Mental Health

Competitive Under-Eating: That Harmful Thing You are Probably Doing and Why You Have to Stop

Joey Chestnut stands at 6 foot 1inch tall but in the world of competitive eating his figure looms much larger. In 2016 he regained the championship belt by consuming 70 hotdogs and buns in 10 minutes. Two month later he held on to the US Chicken Wing Eating Championship by eating 188 wings in 12 minutes. Joey trains for his feats with a combination of fasting and stretching his stomach by drinking gallons of water. It’s a dangerous ‘sport’ as the legal disclaimers attest. The harms of competitive eating are obvious and well-documented so I am not going to talk about them here. I’m concerned about a competitive eating behaviour that happens towards the other end of the spectrum.

Competitive Undereating doesn’t draw the same crowds as Joey and his rivals – though it does require an audience of sorts – and there is isn’t any prize money. There is nothing in it but a misguided sense of triumph, the creation of tension at mealtimes and the risk of psychological harm. Competitive Undereating is a subtle and complex behaviour where a person strives to demonstrate that they have or will eat less than someone else. It can be used to signal that eater isn’t ‘greedy’ or ‘bad’ or that they have superior ‘control’ over their appetites. It is linked with maladaptive perfectionism (the unhealthy kind) and can trigger more serious eating issues in the eater and those around them.

Shared student houses are a hotbed of dietary restriction and I think it is linked to Social Comparison Theory. This theory states that to manage our self-esteem we are driven to make comparisons between ourselves and others. A downward comparison means we look for someone who is ‘worse’ than us to make ourselves feel better. For groups where academic achievement is on a par (such as medical students, for example), physical appearance and attractiveness are the next best targets for comparison. Moving out of home and having to manage budgets and meals for the first time is stressful and can lead to the development of harmful behaviours in those vulnerable. Being thrown in to a group living situation can raise worries about whether you or the way you eat is ‘normal’. Do you eat the ‘right’ foods? Does the way you eat seem weird to other people? Added to that is the unconscious drive, when we are in groups, to establish a hierarchy to see who is the ‘Alpha’. Now the conditions are set for the flourishing of anxiety-driven competition.

But it is not just in unrelated groups. It is common to find Competitive Undereating among households. Siblings do it against each other, especially if one child has already been dubbed ‘The Thin/Small/Skinny One’. Mothers do it with their daughters more than society would like to admit.

Competitive Undereating is not an eating disorder, though it is a sign of disordered eating. I am sure, though, that most people who engage in this harmful, unproductive behaviour don’t even realise it. Simply, they have been around it, and doing it for so long that they do not even notice anymore. Worrying about what someone else thinks of our eating instead of what we ourselves want has become automatic. To understand whether you, or someone around you, is a Competitive Under-Eater, you need to first know what it looks like. Family or group mealtimes are where this kind of behaviour is most obvious. Let’s imagine you and your housemates/friends/colleagues/family are going out for dinner…

Preparation

The competition begins long before arrival at the chosen eatery. Perhaps the choosing of typically low calorie cuisine (e.g. Thai, Japanese or vegan) is an attempt to minimise calorie consumption from the outset. For a Competitive Under-Eater the venue can be the first signal of status. ‘I’m choosing the healthy option because that’s better. I don’t allow my cravings to determine my choices’. If not, if, say, the choice is pizza or burgers then the menu is scanned beforehand, not for efficiency, or in excited expectation, but to find the lowest calorie, healthiest item. The ‘best’ choice.

At The Restaurant

At the restaurant or dinner table we begin to see the different types and strategies of Competitive Undereating. I call them The Proclaimers, Surveyors, Sirens and The Compensators.

The Proclaimers

Sadly, I am not talking about the cheerful Scottish duo (but now the song is in your head). These Proclaimers take two forms, but both involve making an announcement about previous eating.

‘I haven’t eaten anything all day!’ It is less important whether this is or is not a factual statement. The point of the proclamation is set the Proclaimer out as the most ‘controlled’, the best denier of hunger. In a world where being thin is the sign of success, not eating all day is an achievement.

Of course, not everyone who turns up at dinner saying they are starving is competitively undereating. What’s we’re talking about here is the meaning, the intent behind the statement.

The alternative proclamation is something along the lines of, ‘I’ve already eaten’ or ‘I had a big lunch’. This is incredibly common in restrictive eaters and serves to legitimise later under-eating. It is a pre-emptive strike aimed at stopping others from enquiring why they are eating so little.

The Surveyors

Surveyors take an audit of the menu choices of the rest of the group.

  • What are you having?
  • How many courses are you going to have?
  • Are you going to have bread?
  • Are you going to get dessert?

