**4. Gaining clarity through defining terms**

*"The beginning of wisdom is to call things by their right names." Chinese Proverb*

### **4.1 Understanding weight management**

Barring origins in genetic, metabolic, or hormonal dysfunctions, weight management dysfunctions typically originate in an individual's unhealthy relationship with food, leading to a disordered eating lifestyle. The term "weight management" describes the techniques and physiological processes that contribute to attaining and maintaining an individual's ideal weight. Healthy weight management techniques encompass long-term lifestyle strategies promoting healthy eating and daily physical activity, fostering sustainable change and well-being. In contrast, unhealthy weight management strategies, lacking an integrative treatment perspective, fail to achieve sustainable weight goals. Examples of unhealthy weight management include dieting, skipping meals, food restriction, eating only when hungry, and forms of purging that may include vomiting, spitting, compulsive exercise, and the abuse of laxatives, diet pills, and diuretics. Multiple studies have found that dieting for purposes of weight management is associated with greater weight gain and increased rates of binge eating in both boys and girls [14].

#### **4.2 Understanding healthy eating**

Healthy eating is guilt-free, balanced, and fearless eating, with flexibility in accommodating the parameters of the dining moment. Healthy eating includes three meals daily, each including all the nutritionally-dense food groups, as well as snacks. There are no bad foods. What is bad is extremism, compulsivity, and unhealthy attitudes about food and eating, i.e., how we feel about what we eat. What is worse than eating Oreos is never eating Oreos, as forbidding a child to eat Oreos can ultimately lead to sneaking, hiding, or stealing food. Healthy eating results in healthy weight maintenance naturally, through the inherent wisdom of a *Discretion or Disorder? The Impact of Weight Management Issues on the Diagnosis… DOI: http://dx.doi.org/10.5772/intechopen.92152*

body which, when fed healthfully, and having reached its ideal set point weight, will predictably sustain that appropriate weight-to-height ratio indefinitely, through its own natural functions. In most cases, the healthfully fed and exercised body with a healthfully functioning metabolism needs no help from arbitrarily devised dietary interventions to sustain a healthy weight throughout one's lifetime.

#### **4.3 Understanding disordered eating**

• Cardiologists, in the face of a co-occurring activity disorder that takes the form of excessive and compulsive exercise, frequently miss an ED diagnosis by attributing a low heart rate and amenorrhea to "healthy athleticism."

When driven by the fear of weight gain, individuals who suffer from ED, cooccurring anxiety, and obsessive-compulsive disorders (OCD), are particularly susceptible to developing activity disorders. Also known as anorexia athletica, exercise bulimia, or exercise addiction, ED individuals engage in such compensatory compulsions with the intention of burning calories. Between 40% and 80% of AN patients are prone to excessive exercise in their efforts to avoid putting on weight [13].

*Binny ran 10 miles a day, followed by 2 hours of working out. She ate no more than 750 calories a day while training regularly for countrywide marathon races. One 26.2-mile event landed her in a hospital, where her legs swelled and she required an emergency blood transfusion. Because her eating and running regime provided her with a sense of being "alive," upon release from the hospital she felt incapable of curtailing the compulsive behaviors that threatened her life. Her emergency room doctors attributed her blood disorder and amenorrhea to her athleticism, failing to*

Barring origins in genetic, metabolic, or hormonal dysfunctions, weight management dysfunctions typically originate in an individual's unhealthy relationship with food, leading to a disordered eating lifestyle. The term "weight management" describes the techniques and physiological processes that contribute to attaining and maintaining an individual's ideal weight. Healthy weight management techniques encompass long-term lifestyle strategies promoting healthy eating and daily

physical activity, fostering sustainable change and well-being. In contrast, unhealthy weight management strategies, lacking an integrative treatment perspective, fail to achieve sustainable weight goals. Examples of unhealthy weight management include dieting, skipping meals, food restriction, eating only when hungry, and forms of purging that may include vomiting, spitting, compulsive exercise, and the abuse of laxatives, diet pills, and diuretics. Multiple studies have found that dieting for purposes of weight management is associated with greater weight gain and increased rates of binge eating in both boys and girls [14].

