October 11, 2012

Can parents PREVENT eating disorders?

OK, so I consider the question of whether parents cause eating disorders to be clear: no we don't.

But can we prevent them?

This all depends on what we think an eating disorder IS. I consider an eating disorder a built-in psychiatric response to energy imbalance and those symptoms of food refusal and compulsive exercise and binging and purging to be ones that with proper treatment can be put into remission. By that definition, no, parents can't prevent an eating disorder.

I do not consider the symptoms to be the cause or their absense to be the absence of an eating disorder.

In other words, if you are built to respond that way to inadequate or erratic nutrition you will have those symptoms no matter why or how you are undernourished. Therapy and insight and a different environment may help you avoid or cope better but they don't make your response to malnourishment change. And: if you are not undernourished those symptoms need not be part of your life at all.

Of course there are often co-morbid issues that drive malnourishment and make it a struggle to maintain normal nourishment. There are copious social and personal reasons a person may struggle to do so as well. But the illness itself is a paradoxical brain/behavior response when undernourished.

Yet I do think we play a possible role in preventing the onset of symptoms and an enormous role in stopping them once we know about this paradoxical brain problem.

I have wondered over the years whether a different family style around meals might have been protective for our daughter. I have wondered if my own growing dismay over my own weight gain during the years around our daughter's adolescence might have provided fertile ground. I also look at certain personal and international events and wonder "what if they hadn't happened and we hadn't had all that heightened anxiety in the house during that year?"

What I do know is that I'll never know. I'm also confident that the recipe for an eating disorder is unlikely to be that direct and obviously the same dish can have a number of recipes. I am dead sure that the greatest problem in the months after the diagnosis was my own confusion about these factors: they led to distraction and self-involvement instead of action and good sense.

If I could go whisper in my own decade-back ear now, I would recommend slightly different parenting, different modeling, and a higher sense of risk from events that seemed not to be as important at the time. I would go back and erase my own attempts at weight control, every time that I didn't speak up at a fat joke, and my buy-in to the belief that it was "healthy" to avoid certain foods and it was "normal" for a high school kid to skip breakfast and have track practice through dinnertime.

I would change those things not because they "caused" the problem, but because they messed up our response to the situation. What strikes me about the ubiquitous "prevention" advice to parents is that it implies a straight line and a dose-response: a little influence a little eating disorder, a lot of influence a very serious eating disorder. THAT kind of thinking about eating disorders is what I really, really wish we could prevent.


  1. I am very interested in this theory on the etiology of eating disorders. I'm wondering if there is any academic write-up that explains it in more depth? I'm curious about how it jives with some of the research on bulimia - most evidence seems to suggest that restrictive anorexia is highly biological, which would fit with your model, but that bulimia has quite significant social and psychological influences. Would you draw any distinction between them, or do you feel that the most important factor in both is energy imbalance and an underlying biological predisposition?

  2. Anonymous, I'm right there with you in pondering this. I don't think we know. Almost all the research we have is about anorexia, which as you say is now more clearly being seen as not all that dependent on environment. Bulimia and EDNOS are newer concepts and may represent a number of different pathways or syndromes - we really don't know. Until proven otherwise, I'm assuming that research will reveal BN and EDNOS and BED as similar - but maybe not.

    One thing does seem to hold true for all: energy imbalance. Bulimia involves a cycle of restriction, binging, and purging - and holding the body at a lower weight than expected for that person. BED also involves periods of fasting and severely imbalanced nutrition, and a history of dieting.

    If I had to guess, I'm predicting that we'll come to see certain people as having a special responses to malnourishment - something that had evolutionary advantages during times of intermittent famine which has been the history of humankind. See the work of Guisinger.

  3. The last time I checked, about 100 programs aimed at trying to prevent anorexia nervosa from developing had been proposed and studied. However, the research results have been disappointing. None of the programs has been shown to be effective on a consistent basis. That said, does anyone know of a prevention program that has actually been shown to work? If so, please give the citation.
    Meanwhile, in my opinion, the best advice for parents is to focus on early detection and intervention, rather than primary prevention.

  4. I continue to be interested in the intersection of executive functioning and eating disorders. In theory, EF skills are 'teachable'. If we targeted the known areas of weakness in ED's (say, with AN that would be emotional regulation, central coherence and set shifting), in children with either a family history of AN or EF identified weaknesses, could we decrease the number of young people that go on to develop an ED? I think this has research potential. There are assessments out there (such as the BRIEF which has a pediatric version), that could help identify areas of EF weakness in children early on.

    Food for thought, pun somewhat intended!


  5. I'm interested in the EF issue as well, and how Treasure's work informs it. What remains unclear to me is whether these traits really can be affected, and enough to affect risk and prognosis for EDs. Where's the fulcrum on this is the question.

    Ideally I'd like to see health assessments include these aspects and us doing more with young kids to strengthen skills in any area that may improve their future mental health and education of course . Yet I also worry about putting a lot of energy into good things that turn out to affect only tiny degrees of risk when we may need to take another direction.

    This may indeed BE the right direction. I just don't know if we have the evidence of it other than the plausibility factor - but plausibility is why we have extensive "prevention" work involving "loving our bodies" which I find wildly misguided. Yet in autism we've seen amazing progress by starting early with specific skills building.

  6. I may have mentioned this program in some past posting....not sure. Anyway, it doesn't, per se, have a thing to do with ED's. The program is called Tools of the Mind.

    It is the first school program of its kind to try to teach EF skills beginning at a young age. Its big emphasis is on self-regulation, social skills and planning through play. But, I can also see how that begins to teach children other concepts such as the ability to think flexibly, to negotiate, to see the bigger picture. This program, as I understand it, targets young children (preschool through perhaps Grade 2). It does not have much research that I'm aware of to give it a yea or a nea at this time, but I'll watch with interest to see where it leads. I think the research they're looking at is how it impacts academic learning. What I'm more interested in is, "How does it affect the blossoming social / emotional and future mental health of a child?"