result in fewer eating disorders being triggered by malnutrition in the form of dieting or "healthy eating." I'm not sure it will have much effect on eating disorders. I wasn't thinking about supermodels when I first thought about eating "better" and exercising more. I didn't obsess about freakishly skinny women until after I had started losing weight.
There is a fundamental difference between disordered eating and an eating disorder. I might not always be able to tell you exactly what it is, but I'll know it when I see it.
*Full disclosure: she was my MD when I was at Renfrew in 2001, and her last name kind of fits her. She was quite competent, but she also terrified me. Then again, she was also the one increasing my meal plan practically twice daily.