Healthy eating is guilt-free, balanced, and fearless eating, with flexibility in accommodating the parameters of the dining moment. Healthy eating includes three meals daily, each including all the nutritionally-dense food groups, as well as snacks. There are no bad foods. What is bad is extremism, compulsivity, and unhealthy attitudes about food and eating, i.e., how we feel about what we eat. What is worse than eating Oreos is never eating Oreos, as forbidding a child to eat Oreos can ultimately lead to sneaking, hiding, or stealing food. Healthy eating results in healthy weight maintenance naturally, through the inherent wisdom of a

*recognize both conditions as signs of ED pathology.*

*"The beginning of wisdom is to call things by their right names."*

**4. Gaining clarity through defining terms**

**4.1 Understanding weight management**

**4.2 Understanding healthy eating**

**166**

*Chinese Proverb*

*Weight Management*

At times we are all a little eating dysfunctional. Bombarded by nutritional research and food fads in an age of pervasive social media, "normal" eating (i.e., eating all food groups, including moderate amounts of processed foods and sugar) is no longer considered to be "healthy" eating. Certain patterns of DE, in light of their prevalence, are becoming increasingly difficult to recognize as pathological. A study found that nearly 91% of female college students use dieting as a weight control mechanism [15], putting many of them at risk to develop a clinical ED. The prevalence of AN and BN is relatively rare among the general population [16], affecting 1% to 4% of adolescents and young adult women [17]; DE, however, which has been defined as a psychological illness, [18], and the misguided attitudes about food and weight management that lead to them, are widespread and prevalent among all age groups. The consequences of DE, which include rampant dieting and body image obsessions, can be devastating; though not the cause of eating disorders, they are often precursors to their onset. Occasional DE, as well as certain behaviors that manifest themselves in clinical ED, are not in themselves abnormal. Differentiating normalcy from pathology is best accomplished by assessing the patient's attitudes towards food and eating. Benign forms of DE are fully discretionary, dependent upon the individual's capacity for self-awareness, self-regulation, and choicemaking through their own free will.

Picky eating syndrome is a DE pattern that originates in early childhood. Typically indicative of a sensory processing disorder (SPD), food choices tend to be limited to bland "white" foods (containing sugar and flour) of specific textures. Picky eating often results in overweight. Studies show that 40% of overweight girls and 37% of overweight boys are teased/bullied about their weight by peers or family members and that traumatic experiences such as these during the formative years are predictive of weight gain, binge eating, and extreme weight control measures [14]. DE patients have experienced a higher frequency of traumas (childhood adversities in particular), especially in circumstances related to childhood obesity [18]. Childhood picky eaters who do not grow out of the condition and who become malnourished because of the limited variety of foods that they eat qualify for a diagnosis of avoidant restrictive food intake disorder (ARFID), a condition which typically extends into adulthood.

Rising obesity rates, the result of DE lifestyles, clinical ED, and hereditary factors have become a major concern worldwide, especially in North America, where more than 2 in 3 adults (70.2%) are considered to be overweight or obese [19]. Obesity, DE, and ED are considered major health problems among adolescents because of their increasing prevalence in this age group and their potentially serious physical and psychosocial consequences [20, 21]. Dieting and unhealthful weight control practices lead to eating psychopathology in DE, ED, and obesity, particularly when associated with variables such as personality characteristics like perfectionism or anxious temperament, a microbial imbalance, or a genetic predisposition to be influenced by an obesogenic environment. Other possible causal mechanisms linking dieting to later problems are neurophysiological mechanisms associated with food restriction (e.g., effects on neurotransmitters that could increase risks for either obesity or ED via influences on food regulation processes) [21]. In the face of a genetic, hormonal, or metabolic predisposition to obesity, following a healthy lifestyle in which the

individual learns to eat differently, not less, may counteract gene-related risks. Individuals with obesity and co-occurring eating disorders are at higher risk for several medical and psychosocial complications than individuals with either condition alone [22]. Because obesity may become a precursor to an ED, and vice versa, collaborative exchanges of experiences and specialized knowledge between healthcare professionals working in the fields of obesity and eating disorders are essential [22].

