Does Dieting Lead To An Eating Disorder?

QUESTION: I have been trying to follow this program and discussed it with my local RD. She said that any program like this (i.e., a plant based, vegetarian, vegan diet, etc.) that restricts certain foods or food groups can trigger binge eating and overeating and even lead to an eating disorder. Is this true?

Thanks for the question. I have heard the same thing many times over the years, dieting, and especially any form of restrictive dieting, can lead to an eating disorder. I was even told by a colleague during a similar discussion several years ago, that she has several clients who developed eating disorders from their stays at a renowned health center.

In fact, this topic just came up (again) in a recent discussion amongst my professional colleagues. Upon requesting support information for the above statement, I was sent a brief description of the famous Ancel Keys starvation study which was done at the University of Minnesota in the 1940's and was told by one of my colleagues that in the Keys study, "Some (of the men) engaged in bizarre food rituals and eventually cycles of binge eating and some purging."

Keyes A, Brozek , Henschel A, et al. The biology of human starvation. Vols 1 and 2. Minneapolis: University Press, 1950

In addition, I was sent this quote and reference,

"Starvation and self-imposed dieting appear to result in eating binges once food is available and in psychological manifestations such as preoccupation with food and eating, increased emotional responsiveness and dysphoria, and distractibility. Caution is thus advised in counseling clients to restrict their eating and diet to lose weight, as the negative sequelae may outweigh the benefits of restraining one's eating.”

Psychological Consequences of Food Restriction. J AM Dietetic Assoc. 1996: 96:589-592

So, is this true? Can "dieting" and focusing on improving ones eating result in an eating disorder?

No!

But let me clarify this important issue.

First, what happened in the Keys study was unique, because these subjects were truly "starving" and not dieting. These were not overweight or obese subjects who were trying to lose excess weight and fat, but these were men who started out thin with few fat reserves. They were thin and fit men not like the typical overweight and/or obese sedentary man of today who is trying to lose weight. During the study, these men used up all of their fat reserves and went below the level of essential body fat (5%). Very careful records were kept. If you have ever seen the pictures of the subjects, they looked emaciated.

While the calorie level may not appear very low (1500 calories), the men in the study were also made to exercise intensely during the day.

They also lost over 25% of their initial body weight, which, started out relatively low, and remember, they started out thin and fit.

This situation is not the same as an overweight and/or obese person undergoing a healthful program of decreased caloric intake and increased physical activity and losing excess weight and body fat over time. They are two completely different situations.

Dieting is not starvation and starvation is not dieting!

The following is from a review article that appeared in the September 25, 2000 Archives of Internal Medicine. It is an excellent review of this whole issue and also addressed the Keys starvation study done years ago and whether the Keys study is really applicable or not.

Dieting and the Development of Eating Disorders in Overweight and Obese Adults. Arch Intern Med. 2000;160(17):2581-2589.

From the review...

"Such concerns about the relationship of dieting to eating disorders originated with an experiment conducted during World War II with normal weight subjects. Young men who ate a semi-starvation diet for 6 months developed negative emotional reactions including depression, irritability, and anger, and a few engaged in binge eating behavior that persisted even after they had free access to food. These results are often assumed to apply to overweight and obese adults, among whom binge eating disorder (BED) is the most common eating disorder. A key question for the task force was whether weight-loss treatment leads to increased binge eating in these individuals."

"Obese adults enrolled in weight-loss programs that focus on moderate energy restriction, increased physical activity, and group or individual counseling are unlikely to develop binge eating problems, concluded several studies. In contrast, the data suggest that this type of treatment reduces binge eating in those who had recurrent binge eating episodes prior to program enrollment.”

"Does dieting and weight loss in overweight and obese adults cause psychological problems, as early studies suggest? Numerous studies conducted over the last 25 years show reductions in symptoms of depression and anxiety—or at least no worsening of these conditions—in obese patients undergoing supervised weight loss treatment. Almost half of the men and women enrolled in the National Weight Control Registry (a registry of people who have lost at least 30 pounds and maintained the loss for more than a year) lost weight on their own without a formal program. Measures of mood, distress, restraint, disinhibition, binge eating, and purging among these individuals indicate that many people who have lost weight through a variety of methods do not experience significant psychological distress or disordered eating behaviors."

"Based on these studies, the task force concluded that dieting does not induce eating disorders or other psychological dysfunction in overweight and obese adults."

As we saw, dieting, in general does not lead to an eating disorder. However, it is important to acknowledge that 1) there are some really unhealthy diets out there, 2) many people have really bad experiences with these bad diets, 3) many people do some crazy/dangerous things to lose weight, and 4) there are even some health professionals who recommend really bad diets.

But, that doesn't mean that "all" dieting is bad, or that "dieting" per see is bad or that recommending a diet based on a variety of minimally processed, calorie dilute/nutrient rich foods (ie, fruits, vegetables, starchy vegetables, roots/tubers, intact whole grains and legumes) for someone trying to lose weight is somehow dangerous and will lead to an eating disorder.

In fact, it seems to me that the above article actually supports this distinction and agrees with such a recommendation.

So does this article, which appeared in the Southern Medical Journal.

Psychologic and physiologic effects of dieting in adolescents.

South Med J. 2002 Sep;95(9):1032-41.