Again, this is less about the specific behaviour. There are plenty people who are so excited by the whole menu that they just want to talk about. In the mind of a Competitive Under-Eater, though, the value of the survey is to inform their own selection. ‘Well, I don’t want to be seen to be having more than anyone else. I don’t want to look greedy. I don’t want them to think that I eat ‘too much’.’ For this person finding out what everyone else is having is driven by the anxiety of not wanting to stand out or seem different.

The Sirens

I call this group/behaviour the Sirens because, like the mythological creatures, they lure others in to a trap. For example, they may talk about how delicious the dessert menu looks, how they have been craving cheesecake all week. When it comes time to order, feigning indecision, they insist that everyone else order first and then, at the very last moment, decline. The satisfaction here is knowing now that others will be eating more than they have and again signalling their superior ‘control’.  

The Compensators

Whether it comes at the start or the end of the meal Compensators make a public statement about ‘working off’ their food, of the need to undo the harm of eating. Comments like:

‘I’m gonna have to go for the longest run in the morning!’

‘It’s a good thing I did spin this afternoon!’

They may not have under-eaten but this kind of comment makes clear that the speaker has or will have a calorie deficit compared to the other diners and suggests that everyone else should emulate their behaviour.  

What’s The Problem?

The reason this kind of behaviour concerns me is because of the psychological repercussions. Imperceptible at first, with time the behaviours can bed in to become an established pattern.

To start with Competitive Undereating habitualises the judgement of self and others. Silent disapproval becomes second nature. It means that even (or especially) when sitting down to eat everyone at the table is being quietly assessed and critiqued. It creates anxiety (which in itself impairs digestion) and prevents full enjoyment of the meal. It gets in the way of real, healthy social interaction. Competitive Undereating comes between people because, ultimately, the attention is focused back on the self. Whatever the other people are doing or eating you are always thinking about how it relates to, reflects on or affects you.

Secondly, it consumes thinking and is a colossal waste time, energy and creativity.

Third, Competitive Undereating can trigger and perpetuate eating disorders, and hinder recovery. It can be incredibly difficult for someone in recovery to start to rebuild a healthy relationship with food if they continue to be exposed to Competitive Undereating or judgement about their food choices. Not least of all because comparing your food intake to someone else’s ignores biological, metabolic, genetic, hormonal and lifestyle differences between you.

Competitive-Under-Eating looks harmless but it can lay the foundations for deeper problems with food, eating and self-esteem. If you recognise yourself or someone close to you as a Competitive Under-Eater it can be helpful to remind yourself that what you eat does not affect other people and vice versa. It’s dinner. It’s not a competition.

 

If you think you might have a problem with your relationship with food it may be helpful to talk to a professional. Psychologists and registered nutritionists who specialise in Intuitive or Mindful Eating can help you develop a more relaxed, natural relationship with food.

Depression is a Whole-Body Disorder. Why Don’t We Treat It Like One?

Today marks the start of Mental Health Awareness Week in the UK. In previous years the campaign has explored the experiences of living with mental illness, social stigma and support resources. This year the focus has changed from living with illness to asking why so few of us are thriving psychologically. Why are so many of us in ‘survival mode’? It’s an approach that invites us to look at the wider factors influencing mental health on a sub-clinical level. When most of the people who experience depressive or anxious symptoms will not or cannot access treatment it is important to understand other viable and effective avenues for intervention.

This broader theme of what it means to ‘thrive’ reflects a growing appreciation that disorders such as depression are not simply ‘brain-based’ but are biological and psychological responses to social, environmental and lifestyle factors. Just a few days ago a review of 20 years of depression research concluded:

“…one thing is for sure: depression, and mental health problems in general, can no longer be seen only as disorders of the mind, or indeed only as disorders of the brain. The strong impact of the immune system on emotions and behaviour demonstrates that mental health is the health of the whole body.”

Two years ago the Lancet Psychiatry released a statement editorial highlighting that ‘nutrition is as important to psychiatry as it is to cardiology’ and advocated that nutritional status and dietary intervention should be considered when assessing a person’s mental health condition. The recent publication of the ‘SMILES’ Trial was the first study to elucidate diet as a causal factor in depression. Mood improvement in this study was not a factor of weight loss and while this particular study did not assess these parameters it is likely that the improvement was due to a reduction in systemic inflammation, as has been highlighted by a number of observational and RCT trials.

Inflammation is the immune system’s response to illness or injury, which, amongst other things, involves the release of small molecules called cytokines by immune cells. Typically, the inflammatory response is brief and begins to recede when the tissues start to heal. However, a number of stressful external factors also induce inflammation and the secretion of pro-inflammatory cytokines including: early life adversity, traumatic events, chronic work stress, poor diet, obesity and a sedentary lifestyle. When stress is sustained so is inflammation and this state of low-level chronic inflammation is implicated in a range of diseases including heart disease, Type 2 diabetes, Alzheimer’s Disease, and depression. Blood levels of inflammatory cytokines correlate with the severity of depression that patients report. In one trial non-depressed participants were injected with a substance called endotoxin, a toxin found in the cell walls of bacteria that the immune system recognises as harmful. The participants who were injected with endotoxin not only saw an increase in their levels of cytokines but reported significantly increased anxiety, depressed mood and loss of pleasure (a symptom of depression). The participants who received the placebo did not report these mood effects.