**5. Weight management assessment as a form of crisis intervention**

*Discretion or Disorder? The Impact of Weight Management Issues on the Diagnosis…*

*DOI: http://dx.doi.org/10.5772/intechopen.92152*

demands an immediate referral to higher levels of care.

In looking beyond simple, nonlinear solutions for weight management problems, the single-session diagnostic assessment needs to become a discovery process, uncovering the possibility of underlying sources of symptoms in eating pathology or past trauma. In establishing a direction for future treatment, the assessment of DE or ED requires treatment tools of subtle refinement that investigate the patient's current disease and recovery status, as well as the history of past efforts to heal. Following Abraham Maslow's hierarchy of human needs [23], the weight management diagnostician attends to the needs of the patient in a sequence designed first to save lives through medical stabilization, then to remediate life quality through emotional stabilization. For ED patients, the need to refeed body and brain becomes a first priority in minimizing the patient's physiological risk, augmenting receptivity to the therapeutic process and to an environment conducive to the use of medication. Physiological or emotional instability that could result in self-harm or death

Psychoeducation lies at the core of the patient's engagement in the healing process as a mainstay of support, rectifying distorted attitudes and cognitive belief systems; introducing a deeper understanding of weight management problems and

their implications; opening the patient's eyes and mind to insights and selfreflection; and creating the patient's sense of trust in the clinician and the clinical process as well as hope for a full recovery. Psychoeducation emphasizes the importance of maintaining a healthy eating and activity lifestyle to insure short-term and long-term goals for unified mind, brain, and body health. A psychoeducational explanation of the set point weight theory becomes critical in assuaging the AN patient's fear of excessive weight gain during refeeding by describing the wisdom of the human body, which, once having restored optimized bodily functioning, will sustain a constant weight. The AN patient also learns to anticipate that the natural course of ED recovery will involve countless trials and setbacks in regaining lost weight, with the recognition that every movement representing progress or regression represents "grist for the learning mill." Patients and clinicians need to anticipate the emergence of previously buried feelings during the refeeding process,

evoking states of psychophysiological fear and/or emotional distress.

Psychoeducation is also of great benefit for the parents of eating dysfunctional children or young adults living at home. Through family therapy, parents become knowledgeable about the complexities and risks involved with their child's eating dysfunctions and the urgent need for total healing. As advocates for their ED child's recovery, skillfully coached parents become, and remain, effective agents for positive change throughout an ever-changing treatment and recovery landscape.

internal strengths, external resources, environmental influences and mood

**169**

Aside from psychoeducation, the work of the initial diagnostic session or series of early sessions needs to be richly flecked with trust-building and relationship building, along with an action plan, devised even prior to the development of a definitive diagnosis. The assignment of tasks such as journaling, requests for ongoing open and honest personal feedback, and contingency contracts all foster the patient's learning, trust, and treatment engagement. The initial session may include professional referrals to prospective members of a treatment team, as needed, initiating an integrative treatment process. Evoking motivation for change, the quality of the initial patient/clinician connection awakens the patient's recognition and acceptance of oneself, of co-occurring diagnoses that may require attention, and of the need for commitment to a treatment process that can accomplish full and sustainable healing. Aside from identifying current behaviors, levels of function, and past treatment and recovery efforts, history-taking needs to assess the patient's

## **4.4 Understanding clinical eating disorders**

ED onset is an integrative process, stimulated by contributing factors that include genetics, neurobiological vulnerability, physiology, co-occurring mood and emotional disorders, past trauma, and familial and cultural influence. For the individual with AN, BN, BED, or OSFED, behavioral and emotionally based compulsions become etched in neuronal pathways, impacting the structure and function of the brain. ED patients consider their disorder to be a survival tool, an adaptive coping mechanism that they cannot live without. Underlying the clinical ED is the primordial fear of becoming fat. For the ED individual, food is "fattening," and fat, the enemy of a body that can never be too thin, becomes a "feeling," a sensation, a perception. ED are selfregulatory dysfunctions. All types of ED share a great number of symptoms and issues, as aspects of the same disease syndrome; however, ED victims vary in the basic structure and function of personality and emotional makeup, and treatment needs to vary, reflecting these differences. BN behaviors tend to be marked by impulsivity, followed by "undoing" practices, such as various forms of purging. AN behaviors reflect behaviors and attitudes marked by rigidity, restriction, and containment.

