By: Sarah E. Pember, BA, MT
Despite lacking a concrete clinical definition, “otherwise specified” eating disorders are the most prevalent eating disorders in the female population. One study found that less than one-third of college women had ‘normal’ eating habits, with 82% of women engaging daily in some semblance of dieting behavior, such as restriction or calorie counting (Mintz & Betz, 1988). More recent figures show over 50% of young women exhibiting unhealthy weight control behaviors (Eisenberg, Berge, & Newmark-Sztainer, 2013), including 25.9%reporting dietary restraint and 30.8% stating excessive exercise as compensatory strategies for weight loss (Luce, Crowther, & Pole, 2008). Nearly 25% of undergraduate women have also reported more extreme weight-management behaviors, including purging and laxative or diuretic misuse (Luce, et al., 2008). Nearly 18% of women aged 17-24 have reported ‘usually’ or ‘always’ dieting (Gravener, Haedt, Heatherton, and Keel, 2008).
“The Big Three”: Clinical Eating Disorders
The three major eating disorders, as defined by the DSM-V, are anorexia nervosa, bulimia nervosa, and, now, binge eating disorder. The characteristics and health effects of each vary in both description and intensity. To better understand disturbed eating pathology, it is important to first recognize the extremes of disordered eating.
Anorexia nervosa (AN) is the absolute refusal to eat, accompanied by denial of hunger and an extreme fear of gaining weight. Severe dietary restriction may be combined with excessive exercise and a fear of eating in public, all of which result in drastically low body weight, and a myriad of other health symptoms, including potential social isolation, constipation and abdominal pain, amenorrhea (loss of a menstrual cycle), irregular heartbeat, and death (American Psychological Association [APA], 2013).
Bulimia nervosa (BN) is a cycle of overeating accompanied by extreme compensatory behavior, commonly associated with purging, but also includes over-exercise, post-binge fasting, or laxative abuse. Health effects of bulimia may be similar to those of anorexia.
The fifth edition of the Diagnostic and Statistical Manual separates binge eating disorder (BED) from the EDNOS category; research shows that it has sufficiently distinguishable diagnostic requirements (American Psychological Association [APA], 2013). While the consumptive binging cycle is similar to that of bulimia, there is rarely an excess of compensatory behavior post-binge. Clinically defined Binges are marked by a loss of control, excessive food intake in a short period of time, often eating to the point of physical discomfort or pain, accompanied by feelings of guilt or depression.
Otherwise Specified Eating Disorders and the ED Continuum
The difficulties in treating and diagnosing disordered eating symptomology is based in part on the belief that disturbed eating pathology exists on a continuum, rather than opposing poles of ‘normal’ and ‘disordered’ (Polivy & Herman, 1987; Mintz & Betz, 1988; Tylka & Subich,1999; Taylor, et al., 2006; Schwitzer, Hatfield, Jones, Duggan, Jurgens, & Winninger, 2008). At one end of the continuum lie the clinically diagnosed disordered of anorexia, bulimia, and binge eating disorder, and on the opposing end is ‘normal’ eating, classified by relaxed approach to food, healthy body image and acceptance, and healthy body weight. In the middle of the continuum are various manifestations of disordered eating behaviors, including, but certainly not limited to, extreme exercise, dietary restriction or restraint (perhaps accompanied by reactive overeating), fear of weight gain, preoccupation with body shape, poor body image, purging, laxative misuse, fasting, and yo-yo dieting (Nejad, Wertheim, & Greenwood, 2005; Eisenberg, et. al, 2013). Women with otherwise specified eating disorders are likely to have a high knowledge of calories, fat, and nutritional content of foods and may engage in secretive eating or excessively slow eating as weight loss strategies (Schwitzer, 2012). Disordered eating an eating obsession often based in fear weight gain and body dissatisfaction:
“Food became one of my mind’s favorite topics. I got off on the sensation of my stomach grumbling and learned to fall asleep hungry. But God forbid the scale go up. If it did, I seethed… Disordered eating….refers to… eliminating food groups from your diet; regularly replacing meals with energy bars or coffee drinks; excessive weighing and calorie-counting; and tacking on extra miles as punishment for…a cheeseburger the night before. Often, the regimen includes compulsive exercising like hitting the bike after an 18-miler.” (Daniloff, 2012)
The health effects of disordered eating, anywhere along the continuum, can be just as harmful as those of anorexia, bulimia, or binge eating disorder. Lack of proper nutrition can lead to simple fatigue or muscular weakness, or severe malnutrition leading to death.
In addition to maladaptive eating behaviors, women with otherwise specified eating disorders are also likely to have deep cognitive problems, devoting excessive amounts of time and mental energy to their obsession or preoccupation with food, calories, and losing weight (Schwitzer, et al., 2008; Schwitzer, 2012). Concurrent symptoms may include depression, stress, anxiety, social isolation and unstable or fragile self-esteem, all of which can be both driving and side effects of the eating pathology.
