Issue 147 Eating disorders: the potential impact of dietary advice

CONDITIONS & DISORDERS

EATING DISORDERS: THE POTENTIAL IMPACT OF DIETARY ADVICE Many eating disorders (ED) start after a period of ‘normal dieting’.

This raises the obvious question of what are the potential dangers associated with the current dieting culture, weight-loss industry and the social norm of sharing weight-loss advice, tips and inspiration.

ED are defined by negative beliefs and behaviours that individuals experience in association with their eating, body shape and weight. This can result in restricted eating, binge eating and/ or compensatory behaviours.1 It is estimated that 1.25 million people in UK have an ED (25% of which are thought to be male), with research suggesting an increasing prevalence of ~7%/year since 2005.2 The impact and consequences of an ED can be devastating, not only for the individual suffering with the disorder, but also for friends and family members, as they often struggle to support them.

The development of an ED is understood to be complex, often with a number of different factors contributing, including genetic, psychological and social. A recognised environmental contributor is the sociocultural ideal-isation of thinness and the idea that thin is associated with both beauty and health. This has given rise to dieting and diet talk, currently being viewed as a social norm. It has also created a very lucrative dieting and weight-loss industry, despite the poor long-term outcomes associated with weight-loss diets.

It is widely accepted that healthy weight loss can be achieved in the short

term, but is gradually regained by a large percentage of individuals over a longer time frame. With this in mind, it is easy to see how the promotion of weight-loss diets and commencing such diets could potentially increase the risk of developing and maintaining an ED (ie, promote a drive for thinness and fear of fatness).

Nikki Brierley Specialist Dietitian and CBT Therapist Nikki has been a HCPC Registered Dietitian for over 10 years and is also a BABCP accredited CBT Therapist. She works in a dual role within the Adult Community Eating Disorder Service at Cheshire & Wirral Partnership NHS Foundation Trust. She also works privately, providing one-toone and group support.

DIETARY ADVICE

Dietitians are described as, ‘the only qualified healthcare professionals who assess, diagnose and treat diet and nutritional problems’,3 and the title of 'dietitian' can only be used by a suitably qualified individual who is registered with the Health and Care Professionals Council (HCPC), a statutory register of health and care workers, which exists to ‘protect the public’.4 Unfortunately, there appears to be a vast amount of dietary advice provided currently, by individuals who are not HCPC registered, via a variety of sources. This advice seems to largely come from ‘personal experience’ (ie, someone who has apparently improved their own health or appearance through following a specific diet and is sharing advice with others based on this experience), or by so-called ‘experts’ (ie, someone who claims to have a high

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CONDITIONS & DISORDERS level of knowledge relating to diet, weight and/ or health, for example, personal trainers, exercise experts, wellness/wellbeing/lifestyle coaches), or by ‘celebrities’ (ie, someone who is famous and providing dietary advice/endorsement).

An individual can be fined up to £5000 if they call themselves a dietitian and are not registered with the HCPC. Unfortunately, it is difficult to ascertain clear information on legal enforcement against those who provide

nutritional and dietary advice without adequate training and qualifications to safely do so. This raises the question: does more need to be done to protect the public from potential known risks, which include, but are not limited to, the development of an ED? Below is an illustrative case study that highlights the potential role of the social idealisation of thinness and dietary advice in the development of an ED.

CASE STUDY C1: a 22-year-old female referred to specialist community ED service after presenting to her GP with low mood/depression and anxiety symptoms.

Weight 52kg, BMI 19.3kg/m2 She reported dissatisfaction with her body due to recent weight gain of ~4kg over a six-month period and disclosed a restrict binge and purge pattern (self-induced vomiting, exercise and laxatives), which had developed following an initial period of dieting and weight loss.

HISTORY OF EATING DIFFICULTIES Childhood C1 described herself as subjectively feeling overweight as a child and compared herself negatively with her smaller and thinner friends. She reported being aware that her mum was unhappy with her own weight and regularly observed her mum’s attempts to lose weight (via attending mainstream weight-loss groups). She described also being aware that her grandad had Type 2 diabetes and raised cholesterol and that he had been advised by a dietitian, nurse and doctor to lose weight and to reduce his sugar and fat intake. She recalled her grandad expressing his concern that other family members could also be at risk of developing diabetes and she recalled that he would regularly encourage them to also lose weight and reduce their sugar intake, so as to reduce their risk. She reported a positive relationship with her grandad, but she worried that he thought she was fat and unhealthy (although he did not express this to her).

Adolescence C1 reported becoming focused on her own weight at around 15 years of age, when her mum encouraged her to join her and lose weight together in the lead up to a family wedding. She described enjoying this experience with her mum, who provided praise and encouragement throughout and that they spent more time together going for walks and planning, preparing and eating food.

She described experiencing a gradual weight loss (12kg in three months; 68kg, 25.3kg/m2, reducing to 56kg, 20.8kg/m2) by “healthy eating” (as promoted by a slimming group) and increased exercise (mainly walking and also attending an organised exercise class with her mum). She described increased confidence during this time and that she enjoyed the many positive comments from family (including her grandad) and friends when she attended the wedding (BMI 20.8kg/m2).

C1 recalled maintaining “healthy eating” and was determined to start college as a “thin and healthy” person. She described feeling anxious about starting college and reported that she felt that if she was thin, she would make friends easier and be more popular. She explained that during her time at college, she strictly followed her previous diet (<1500kcals/day) and increased her exercise (5-6/week, various exercise classes and gym workouts) and reduced her weight further (~50kg, BMI 18.6kg/m2).

She described feeling frustrated when her mum raised concerns at her 18th birthday about her “looking too thin” and thought that she might be envious, as she had been unable to maintain her previous weight loss.