Though ED are essentially not about food, their successful healing depends upon the resumption and maintenance of a healthy weight and relationship with food [22]. ED are disorders of the core self, characterized by diminished self-control, self-regulation, self-attunement, self-trust, self-agency, self-reliance, selfperception, self-sensing, and self-worth. A full ED recovery is defined by several factors, including the return of a healthy and sustainable eating lifestyle and relationship with food; the reintegration of the mind, brain, and body, reconstituting a fully integrated self; the arrival at one's set point weight; and a full restoration of healthful physiological functioning leading to the natural resumption of menstruation. Observable weight change is typically the factor that brings ED patients to treatment. Once in treatment, additional predictive assessment factors include the ED mentality, marked by perfectionistic, obsessive, black-and-white thinking, cognitive rigidity, the compulsive quality of behaviors, the intolerance of uncertainty, and the fear of gaining weight and becoming fat. It is important to note that many individuals with various forms of ED maintain a normal weight, a phenomenon observed particularly in BN and BED because of "weight cycling," where patients alternate between starvation and gorging or compulsive bingeing followed by compensatory forms of purging.

ED do not stand still; any ED that is not in the process of healing is becoming increasingly entrenched in the brain and nervous system, destroying life quality, if not taking lives.

*Pamela suffers from BED. She is not overweight, as might be expected, the result of yo-yoing between gorging and starvation for days on end. Aware of her illness and her need for professional help, she spoke of her frustration in not having been able to get the attention of her family or the healthcare professional community, who refused to acknowledge that she had an ED because her weight was "normal." Having been denied treatment, compassion, much needed support and attention, upon arrival at my office, she spoke of feeling depressed, isolated, and hopeless.*

*Discretion or Disorder? The Impact of Weight Management Issues on the Diagnosis… DOI: http://dx.doi.org/10.5772/intechopen.92152*

#### **5. Weight management assessment as a form of crisis intervention**

In looking beyond simple, nonlinear solutions for weight management problems, the single-session diagnostic assessment needs to become a discovery process, uncovering the possibility of underlying sources of symptoms in eating pathology or past trauma. In establishing a direction for future treatment, the assessment of DE or ED requires treatment tools of subtle refinement that investigate the patient's current disease and recovery status, as well as the history of past efforts to heal. Following Abraham Maslow's hierarchy of human needs [23], the weight management diagnostician attends to the needs of the patient in a sequence designed first to save lives through medical stabilization, then to remediate life quality through emotional stabilization. For ED patients, the need to refeed body and brain becomes a first priority in minimizing the patient's physiological risk, augmenting receptivity to the therapeutic process and to an environment conducive to the use of medication. Physiological or emotional instability that could result in self-harm or death demands an immediate referral to higher levels of care.

Psychoeducation lies at the core of the patient's engagement in the healing process as a mainstay of support, rectifying distorted attitudes and cognitive belief systems; introducing a deeper understanding of weight management problems and their implications; opening the patient's eyes and mind to insights and selfreflection; and creating the patient's sense of trust in the clinician and the clinical process as well as hope for a full recovery. Psychoeducation emphasizes the importance of maintaining a healthy eating and activity lifestyle to insure short-term and long-term goals for unified mind, brain, and body health. A psychoeducational explanation of the set point weight theory becomes critical in assuaging the AN patient's fear of excessive weight gain during refeeding by describing the wisdom of the human body, which, once having restored optimized bodily functioning, will sustain a constant weight. The AN patient also learns to anticipate that the natural course of ED recovery will involve countless trials and setbacks in regaining lost weight, with the recognition that every movement representing progress or regression represents "grist for the learning mill." Patients and clinicians need to anticipate the emergence of previously buried feelings during the refeeding process, evoking states of psychophysiological fear and/or emotional distress. Psychoeducation is also of great benefit for the parents of eating dysfunctional children or young adults living at home. Through family therapy, parents become knowledgeable about the complexities and risks involved with their child's eating dysfunctions and the urgent need for total healing. As advocates for their ED child's recovery, skillfully coached parents become, and remain, effective agents for positive change throughout an ever-changing treatment and recovery landscape.