Research in female populations tends to use dieting behavior and body esteem as indicators of the level of a woman’s eating disorder pathology (Nejad, et al., 2005). Dieting frequency, weight concerns, and a focus on body image are associated with greater severity and prevalence of eating disorder symptoms and unhealthy weight-control practices in college women, regardless of their actual weight and shape. Diet and weight-control behaviors, including excessive exercise, may be descriptive and predictive of a broader pattern of disordered eating not meeting clinical criteria (Ackard, Croll, & Kearney-Cooke, 2002; Taylor, et al., 2006; Lindner, Hughes, & Fahy, 2008). Young adult women, between 18 and 24 years old are more likely to exhibit signs of eating disturbances than older women (Hilbert, de Zwaan, Braehler, 2012), but weight concern is a life-long trend among females (Wharton, Adams, & Hampl, 2008). Reducing weight concerns reduces the likelihood of an onset of eating disorder symptomology (Taylor, et al., 2006).
Eating disorders ‘otherwise specified’ are the most prevalent, least diagnosed, and deadliest of all disordered eating pathologies. Because they are so difficult to define, examinations of the ways in which disordered eating behaviors manifest themselves in perceptions, intentions, and actions are imperative. With the issuance of the DSM-V, health practitioners must focus on the development of effective diagnostic tools and criteria, along with effective preventative interventions, to tackle what will continue to be a serious health issue among young women.
Culturally Normative Disorder
The impact of the media on disordered eating behavior is well known. The ‘thin ideal’ and ‘cult of thinness’ present in American culture has been blamed for the widespread misperceptions of thinness in society (Hesse-Biber, Leavy, Quinn, & Zoino, 2006; Strahan, et al., 2007). In fact, otherwise specified eating disorders are so widespread that some consider them the result of cultural norms. This idea of ‘culturally induced eating’ is defined as:
“a pattern of behavioral eating-disordered symptoms in individuals who do not manifest the psychological symptoms usually associated with clinical Eating Disorders; a pattern of behaviors that directly stems from the socio-economic and cultural context within which women’s lives are embedded. Disordered eating and obsession with food is a widely accepted way to deal with weight and body image issues. It is largely considered normative behavior for women…” (Hesse-Biber, et al., 2006, p. 211)
It has been shown that peers exert the strong perceived pressure on adolescent girls desire to be thin, above the influence of family or the media (Dunkley, Weirtheim, & Paxton, 2001). However, both media information regarding weight loss methods and encouragement from parents to diet also have direct associations with dietary restraint and intentions to diet in both adolescent and college-age women (Dunkley, et al., 2001;Giles, et al., 2007). The combined influence of peer, parent, and media influence predicted body dissatisfaction and dietary restraint more significantly than any one agent of influence individually. Drive for thinness and body dissatisfaction exist at higher levels for young women who live in a subculture that promotes the thin ideal.
Social Media: The New Normative Influence
Social media is the new social norm. The Internet is the most commonly used media type among women, nearly four times as often as magazines (Bair, Kelly, Serdar, & Mazzeo, 2012), which have been shown to consistently predict eating disorder symptomology (Harrison & Cantor, 1997). The percentage of women using social media sites like Facebook and Instagram, both of which allow for the perpetuation of images, real or idealized, is continually rising. As this new form of media influence expands, so too do the concerns of its effects on women’s body dissatisfaction, and concurrently, eating and exercise behaviors.
Obvious, ‘pro-ANA’ (pro-anorexia) sites have historically been the focus of what research regarding the Internet as a media influence affecting eating disorder pathology (Harper, Sperry, Thompson, 2008; Jett, Laporte, & Wanchisn, 2010). If reading pro-ANA websites has been shown to lead to increased dietary restraint in women already at risk of disordered eating (Harper, Sperry, Thompson, 2008; Jett, et al., 2010), it is also worth paying attention to the proliferation of thin ideal images that permeate the social networking sites more consistently (and constantly) accessed by young women.
The implications of social media use and the rise of disordered eating (and exericise) behavior are severe. Thinspiration is an umbrella term for the sharing or posting photos and mantras encouraging extreme dieting or disordered eating behaviors (Lewis & Arbuithnott, 2012) on internet networking sites such as Tumblr, Pinterest, or Instagram, visually-based networking and blog sites whose traffic is comprised predominantly of females. Although there is some evidence that this concept of thinspiration—dieting with the intention of approaching a thin ideal—is not related to weight-loss dieting, and it is only perceptions of similarity to an ‘over-fat’ prototype, and fear-related avoidance of being associated with that identity, that are directly related to weight-loss dieting (Dalley & Buunk, 2009). Thinspiration on the Internet effectively encourages fasting and compensatory overexercise. The search terms for thinspiration and thinspo have been found to be associated with the most detrimental and pro-eating disorder content on the web (Lewis & Arbutchnott, 2012).
New research is emerging exists the impact of the constant barrage of social media images on young women’s eating behaviors, body image, self-esteem, or normative perceptions, including the detrimental health effects of body image comparison on Facebook (Fardouly, Diedrichs, Vartanian, & Halliwell, 2015).
When the norm for eating has moved so far from a healthy end of the disordered eating continuum, it is justifiably difficult to even convince women there is a problem, much less know how to treat what society considers the norm for behavior. With the rise of image-based social media adding to contemporary normative pressures and socialized misperceptions (Chou & Edge, 2012) , it is even more imperative that efforts are made to change attitudes about what constitutes healthy eating, address the realities of extreme dieting, and end the normalization of disorder.
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