As well as improving diet, exercise has been shown to be effective in reducing levels of inflammation, improving mood and increasing the levels of a substance called BDNF. BDNF is a growth factor that promotes the growth of new brain cells, as well as protecting the ones we already have. Low levels of BDNF have long been associated with depression and other mental illness. Exercise mimics the action of antidepressants by raising levels of BDNF and improving the availability of the neurotransmitter serotonin, which is associated with good mood. Exercise has the additional benefit of improving heart health and general brain structure and function, and improving sleep (sleep disorders are a common factor in depression).  Taking a similar position to the Lancet Psychiatry report, a recent editorial in the journal General Hospital Psychiatry makes the case that the evidence for the beneficial effects of exercise on mental health is so compelling that it is time to start thinking about how to apply it as treatment.

Other lifestyle factors have also been shown to be effective in improving mental health including meditation, learning, fasting and even sauna use. Combined, these factors present us with the best cost-effective opportunity to reduce and prevent the development of depression and associated disorders. Sadly, few people will have access to this valuable information and support. Conducting a thorough assessment into what might be causing one person’s depression takes more time than the ten minutes GP’s are allotted per person. Psychological therapies are effective but can be difficult to access. Thus, antidepressant medication remains the most cost-effective treatment available in Primary Care. The problem is that rates of treatment-resistance (patients not responding to antidepressants) are increasing. The lifestyle factors outlined above provide opportunities to both improve the efficacy of standard treatments and as standalone options for those with mild-moderate symptoms.

Hopefully, this year’s campaign will make the case for considering lifestyle interventions in the treatment of depression. For my part, my clinical practice starts with a comprehensive assessment of both psychological and lifestyle factors including: work satisfaction; relationships; childhood illnesses, exercise; diet and nutrition, and sleep habits so that the client and I can come to as clear an idea as possible of what might be causing their distress and illuminate a number of areas for intervention to give us the best chance for a positive outcome.

To increase the availability of this valuable information I am launching a series on online seminars on a range of topics including Stress Management, Sleep, Nutrition and Obesity. It’s times for us to move away from a model of symptom management to one of illness prevention, and all change starts with awareness.

http://www.monumentalhealth.co.uk/seminars/

References

Dantzer, R., O'Connor, J. C., Freund, G. G, Johnson, R. W, Kelley, K. W. (2008). From inflammation to sickness and depression: when the immune system subjugates the brain. Nature Reviews Neuroscience, 9(1), 46–56. doi:10.1038/nrn2297

Ekkekakais, P. & Murri, M. B. (2017). Exercise as antidepressant treatment: Time for the transition from trials to clinic? General Hospital Psychiatry. Doi 10.1016/j.genhosppsych.2017.04.008

Miller, A. H., & Timmie, W. P. (2009). Mechanisms of Cytokine-Induced Behavioral Changes: Psychoneuroimmunology at the Translational Interface Norman Cousins Lecture. Brain, Behavior, and Immunity23(2), 149–158. http://doi.org/10.1016/j.bbi.2008.08.006

Pariante, C. M. (2017). Why are depressed patients inflamed? A reflection on 20 years of research on depression, glucocorticoid resistance and inflammation. European Neuropsychopharmacology. In press.

Sarris, J. et al. (2015). Nutritional medicine as mainstream in psychiatry. The Lancet Psychiatry, 2(3), 271-274.

Talking Mental Health Self-Care with Laura Thomas PhD.

Many of you will have watched the moving and insightful BBC documentary Mind Over Marathon, which followed 10 volunteers, each with their on mental health concern. Part of the Heads Together mental health awareness campaign, the programme followed the volunteers as they used training for the London Marathon both as a personal challenge and treatment. I have written elsewhere about the value of exercise as a mental health intervention and it is great to see it receiving more recognition for its benefits.

Laura Thomas PhD was the nutrition consultant on the programme and on the latest episode of her podcast we talk about the five pillars of mental health self-care, the role of nutrition on brain health and dinosaurs. Enjoy!