Aside from psychoeducation, the work of the initial diagnostic session or series of early sessions needs to be richly flecked with trust-building and relationship building, along with an action plan, devised even prior to the development of a definitive diagnosis. The assignment of tasks such as journaling, requests for ongoing open and honest personal feedback, and contingency contracts all foster the patient's learning, trust, and treatment engagement. The initial session may include professional referrals to prospective members of a treatment team, as needed, initiating an integrative treatment process. Evoking motivation for change, the quality of the initial patient/clinician connection awakens the patient's recognition and acceptance of oneself, of co-occurring diagnoses that may require attention, and of the need for commitment to a treatment process that can accomplish full and sustainable healing. Aside from identifying current behaviors, levels of function, and past treatment and recovery efforts, history-taking needs to assess the patient's internal strengths, external resources, environmental influences and mood

individual learns to eat differently, not less, may counteract gene-related risks. Individuals with obesity and co-occurring eating disorders are at higher risk for several medical and psychosocial complications than individuals with either condition alone [22]. Because obesity may become a precursor to an ED, and vice versa, collaborative exchanges of experiences and specialized knowledge between healthcare professionals working in the fields of obesity and eating disorders are essential [22].

ED onset is an integrative process, stimulated by contributing factors that include genetics, neurobiological vulnerability, physiology, co-occurring mood and emotional disorders, past trauma, and familial and cultural influence. For the individual with AN, BN, BED, or OSFED, behavioral and emotionally based compulsions become etched in neuronal pathways, impacting the structure and function of the brain. ED patients consider their disorder to be a survival tool, an adaptive coping mechanism that they cannot live without. Underlying the clinical ED is the primordial fear of becoming fat. For the ED individual, food is "fattening," and fat, the enemy of a body that can never be too thin, becomes a "feeling," a sensation, a perception. ED are selfregulatory dysfunctions. All types of ED share a great number of symptoms and issues, as aspects of the same disease syndrome; however, ED victims vary in the basic structure and function of personality and emotional makeup, and treatment needs to vary, reflecting these differences. BN behaviors tend to be marked by impulsivity, followed by "undoing" practices, such as various forms of purging. AN behaviors reflect behaviors and attitudes marked by rigidity, restriction, and containment.

Though ED are essentially not about food, their successful healing depends upon the resumption and maintenance of a healthy weight and relationship with food [22]. ED are disorders of the core self, characterized by diminished self-control, self-regulation, self-attunement, self-trust, self-agency, self-reliance, selfperception, self-sensing, and self-worth. A full ED recovery is defined by several factors, including the return of a healthy and sustainable eating lifestyle and relationship with food; the reintegration of the mind, brain, and body, reconstituting a fully integrated self; the arrival at one's set point weight; and a full restoration of healthful physiological functioning leading to the natural resumption of menstruation. Observable weight change is typically the factor that brings ED patients to treatment. Once in treatment, additional predictive assessment factors include the ED mentality, marked by perfectionistic, obsessive, black-and-white thinking, cognitive rigidity, the compulsive quality of behaviors, the intolerance of uncertainty, and the fear of gaining weight and becoming fat. It is important to note that many individuals with various forms of ED maintain a normal weight, a phenomenon observed particularly in BN and BED because of "weight cycling," where patients alternate between starvation and gorging or compulsive bingeing followed by

