Should eating disorder patients be introduced to “junk food” or “hyper-palatable” foods during treatment? A few days ago, I stumbled across a blog post where Dr. Julie O’Toole, Founder and Director of the Kartini Clinic for Disordered Eating, argues against introducing “junk food” during ED treatment. The crux of the argument is that “hyperpalatable foods”—e.g., chips and Cheetos—are not real food and should never be forced or encouraged for anyone, regardless of the presence of an eating disorder:
A lot of ink has been spilled on teaching Americans in general and children in particular to make good food choices. Just because you have anorexia nervosa as a child, and desperately need to gain and maintain adequate weight, does not mean that you will be immune from the health effects of bad eating as you get older. This is true whether or not you get fat later on. You can be thin and unhealthy; you can destroy a lot of things by ingesting a chemical cuisine in the place of real food.
While I don’t disagree that some foods are more nutritious and less processed than others, I would argue that—particularly for individuals with eating disorders—a hyper-focus on healthy eating, while seemingly lauded behavior, can actually be counter productive for mental health.
It is true that having anorexia nervosa as a child does not make one immune to bad eating habits later on. In theory, anyway. However, research suggests that bad eating habits are largely unlikely. In a small one-year follow-up study, Nova et al. (2011) showed that recovered AN patients tended to return to eating patterns exhibited at admission—reducing overall caloric as well as carbohydrate and fat intakes compared to immediately post-treatment. In a similar study, Delluva et al. (2011, open access) found that “after recovery, women with histories of AN focus on health benefits of foods more than non eating disordered peers, although overall energy intake did not differ between the groups.”
In the current study, recovered women did indicate a higher preference for food choice selection based on health benefits compared with control women. Selecting food items based on perceived health benefits could result in lower consumption of unhealthy, unnecessary components of food items (i.e., trans fat and added sugars). Higher importance of food selection based on health benefits in recovered women might serve as an indication that individuals who are able to recover from AN develop healthy eating and lifestyle habits. . .
Getting Fat from Eating Junk?
As I read Dr. O’Toole’s posts, I was struck by her apparent fear of patients going above a “healthy weight”, or, in her words, “getting fat”. Consequently, Kartini patients are restricted from hyper-palatable—i.e., “high calorie, high fat, sweet dessert” for at least the first year. Kartini is one of the only ED treatment centers that do not allow its patients eat “junk” while in treatment. In support of this stance, Dr. O’Toole references Ancel Keys’ Minnesota Semi Starvation Study (MSSS): The main points from the study that she highlights involve the consequences of “ad-lib” refeeding with access to calorie dense, sweet, high-fat foods, including:
- Binging and resultant weight gain
- Lack of self-control around these types of “junk” foods
- Gaining past an (arguably arbitrary) “goal weight”
The first and most important point I’d like to address is that the participants in the MSSS did not have eating disorders. They were healthy, young men with no psychiatric history. So, no matter how scientifically accurate and significant the information from the study may be, it should not be interpreted as necessarily reflective of what occurs during eating disorder treatment and recovery. Eating disorders are mental illnesses with biological and environmental causes and thus results from a controlled, scientific study of healthy men who were deprived of calories do not necessarily apply.
From my own experience with dozens of treatment providers in different centers, I have always been provided with a meal plan incorporating challenging “junk food” along with more nutrient-dense and healthy options. I was never re-fed on an “ad-lib” free-for-all basis, like participants in Keys’ were, nor was I restricted from all junk food. Both seem black-and-white to me, and neither present a model of healthy and flexible eating. Why should nutritional rehabilitation be all-or-nothing in terms of these calorie dense, sweet, high-fat foods? And a perhaps more important question: how can eating disorder patients be expected to magically be okay with “normal” eating, particularly in social settings that will, inevitably, include cupcakes, chips, and soda, if they have not ever been exposed to such foods for an entire year in treatment?
Applying Moral Standards To Food
I also question the moral and ethical judgments that are attached to “healthy” vs. “junk” food, and the implication that allowing children to eat “junk food” is akin to offering them cigarettes.
Throughout various treatment centers, I have experienced first-hand different approaches to refeeding. A particular program I was in sang the mantras “everything in moderation” and “variety is the spice of life” – we would have approximate servings of anything from tacos to salad to ice cream pie. Another hospital seemed mostly concerned about caloric intake (so much that every food item was precisely served and calculated down to the ½ exchange) and we could generally eat whatever we wanted, within reason, so long as we finished exactly at our required calorie level.
Existing Guidelines on Refeeding During Eating Disorders Treatment
In researching existing nutritional guidelines, I found that there is shockingly little nutritional information regarding the treatment EDs. I searched multiple databases and while there were many suggestions on how much patients should eat, I could hardly find any guidance on what they should be eating.
