When dieting gets dangerous

Let me introduce you to two hypothetical teens: Teen A and Teen B. Both teens go on diets. It could mean they want to lose a few pounds, it could be they are trying to “eat healthy” or be better at their sport. Regardless of why, they start cutting back on the amount and variety that they’re eating. Most people will be like Teen A- maybe they’ll stick with it, maybe they won’t. They might get a little odd about food, but all in all, they’re fine. Teen B, however, isn’t fine. First there’s the attempt at weight loss or eating less, then there’s a full-blown eating disorder.

Exactly why an individual develops an ED is going to vary from person to person, as each individual will have different contributions of genetic and environmental factors involved in their disorder. There’s the saying that “Most EDs begin with a diet.” Which I think should be amended to “Most EDs begin with a negative energy balance,” but that’s not nearly as catchy. There’s kind of a corollary to that: most diets don’t lead to EDs. So what factors make someone vulnerable to an eating disorder after a period of negative energy balance?

There’s genetics, sure, but no one knows exactly what genes are tugging on what behaviors. Researchers wanted to know if there’s a way to predict which dieting young people are at higher risk of developing an ED. It turns out there is. The answer appears to be in understanding a person’s motivation for their food restriction. If a person is motivated by negative affect, which includes symptoms of anxiety, depression, guilt, and anger, then they are much more likely to develop an ED than “normal” dieters.

Beware the negative affect

Researchers in Finland had asked the same question I had: what factors make some adolescents more likely to develop an ED after dieting (term used loosely) than others? They looked at not only differences in dieting behaviors but also (more importantly to their findings) psychological variables. To answer this question, they first gathered baseline data on 595 adolescents currently in the 9th grade in one area of Finland. All of these teens (average age: 15) filled out questionnaires about current and past mental health, health behaviors, life circumstances, and brief questions about dieting and EDs (Isomaa et al., 2010).

128 teens endorsed both dieting and fulfilled one or more of any of the DSM-IV criteria for EDs, and were called back for a longer in-person interview. Of the 113 teens who returned, 81 were classified as “confirmed dieters.” The researchers were able to conduct follow-up interviews with 65 of the teens. They researchers did not provide data on the number of teens who dieted without fulfilling at least one DSM-IV eating disorder criterion, nor did they follow up on these people, which is a weakness of the study (they are already selecting for higher rates of psychopathology, which could influence the significance of their findings).

With all of these interviews, the researchers were able to create four mutually exclusive groups of dieters, below (the descriptions are copied directly from the paper):

Vanity dieters (n=28) had started to diet to obtain a figure in line with the present body ideal. They had a clear purpose for their dieting and usually dieted by omitting high-fat foods and sweets combined with moderately increased exercise.

Overweight dieters (n=12) dieted to lose weight to avoid associated adverse health consequences of their overweight. They appeared to have a sensible approach to means of dieting and exercise. All overweight dieters had an age-adjusted BMI ≥25 at the onset of dieting.

Depressed dieters (n=33) dieted because of depressed mood and emotional problems, which they believed would be resolved by losing weight and obtaining a slim figure. The means of dieting varied among the depressed dieters, but approximately two-thirds used meal-skipping, purging or intense exercise to regulate caloric intake and expenditure.

Feeling fat dieters (n=8) could not give any other explanation for their dieting than a diffuse feeling of being fat, even though objectively being normal or underweight. They usually dieted by skipping meals, eating very little or exercising intensely.

The description of the “depressed dieter” resonated with me on a personal level, as that was my motivation for eating less and exercising more when my ED began in earnest: I thought it might make me less depressed if I lost weight.

The last two of these groups had higher levels of depression and anxiety, as well as lower self esteem, when compared to vanity and overweight dieters. Based on this, the researchers divided these four groups into two broader categories: vanity and overweight dieters were considered low risk dieters, whereas depressed and feeling fat dieters were high risk.

These classifications were confirmed at the three year follow-up. In the low-risk dieters group, five people (16.8%) developed a subclinical ED and only one person (3.3%) developed a full-blown eating disorder. In contrast, 10 people (28.6%) in the high risk group had developed a subclinical ED at follow-up, and 19 (54.3%) met the full DSM-IV criteria for an eating disorder. The differences were statistically significant even when controlling for known ED risk factors like depression and self-esteem. Dieters in the high risk group were 15 times more likely to develop an eating disorder. That’s a HUGE risk factor.

The authors conclude:

The findings have clear clinical implications, since asking adolescents about their reasons for dieting is a task manageable for people who are in every day contact with adolescents, for example parents, teachers, youth workers and school health personnel. Adolescents who start to diet because of emotional problems or a diffuse feeling of being fat should be closely monitored. The study also suggests that merely dieting among adolescents, in most cases, is quite harmless, if not accompanied by depressed mood.

Although I don’t agree that people who are overweight and dieting should be automatically lumped into the low risk group (if they have intense body image distress or depressed mood, they are clearly high risk whatever their weight is), these results are really important and interesting because they indicate a way to try and tell whether a dieting teen might be moving along a high-risk path towards developing an ED or whether it’s a slightly more benign practice that might not have any majorly serious consequences–though if it were my kid, I would discourage dieting because it’s pointless, not to mention the genetic risk for EDs that they would have. Clearly, if your family tree has eating disorders in them, especially in close relatives like parents, grandparents, aunts, cousins, siblings, etc, then dieting should be actively discouraged.

