Ah, the holidays—it’s the time when the workplace and the dinner table are filled with cookies, peppermint bark and booze, leading the voice in your brain to go into overdrive with competing messages—“Eat all the cookies!”/“Don’t eat any of the cookies!” But when do those thoughts and actions cross the line from normal to an eating disorder? Wendy Hoyt, a licensed psychologist and owner of the Utah Center for Eating Disorders, talked to City Weekly about how eating disorders work—and why more people have them than you might think.
Are eating disorders becoming more prevalent?
Eating disorders, self-harm, have a contagion effect. So if you’re looking at a group of high school girls and one develops an eating disorder, there’s a good chance that the others will end up with an eating disorder, as well. I think there has been an increase over the years with that contagion. I think at this point, they’re so common—there’s been research that showed that on a college campus there were more women who were disordered eaters than normal eaters.
Are most people who have eating disorders diagnosed?
Most people who have eating disorders don’t meet criteria for either anorexia or bulimia. To meet criteria for anorexia is actually very difficult—it requires a very, very low weight. So, plenty of people have all the behaviors of anorexia without being at the very low weight. The vast majority of people are diagnosed with what’s called Eating Disorder Not Otherwise Specified. Those are the people who are engaging in eating-disorder behavior—they’re binging, they’re restricting, they’re purging. Everyone’s image of an eating disorder is someone who’s emaciated. That’s like 1 percent of the population, and a small percentage of the number of people who have an eating disorder.
A lot of people do go unrecognized. When you get to a low weight, then yeah, more people are going to catch on and potentially comment about it. But if it’s someone who’s at a normal weight, or even above normal weight, but they’re still doing all the behaviors, they tend to get ignored.
What are the behaviors of an eating disorder?
Restricting—which is a bunch of different things. So basically not eating enough food, or eating only specific foods—the big thing in our society is health foods, so there’s actually an informal type of eating disorder called orthorexia, which is basically people who are obsessed with eating only healthy foods. They’re eating all organic, or vegan, but they’re not doing it based on belief; they’re doing it to try to control their weight.
Binging is defined as eating a large amount of food in a short amount of time. Purging is done a bunch of different ways. Most people, when they hear purging, think vomiting. But it actually includes vomiting, laxatives, diuretics and exercise. And exercise is the tricky one, because everyone looks at someone who exercises a lot and says, “Good job, you’re so amazing, wow!” not recognizing, necessarily, that it’s purging.
What makes it a disorder and not just someone who loves health foods or working out?
When it interferes with the person’s life. If you tend to eat kale but then you go out to Olive Garden, and they don’t serve that, someone who just prefers the healthy food is going to eat something else. When it’s a disorder, it’s more like, “Well, they don’t have my kale, so I guess I won’t eat.”
When people die of anorexia, do they simply wither away?
The main cause of death in someone with an eating disorder is suicide. It’s so miserable, and they become so hopeless that they kill themselves. Beyond that, both starvation and purging will throw off electrolytes, so when you hear of people dying from heart attacks as a result of their eating disorder, it’s because their electrolytes were so off.
What’s really sad is that the gymnast Christy Henrich, by the time she got down to the really low weight, she wanted to get better, but she basically was just too far gone, so she ended up dying as a result of the medical consequences.
What’s usually the catalyst that gets people into treatment?
Most people basically say, “I felt like I could do it on my own, and now I realize I can’t.” So they’ve been fighting it for a while, and they’re miserable, and they don’t want to live that way anymore.
Do you see people from the whole spectrum of eating disorders?
We treat people who are very, very ill, and who oftentimes would end up in a treatment facility. We give them a chance to do it outpatient. We’ve had a good number of people who are very, very ill succeed in outpatient, which saves a large sum of money. In-patient is about $1,000 a day, and we max out at around $300 a week. We treat everything from anorexia to binge-eating disorder, and everything in the middle. The majority of people are those people who don’t necessarily meet criteria of any formal eating disorder, but have the disordered eating habit that’s ruining their lives.
What’s at the root of an eating disorder?
That’s the question that everyone—and all parents—wants an answer to. But most people are not going to figure out what caused their eating disorder. It’s a combination of things—a little bit of this, a little bit of that. Certainly, genetics is a big part—eating disorders do run in families. The cliché phrase is, genes loaded the bullet and environment pulled the trigger.
What we have more luck identifying are essentially the maintaining factors. The precipitating factors—the things that started the eating disorder—who knows. But we are able to identify the ways the eating disorder is “helping” now, and figure out other ways to cope with that. Most people are going to walk in the door and say, “It’s because I want to be thin,” and we start there, and kind of have to go beneath it.
There are two levels you have to look at. One is the physiology. The thing that’s most misunderstood about binging is people think that people who binge, binge all the time. In reality, almost everyone who binges restricts. The most common pattern is that they restrict throughout the day—they do their diet—and then they binge at night. And then they feel bad and they starve all the next day and then they binge at night and then they feel bad. … And the same thing with bulimia; it typically is restrict-binge-purge, over and over. It can go on a daily basis or it can go every few days—I restricted for two days and then I binged for two days and then I switched back.