 

Treating Depression with Diet: The 'SMILES' Trial

Regular readers of this blog or anyone who follows me on Twitter for even half a day will be familiar with some of the research on lifestyle interventions for mental health. While these include sleep, exercise and creative pursuits, one of the ones that I keep coming back to is diet. I have reported on epidemiological studies that show a relationship between a consistently healthy diet and depression in the general population and in women. This research has been correlational, it shows that there is a relationship but, technically, cannot say that what causes what. It could be that depressed people are more likely to eat a poor diet. All that changed recently with the publication of a randomised controlled trial of the use of diet as a treatment of depression; The ‘SMILES’ Trial. The research was led by Professor Felice Jacka, who, if you are interested, I recommend you follow on Twitter for updates and links to similar research.  

The 67 participants in this 12-week Australian study were adults who were depressed at the time and who had a clinically defined poor diet. A poor diet was one that was low in fibre, fruit and vegetables and lean protein, and high in sweets, salty snack foods and processed meats. Some participants were receiving treatment in the form of medication, talking therapy or both.

The participants were randomly assigned to either a nutritional intervention group or a befriending control group. In the intervention group the participants had seven one-hour sessions with a registered nutritionist who provided them with personalised nutritional advice including example recipes and meal plans, and coached them around goal setting and motivation to help them to stick to the nutritional recommendations. They were encouraged to eat (servings in brackets):

  • Whole grains (5–8 servings per day);
  • Vegetables (6 per day);
  • Fruit (3 per day); 
  • Legumes/beans (3–4 per week);
  • Low-fat and unsweetened dairy foods (2–3 per day);
  • Raw and unsalted nuts (1 per day);
  • Fish (at least 2 per week);
  • Lean red meats (3–4 per week);
  • Chicken (2–3 per week);
  • Eggs (up to 6 per week); and
  • Olive oil (3 tablespoons per day).

In addition, participants were encouraged to reduce their intake of “‘extras’ foods, such as sweets, refined cereals, fried food, fast-food, processed meats and sugary drinks (no more than 3 per week). Red or white wine consumption beyond 2 standard drinks per day and all other alcohol (e.g. spirits, beer) were included within the ‘extras’ food group. Individuals were advised to select red wine preferably and only drink with meals.” They were told to eat to their appetites and not worry about trying to lose weight, so it wasn’t a ‘diet’ in the colloquial sense. Those in the social support/befriending group had seven one-hour meetings with a trained professional who talked to them about neutral subjects (i.e. not nutrition, mood or anything that might be considered therapy). Anxiety, depression and general mood were assessed at the beginning and end of the study, along with biological data such as weight, waist circumference, fasting blood glucose and cholesterol.

People in the dietary intervention group were four times more likely to be in remission (not depressed) at the end of 12 weeks than those in the befriending group. They also had reduced severity of anxiety symptoms. There was no change in BMI, blood glucose, cholesterol or physical activity within or between the groups. People were not feeling better because they had lost weight but they were definitely feeling better.

What is also interesting is an analysis called the Number Needed to Treat (NNT). The NNT is a rating of a treatment’s efficacy and describes the number of people that need to be on the treatment in order for one unwanted outcome to be prevented or avoided. So, if a (miracle) drug worked for absolutely everyone then the NNT would be 1. If, for example, a migraine treatment had an NNT of 100 then 100 people would need to be on the treatment to prevent one person having a migraine. The NNT in the SMILES Trial was four. This compares favourably to common antidepressant medication which can vary from 5-16, which is still considered effective particularly in relation to the high global rates of depression. The authors also make the point that that this nutritional intervention would also have positive outcomes for other problems that are commonly associated with depression such as heart disease, type 2 diabetes and obesity.

Crucially, the researchers also looked at the affordability of the diet and found that, on average, people adhering to the diet spent $26 less per week on food and drink than they were at the start of the study.

Of course, we have to bear in mind that this was a small study of people from a particular part of the world and it will both interesting and exciting to see the trial replicated with more participants from different ethnic backgrounds. However, it is also, I think, hugely important. It is the first study (as far as I can see) that demonstrates a direct influence of diet on depression. Depressed people who improved their diet felt better. This trial doesn’t tell us how the diet had this beneficial effect; the results were unrelated to any of the other measurements they took. My guess is that future replications will find a link to systemic inflammation and perhaps to action of the gut microbiome, but time will tell. The upshot is that improving diet in line with general guidelines (no extreme diets) had a significantly positive effect on depression. The benefit of this kind of intervention is that there are no waiting lists or side-effects, and it doesn’t have to be expensive. We eat several times a day and this research shows us that each meal provides us with a valuable opportunity to make a difference to how we feel.

Reference

Jacka, F. N., O’Neil, A., Opie, R., Itsiopoulos, C., Cotton, S., Mohebbi, M., Castle, D., Dash, S., Mihalopoulos, C., Chatterton, M. L., Brazionis, M., Dean, O.M. Hodge, A. M. & Berk, M. (2017). A randomised controlled trial of dietary improvement for adults with major depression (the “SMILES” trial). BMC Medicine15, 23. http://doi.org/10.1186/s12916-017-0791-y