The article clearly states exactly that...

"Among these adolescent dieters, a significant percentage report unhealthy or dangerous weight-loss methods, including use of diet pills, fasting, skipping meals, or using very-low-calorie diets (Table 2). Dieting can be associated with both positive and negative consequences. Dieting adolescents report more health-promoting behavior, such as increasing fruit and vegetable intake, decreasing fat intake, and increasing exercise."

It also noted that most all the negative consequences of dieting were associated with the above mentioned "dangerous" diet habits and not healthy dieting. The article states that many of the physical problems are associated with diets that are too low in calories and/or the low carb, high fat/protein diets....

"The common theme in many of the reports of morbidity and/ or mortality related to dieting practices is the use of diets that induce ketosis (very-low-calorie diets or low-carbohydrate/high-fat diets)."

And, it was the same for the negative psychological consequences also....

" The most negative patterns of psychosocial and health behavior were found among frequent dieters and purgers."

" Seventy-four percent of patients with bulimia attributed the development of their eating disorder to the inability to maintain a low-carbohydrate diet, leading to carbohydrate craving and subsequent cycles of binging and purging. "

As most of the negative comments about dieting is in relation to working with the obese and teenagers who are said to be most prone to developing eating disorders, I find the following comments from the article most interesting...

"Dieting and weight loss in obese teens have several potentially positive health outcomes."

I also agree with the conclusion...

“When weight loss is necessary, the most appropriate method remains modest caloric restriction incorporating a balanced intake of macronutrients and micronutrients, along with increased physical activity."

Lastly, a few more studies also found that dieting does not cause eating disorders. However, once again, we see "unhealthy dieting" (diet pills, laxatives, and diuretics) can lead to some problems both physically and psychologically but hopefully no health professional is recommending any such thing.

1) Dieting and the development of eating disorders in obese women: results of a randomized controlled trial. Am J Clin Nutr. 2004 Sep;80(3):560-8.

"During the first 20 wk, there were no significant differences among groups in the number of persons who had objective binge episodes or in reports of hunger or dietary disinhibition."

"No differences, however, were observed between groups at weeks 40 or 65 (a follow-up visit).

"At no time did any participant meet criteria for binge-eating disorder."

CONCLUSION: Concerns about possible adverse behavioral consequences of dieting should not dissuade primary care providers from recommending modest energy restriction to obese individuals.

2) Treatment of overweight in children and adolescents: does dieting increase the risk of eating disorders? Int J Eat Disord. 2005 May;37(4):285-93.

"Significant improvements in psychological status also were observed in several studies.”

“Concerns about potential ill effects of dieting should not dissuade overweight youth from pursuing sensible methods of weight loss."

3) Obesity, disordered eating, and eating disorders in a longitudinal study of adolescents: how do dieters fare 5 years later? J Am Diet Assoc. 2006 Apr;106(4):559-68.

"Adolescents using unhealthful weight-control behaviors were also at increased risk for binge eating with loss of control and for extreme weight-control behaviors such as self-induced vomiting and use of diet pills, laxatives, and diuretics 5 years later."

Lastly, to clarify the issue in regard to plant-based, vegetarian and/or vegan diets... these diets do not lead to eating disorders. However, about 12-25% of those who have an existing eating disorder (underlying, developing or manifested), may choose vegetarianism &/or veganism as a way of restricting their eating. Dieting/restrictive eating does not lead to an eating disorder, but unhealthy dieting/restrictive eating may be a sign of someone with an eating disorder.

Vegetarianism: Risk for an Eating Disorder?

Christopher D. Keiper, M.A.[1],[2], Lauren M. Cash, B.S.2, and David M. Garner, Ph.D.1 of River Centre Clinic

Vegetarianism, ED, and Dietary Restraint

Which comes first, the vegetarian or the ED? Bardone-Cone and colleagues (2012) found that 61 percent of current ED individuals who have had a vegetarian diet said they believe there was a relationship between their ED and choosing to be a vegetarian. These authors found vegetarianism in the history of about half of people who develop AN, and that more AN patients who were vegetarian struggled to complete ED treatment (Bardone-Cone, et al., 2012). However, they also found that people with an ED on a vegetarian diet reported ED symptoms before choosing to be vegetarian with an average of one year between the onset of ED symptoms and eating vegetarian. Consistent with earlier studies (for example, O’Connor, Touyz, Dunn, & Beumont, 1987), these authors suggest that though ED sufferers are more likely to be vegetarian, it seems that vegetarianism is not usually a specific precedent to an ED. Rather, it seems that people who are predisposed to risk for developing an ED are more likely to engage in vegetarian eating patterns (Bardone-Cone, et al., 2012).

So, there we have it. Unhealthful and dangerous methods to lose weight and diet can lead to both psychological and physical problems. Hopefully, that would not be a surprise to anyone and hopefully no one, especially any health professional, is recommending any unhealthy and/or dangerous methods to lose wight. Somehow though, because of the problems associated with dangerous diets, some people want to throw out all and any attempts to diet and/or lose weight.

However, a plan recommending an appropriate caloric intake through the consumption of healthful, low calorie dense & minimally processed plant foods along with a healthful plan of activity and exercise is still the best and safest way to lose weight and maintain a healthy weight.

In Health

Jeff