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CONDITIONS & DISORDERS Case study continued Adulthood C1 described finding it increasingly difficult to stick with her diet and exercise plan once she commenced university (moved away from the family home and commenced part-time work in addition to studying) and that she started to gain weight and became very fearful of this.

She described seeking alternative diet and exercise advice from online sources and commenced training with a personal trainer (PT). She described setting herself a goal weight of 47kg, BMI: 17.5kg/m2. She described achieving this (her lowest reported weight) at 19 years of age, whilst strictly following a low-carbohydrate, no-added-sugar, no-wheat/gluten and no-dairy diet (as recommended by her PT). She reported finding this difficult to adhere to and reported developing a significant fear of weight gain, as she started to subjectively binge on non-allowed foods (mainly chocolate, bread and biscuits). She reported that at this time, if her weight exceeded 50kg, BMI 18.6kg/m2, she would feel “fat and panicky”.

C1 reported that she stopped training with the PT, as she disliked not achieving the agreed diet, exercise and weight goals. She reported that after this, she used many different social media outlets and weight-loss apps, as sources of motivation and inspiration to stay focused on her diet and exercise programme.

She described not always able to stick to the recommendations and that she continued to experience subjective binges that were increasing in frequency (2-4/week).

She recalled that the first time she self-induced a vomit was before a planned return visit home from university (20 years of age). She described that she had been restricting her diet to reduce her weight before seeing friends and family and that she had then binged on “bad” food (high fat, sugar and carbohydrate foods) and due to feeling fat and worrying about how her friends and family would view her, she induced a vomit to get the “bad” foods out of her body.

She described feeling shocked by her behaviour and had no plans to repeat it. However, she reported that self-induced vomiting and laxative use became a regular method for her to try and control her weight (3-7/ week).

CURRENT EATING DIFFICULTIES ED diagnosis: bulimia nervosa Weight: 52kg (4kg weight gain ~4 months) BMI: 19.3kg/m2 C1 described feeling scared to eat most of the time and reported a significant fear of weight gain and becoming “unhealthy and fat”. She described viewing most food as “bad” and to be avoided, and feeling confused by the many different sources of dietary advice that she had followed.

She described avoiding eating until lunchtime (in order to induce “fasting”), eating a salad with lean protein for lunch, followed by fruit and then binging most days on chocolate and biscuits once home from work (followed by a self-induced vomit), eating a “healthy” evening meal (lean protein, vegetable, small serving of wholegrain carbohydrate, <500kcals) and then trying to avoid eating after 7pm (to induce fasting), but that some evenings she would binge and then induce vomiting.

She described her aim to avoid sugar, wheat/gluten and dairy and that she wanted to follow a plant-based/ vegan diet, but had been unable to adhere to it.

She described feeling guilt and shame at consuming bad foods and that she felt weak and disgusted by selfinduced vomiting and her inability to stop this behaviour. She described daily self-induced vomiting, trying to avoid laxative use (limiting to weekends only) and exercising most days (despite not wanting to).

She also described being aware that diet can contribute to mood and mental health and, therefore, being worried had caused her depression and anxiety.

She described feeling overwhelmed and confused by the differing dietary advice and knowledge that she had accumulated relating to nutrition, exercise and health from various sources.

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CONDITIONS & DISORDERS DISCUSSION

The illustrative case study (C1) in this article is representative of many individuals who present with ED, in that they have often accumulated a wealth of ‘nutritional knowledge’ from a variety of sources and sometimes over many years.

Challenging these dietary beliefs (that have often initially proved beneficial, in that they achieved weight loss in the short term), and adding more dietary advice, can be very difficult. This can be further compounded by the large claims and often glamorised promises of many popular and highly-marketed/publicised weight-loss diets, which are promoted by non-HCPC registered individuals/groups.

Individuals can often fail to see that the diets were indeed the problem (ie, following a restricted diet, physiologically and psychologically, significantly increases the risk of binge eating) and instead, blame themselves for not adhering to the diet that previously proved successful. This raises the question: is enough being done to protect the public against the potential risks of ‘weight-loss/ health diets’ promoted by non-HCPC registered individuals? It also gives rise to further questions: Whose responsibility is it to provide this protection, and what is the role of the dietitian in protecting the public? Could we be doing more? As a profession and as individuals, should we be challenging non-evidence-based and potentially dangerous practices? Can we do more to increase public awareness of the value of seeking dietary advice from a dietitian?

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This highlights the need for clearer guidance on the risks associated with promoting thin as healthy and beautiful and the negative body image and increased dieting behaviour (and, thus, an increased risk of developing an ED) that this can cause. Is it possible to legally prevent inadequately qualified individuals and groups from providing and profiting from non-evidencebased and unsuitable dietary advice and unrealistic expectations/goals? Can they indeed be held accountable for the physical and mental health problems that their advice can contribute to?

CONCLUSION

ED are complex with many contributing factors.

The idealisation of thinness and the dietary advice available to promote weight loss to achieve this, are recognised risk factors in the development and maintenance of ED. It is also recognised that there is a need to protect the public from poor/unsuitable nutritional and dietary advice/ recommendations and, thus, the title of dietitian can only be used by those regulated by the HCPC. However, there is a plethora of non-HCPC registered individuals and groups who provide and profit from nutritional and dietary advice.

It is difficult to identify if/how the public can be protected against unregulated advice and this, therefore, gives rise to the suggestion that clearer guidance and enforcement procedures are needed. It also highlights the need to further explore the potential role of the dietitian and the dietetic profession, in raising awareness of the risks and challenging unsuitable practices.

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