One article that I did find helpful studied psychological affect (i.e., feelings, attitudes) towards food and weight stimuli in three groups: patients with acute AN, patients recovered from AN, and healthy controls with no AN history (Spring & Bulik, 2014). In this study, participants from each group were shown a variety of high-calorie, low-calorie, thinness-related, and fat-related images, amongst others. Their reactions to these images were measured implicitly and explicitly.
As hypothesized, both implicit and explicit affect regarding high-calorie food stimuli was statistically significantly different between the acute AN group and the control group, and between the acute AN group and the recovered group. In both cases, the acute AN group displayed a much more negative affect. However, there were no statistically significant differences between any of the three groups regarding low-calorie food stimuli. This indicates that, contrary to previous beliefs, AN patients do not display negative affect towards all foods, but only high-calorie foods (Spring& Bulik, 2014).
So what does this mean? Spring and Bulik argue that AN may be “driven more by a desire to avoid high-calorie foods (possibly due to fear of fat) than by a desire to consume low-calorie foods”. Elaborating on this, Steinglass et al. (2011, open access) provide an anxiety-centered model of AN:
Steinglass et al. (2011) argue,
AN can be conceptualized as traits of anxiety and obsessionality that result in a combination of fearful avoidance of calorie dense foods, irrational beliefs surrounding eating, and ritualized behaviors that manage the distress around eating. These psychological and behavioral features are present even after successful treatment aimed at restoring weight to within the normal range (Attia et al., 1998) and may be characterized as fear and avoidance behaviors, which could increase vulnerability to persistence of the disorder and relapse.
Setting Priorities in Eating Disorder Treatment
In their article, Spring and Bulik recommend that treatment should help patients reduce negative reactions to high-calorie (junk, hyper-palatable, etc.) food through exposure therapy. They also suggest that recovery may be associated with a decrease in negative affect reactions towards high-calorie foods, which cannot be done by avoiding food:
Treatments may benefit from focusing on reducing negative reactions to high-calorie foods through exposure therapy. Indeed, there was a large difference between implicit affect to high-calorie foods in the patient and recovered groups.
While Dr. O’Toole does not advocate for eliminating high-calorie foods—just so-called “junk foods,” arguably, eliminating negative reactions toward all foods, including “hyperpalatable” or “junk” foods is also an equally worthwhile goal. Indeed, the cognitive behavioural model of eating disorders posits that binge eating occurs as a result of the inability to maintain rigid dietary rules. Consequently, eliminating the rigid and inflexible dietary rules should, in the long run, decrease binge eating–especially when the binge eating is triggered by a sense of failure to maintain the rigid rules (for example, eating a piece of a forbidden food leading to a sense of “failure” that precipitates a binge.)
Recently, Joanna Steinglass and colleagues have published a few papers developing a treatment intervention, Exposure and Response Prevention for AN (AN-EXRP), targeting precisely these eating-related anxieties (see here and here). They argue that, particularly given the fact that “eating patterns prior to discharge are related to such individuals’ ability to maintain longer-term health” (Schebendach et al., 2012 (open access); Schebendach et al., 2008), it is important to engage “patients in the task of confronting, rather than avoiding, fears” so that they can “experiencing decreasing anxiety over time”:
AN-EXRP sessions emphasize the importance of intensifying and experiencing eating-related anxiety rather than avoiding it, and may involve maneuvers to highlight such anxiety (e.g., a session might incorporate holding a greasy food for a prolonged amount of time). These techniques allow the therapist (in collaboration with the patient) to enhance eating related anxiety and provide prolonged exposure to the situation such that the patient learns experientially that anxiety dissipates.
Personally, I believe that being encouraged, and at times, forced to eat chips and drink soda was an essential part of my treatment. I also wholeheartedly believe that the danger of continuing to suffer from an eating disorder far outweighs the evils of processed food (no pun intended). If the choices are between severe restriction or frequent binge/purge episodes and Cheetos, I’ll take the tasty little cheese bites any day.
What do you think, and what are your opinions? Have you ever experienced being presented with “junk food” in treatment, and if so, what was that like for you and how did it affect your treatment? Or, if you are a treatment professional, what types of nutritional guidelines do you/your treatment center follow? Please share your thoughts; I’d love to hear them!
Tetyana’s note: In the next post, Liz will evaluate the animal studies on dietary restriction and binge eating that Dr. O’Toole cited in the comments to the post in support of Kartini Clinic’s guidelines.
Spring, V.L., & Bulik, C.M. (2014). Implicit and explicit affect toward food and weight stimuli in anorexia nervosa. Eating Behaviors, 15 (1), 91-4 PMID: 24411758
Steinglass, J.E., Sysko, R., Glasofer, D., Albano, A.M., Simpson, H.B., & Walsh, B.T. (2011). Rationale for the application of exposure and response prevention to the treatment of anorexia nervosa. The International Journal of Eating Disorders, 44 (2), 134-41 PMID: 20127936