The physiology piece is really important to understand. Most people look at eating disorders and think, “Oh, this is just something you’re doing, you’re choosing to do this,” almost like, “You’re kinda dumb to be doing this.” But physiology really is the key to all of it, for any of us. If we drop to too low of a weight, because we have an illness or something else, we will actually start thinking like someone who has an eating disorder. I had a colleague who didn’t understand eating disorders, but then she got cancer, and she had to go through chemo and radiation, and her weight dropped. And she was like, “I finally understand, because I know my weight’s too low, but I don’t want to gain weight.” It’s physiology that starvation effects. So for some people, all you have to do is get the weight back up, and they no longer have an eating disorder.
Obviously, though, most people have on top the psychological component. Essentially, the eating disorder is serving some purpose. It’s making it so they don’t have to think about something that’s very difficult; there’s the cliché that “they’re all about control”—that applies to some percentage of people with eating disorders. But the main thing is, it’s essentially a way of coping with emotions. They’re thinking about food like 90-plus percent of the day, so then they don’t have to think about the boyfriend who just dumped them, the trauma in their past, stuff with their family, whatever it is.
What are some of the societal problems that contribute to eating disorders? Is it really all the media?
There was a really cool study done a few years ago, where basically, prior to the study, there was not television in Fiji. They studied attitudes toward body and weight prior to TV being introduced, and TV did make body image in the Fijian culture worsen. So, yeah, media does play a role, but I think that gives people a superficial image. It’s really about all the emotional pieces.
Does Utah have a higher number of eating disorders?
Yeah, it does. One of the things that’s really big in Utah that isn’t as big outside of here is the constant diet.
And driving down the interstate, you can [see that you can] do liposuction five different ways, you can take HCG in three different ways—it’s just a constant bombardment. I think there’s just an extremely large percentage of people who are caught up in dieting. Weight-loss surgery is huge here. Weight-loss surgery is pretty bad. It makes people pretty sick, and they develop eating disorders.
Some people are just naturally at a higher weight, and trying to force them to a lower weight makes them unhealthy. In our society, we believe high weight has the highest mortality and morbidity; the reality is that low weight has the highest mortality and morbidity.
What are the downsides of a constant diet?
Your body needs a wide variety of food. It needs carbs—regardless of what all the low-carb diets want to say, your brain primarily runs on carbs, your body primarily runs on carbs. What you’ve probably seen is this “I’m only going to eat soup for two weeks” thing, and then the next two weeks they eat the house. It’s the same pattern—they go from restricting to binging.
They’ve done a ton of research on diets, and 95 percent to 98 percent of diets fail. And they fail because it actually creates a yo-yo effect. Let’s say someone starts at this weight. They diet, and they lose weight. Then they switch, and start over eating, they get to their previous weight plus 10 percent. They panic, they diet, they lose weight … they can only maintain it so long; they go to the previous weight plus 10 percent. So, in reality, dieting actually causes overweight.
Is something like that bad enough to need treatment?
Those folks come in saying, essentially, that they’re absolutely tortured. They’re just consumed by thoughts of what’s OK to eat and what’s not OK to eat. Treatment can actually get them to eating without having to think about it all the time, and it is a hard process. What we’re trying to get everyone to is what’s called intuitive eating. The short version of that is that it’s the way a child eats. If you put a bag of M&Ms in front of a child (before we screw them up), they’ll eat so many M&Ms and then go, “Eh, that doesn’t taste good anymore,” and walk away. Then our society screws them up, and they eat the whole bag, or they don’t eat any at all. Intuitive eating is basically getting back to eating when you’re hungry, stopping when you’re full, eating a variety of foods.
There’s no good food, there’s no bad food—food is food. Then they’re able to eat the “bad” foods that tend to trigger binges—“I’m not supposed to eat cookies … well, I ate a cookie, I might as well have 10!” They get to where, “OK, I can have a cookie, no big deal.” But it’s a very hard process.
The other thing our society does is override fullness cues. Our society is all about eat more, and eat everything. As parents, we’re like, “Eat everything on your plate.” Well, oops. You’re making this kid eat past their fullness. We need to get people back to where they slow down their eating enough so that they recognize their fullness, and then they can say, “Oh, I’m full. Well, I can have more later.”
If you’re in that dieting mindset, you’re like, “Well, I’m going to start my diet over on Monday, so on Sunday, I need to eat everything that’s standing still.” But if you switch to intuitive, it’s like, “Well, I really enjoyed this cookie today, and look at that—there’s still more cookies in the grocery store! If I still want them tomorrow, I can go get them tomorrow, and only eat a couple.” It’s just a really hard process to re-learn.
How did you get started treating eating disorders?
I have worked in a variety of in-patient settings, and about five years ago I opened a private practice. This March, it expanded to Utah Center for Eating Disorders. Right now, it’s Nicole Holt, the dietician, and I; we work with University of Utah physicians. The appropriate treatment for an eating disorder is having a therapist, a dietician and a physician, all treating the same patient. We have a therapist and a dietician in the same place, and we have physicians who we work closely with. It’s all outpatient, we do individual, group and family therapy, and then dietary, also.