ED do not stand still; any ED that is not in the process of healing is becoming increasingly entrenched in the brain and nervous system, destroying life quality, if

*Pamela suffers from BED. She is not overweight, as might be expected, the result of yo-yoing between gorging and starvation for days on end. Aware of her illness and her need for professional help, she spoke of her frustration in not having been able to get the attention of her family or the healthcare professional community, who refused to acknowledge that she had an ED because her weight was "normal." Having been denied treatment, compassion, much needed support and attention, upon arrival at my office, she spoke of feeling depressed, isolated, and hopeless.*

**4.4 Understanding clinical eating disorders**

*Weight Management*

compensatory forms of purging.

not taking lives.

**168**

dysfunctions, always with attention to the possibility of past or current trauma. Studies that include partial or subclinical forms of posttraumatic stress disorder (PTSD) show that well over half of individuals with BN have PTSD or significant PTSD symptoms [24]. In light of the prevalence of trauma in the background of ED patients, trauma investigation needs to become a central focus within the initial inquiry. The diagnostician does well to become self-aware of personal propensities towards countertransference responses or cultural biases (reflecting weightism). The latter are forces which might preclude the clinician's recognition that many overweight and genetically large individuals who eat healthfully and exercise regularly are physically fit, healthy, and strong.

Establishing and maintaining a goal-weight range is but one of many integrative

environmental factors contributing to a complete and sustainable ED recovery.

• Weight gain from edema (swelling or bloating) can be caused by hormonal changes brought on by starvation. AN can lead to kidney-related issues that include severe electrolyte disturbances (hypokalemia, hypophosphatemia, etc.), nephrolithiasis, and alterations in water metabolism (with hyponatremia and edema.) Patients with the binge eating/purging subtype of AN are more likely to have kidney disorders, particularly electrolyte disturbances and volume depletion, than those with the restrictive subtype. 'Refeeding edema'

• Weight gain is a common side effect for people who take insulin to manage type 1 diabetes. The deliberate insulin underuse with type 1 diabetes for the purpose of controlling weight is known as diabulimia, a condition leading to a

• Sarcopenia, the loss of muscle mass in moderate to severe AN is frequently overlooked by clinicians. Appropriate exercise is required to restore muscle

amenorrhea. Hormonally based bone softening and/or bone loss may never become restored to a state of normalcy, even following weight restoration.

matter brain volumes. It remains unclear if gray matter alterations are present

Issues complicating the achievement of full weight restoration matter a great deal, as halting the process of weight restoration at much lower levels than needed for full and sustainable recovery increases the rate of treatment dropout [33] and relapse [34]. The restoration of nutrient status and weight needs to start slowly and gradually, accelerating as tolerated. The refeeding process needs to focus on modifying the disordered dietary patterns that AN patients commonly practice, which might include slow and irregular eating, vegetarianism, and the consumption of a restricted range of foods. Severely malnourished AN patients often need to be admitted to a hospital in order to receive more aggressive treatment, with extra care and monitoring required to prevent the occurrence of refeeding syndrome [26], a clinical complication involving kidney dysfunction [30]. A person may finally be considered "in remission" after maintaining a stable weight for a number of years and experiencing the natural resumption of mensuration, as well as other normal hormonal, metabolic, and gastroenterological processes. Sustained remission is marked by the return of the reintegrated core self, following its fragmentation by

**7. Discovering and managing the roots of weight management problems**

Trauma in the form of sexual abuse occurs in 30–65% of women with ED [35]. The vast majority of women and men with AN, BN, and BED report a history of

• The strongest predictors of osteoporosis include low body weight and

• AN has consistently been associated with reduced gray matter and white

physiological, neurobiological, nutritional, cognitive, emotional, and

*Discretion or Disorder? The Impact of Weight Management Issues on the Diagnosis…*

occurs during the process of weight restoration [30].

threefold increase in mortality risk [27].

*DOI: http://dx.doi.org/10.5772/intechopen.92152*

mass and strength [31].

following recovery from AN [32].

the encroachment of the ED "pseudo-self."

**in current or past trauma**

**171**