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12 Responses to “When dieting gets dangerous”

  1. Hmmm. Those findings ARE quite impressive. They point to “dieting” being significantly more dangerous than it’s worth, in many cases, if dieting is as described in their findings…

    Does a person have to “think” they are “dieting” in order to BE “dieting”? I ask because if anyone asked me if I ever dieted, I would state, emphatically, NO. I have never dieted. I have never thought of what I do with food as “going on a diet.”

    I have restricted. A LOT. I went for days sometimes. But I never thought of it as a “diet.” I never thought of it as anything. I just didn’t want to eat. Period. I didn’t even think about losing weight. The food just looked disgusting and dangerous and it caused me great anxiety to eat it, so I didn’t- I couldn’t. I wasn’t trying to get healthy. I just couldn’t eat.

    I guess I’m just curious if people would call that “dieting”- because I wouldn’t- since the intent is not “to eat healthier” or “to lose a few pounds and be healthier” but rather just to feel ok. And I wonder about these people: “approximately two-thirds used meal-skipping, purging or intense exercise” and these people: “They usually dieted by skipping meals, eating very little or exercising intensely.” That doesn’t sound like a “diet” to me, either. It sounds like just trying to feel ok.

    I guess maybe I don’t understand what “diet” means- I always thought “going on a diet” meant “eating healthier” for someone who was having trouble eating healthy, or for someone who had medical needs (diabetes, for example) that needed regulating through means of food. I don’t understand why the word “diet” is used in their findings to describe people purging, skipping meals altogether, or over-exercising. That seems like a misuse of the word. I would say, “INSTEAD of ‘dieting,’ these people purged, skipped meals, etc.”

    I don’t think I like the word “diet.” I think it should be used medically, meaning “a prescribed meal plan for a specific medical goal.” In that case, I am on a “diet” currently- a prescribed diet that consists of significantly MORE than I used to eat, in order to get me healthy. THAT is a “diet.” A monitored meal plan with a medical purpose.

    • You’re right- it would have been good to see a more thorough explanation of how they defined dieting, and whether how dieting is framed affects how many people say they are currently engaging in these behaviors.

      Because I never really thought of myself as being “on a diet.” And if someone asked if I was currently dieting I probably would have said no.

      • Right. It seems like they are classifying “restricting” kids as kids “on a diet”- and I really don’t think those are the same things.

        • It would have been nice if the study went one step further and said that maybe these aren’t diets at all–maybe they’re the prodromal stage of EDs. We don’t have enough to say whether there is a prodromal stage for EDs (I would be surprised if there wasn’t) or what it looks like.

          Still, the study did seem to show that, for some people, it isn’t “just dieting,” it’s something more serious and potentially dangerous.

  2. Alarming and brilliant follow-up insights from both hm and Carrie Arnold. I will be showing this eye-opening offering to my ED team as well as family members. It explains so much and provides critical information about just what “dieting” versus restriction means and “heads up” warning signs for detection within the family circle and for those dealing on a professional level with ED’s..These findings and your brilliant analysis clearly shows that being on a diet is not synonymous with being on a quest for health. Restriction is not a “diet”.

  3. Interesting study, although you point out some limitations. Having a 16 yo daughter with AN it is interesting to hear her side of what dieting means amongst her age group. Notably her illness started with increased exercise, and “eating healthy” during a growth spurt. Prior to this it turns out she had engaged in skipped meals, and restriction with no clear goal as to why. She tells me that most of her classmates at times talk about being on a diet. For some this equates to I am not eating today because I am on a diet (significant restriction), for others it is very much the eating less fat, reduced intake of sweets with exercise intake. What do 15 year olds mean when they say they are on a diet? I suspect it means engaging in any alteration of food intake with the intention of losing weight.

    • Actually, that would be interesting to find out: how do teens in various categories (non-dieter, dieter, disordered eating, ED) define “dieting.” Do people with EDs think of themselves as dieting, especially in the beginning of their disorder?

      The generally accepted definition of dieting in the clinical literature is exactly your last sentence. But understanding how different populations use that word is really important.

  4. Wow, this really put things in perspective for me. It explains alot of why I am where I am today. Thanks for the post. I think I needed it..

  5. Such an interesting post, as someone that has suffered with various EDs I can now reflect and see that mine started after going on a very restrictive diet. I was not overweight, I was just unhappy with how I looked. More research needs to be done to help the younger generation!

  6. What I found for my family could only come in retrospect. While in retrospect she carried the traits that are so magnified in restriction and starvation, anyone including me, only saw those traits as human differences NEVER seemingly brewing a risk like anorexia.
    I believe she fell into the abyss via energy calorie expenditure deficit. She was a friendly social very perfectionist child and teen. Nothing anyone told her about her accomplishments were satisfying enough to stop the drive. I believe it started in her brain chemistry and grew. Energy calorie expenditure deficit despite her love for a variety of food, and even the sports she competed and played in, triggered the perfect storm. The enhancing of these traits in the form of distortions and increased anxiety, obsessiveness and mood changes.
    So maybe we can identify the kids at risk but highly unlikely that we would see their risks before they trigger the responses.
    Can we intervene earlier and more effectively.
    ANSOLUTELY! I believe here lies our best efforts. Early identification and effective interventions. I think it may have saved my daughter a freak deal of pain and suffering and for many, their lives.