BRIDGING THE GAP, PART II: Dangers Of Dietary Restraint
by Dr. Gabrielle Fundaro, PhD |
Feb 27, 2020
The first article in this series, also authored by Dr. Gabrielle Fundaro, PhD, CISSN, CHC, sought to clarify the misconceptions around weight-neutral approaches and illustrate our capacity for regulation via interoceptive awareness. The purpose of the following article is to highlight the risks of dietary restraint and acknowledge a need for change in order to facilitate more adaptive styles of eating.
"Diets don’t work!" shouts one camp.
"All diets work!" furiously retorts the other.
Both camps are correct, of course.
So why the war?
Pseudo-dieting vs Energy Deficit
Dieting, defined as the restriction of certain foods or food groups in order to facilitate fat loss, is notoriously ineffective long term. Dichotomous thinking and high levels of rigid dietary restraint (common characteristics of chronic dieters) are associated with increased BMI and higher occurrences of binge eating. In fact, dieting usually precedes binging. A cognitively regulated eating style is usually necessary to overcome the physiological defense of body weight through conscious decision-making, but an overly-restricted one primes the dieter for overeating. The drive to overeat has both physiological and psychological roots; reduced sensitivity to hunger and satiety cues, prolonged hunger, perceived deprivation and dichotomous thinking are key features.
Counter-regulatory eating is common: a dieter commits a perceived dietary transgression (eating a food that is "off-limits") and the abstinence-violation effect takes place. The resulting overconsumption of food is accompanied by feelings of shame and guilt which drive further restriction. The trap of chronic dieting and weight-cycling is inescapable for many.
The damage caused by chronic dieting extends far beyond simple weight gain. Many individuals, dieters and non-dieters alike, self-identify with their eating behaviors. When a "perfect" diet is not achieved, self-image suffers. In addition, dieters tend to internalize the media’s portrayal of an ideal body: thin women and muscular men. This is the same media that feeds the flames of pervasive diet culture by promoting arbitrary food rules - most recently under the guise of "wellness" labels. The diet paradigm is inflexible, prescriptive, fear-driven and guilt-inducing. In summary, dieting and body dissatisfaction go hand in hand, and disordered thinking is a pathway to disordered eating.
Weight-neutral approaches, such as Intuitive Eating and Health At Every Size (HAES), are borne to protect individuals from the physical and psychological harm caused by destructive dieting. The non-diet paradigm is flexible, accepting, nurturing and freeing. Contrary to popular belief, the goal of these approaches is not to encourage the individual to "give up" on health-seeking behaviors, but quite the opposite. Raising awareness of the harm caused by dieting addresses pervasive diet culture; it does not follow that weight change is inherently bad or harmful. Rather, weight-neutral approaches promote participation in health-seeking behaviors by fostering a healthier attitude to eating behaviors and physical activity whilst addressing the motivations behind these behaviors.
It is clear that arbitrary fad diets do not lead to long term weight loss success. Yet, cognitive restriction does not equate to caloric restriction, and long term weight loss certainly is possible. An energy deficit will result in fat loss when sustained over a period of time - the first law of thermodynamics dictates this. Weight data from 14,306 participants (age 20-84 years) in the 1999-2006 National Health and Nutrition Examination Survey (NHANES) shows that 1 in 6 overweight or obese US adults has successfully achieved long term weight loss of over 10% body weight. Over one third (36.5%) achieved long term weight loss maintenance of at least 5% and 10–20% of subjects in clinical trials are able to maintain a loss of at least 5% for over 5 years. Some individuals benefit greatly from weight loss with improvements in blood pressure, cholesterol, glucose and lower risk of metabolic syndrome after just minor reductions in weight. These findings should not be dismissed.
Some are concerned that encouraging acceptance of oneself fosters a fixed mindset - "I will never change, so why try?’" - and point to extremist advocates of weight-neutral approaches as culprits for fostering this idea. Discouraging individuals from change may prevent them from achieving beneficial health outcomes. To reiterate: this is not the true message that weight-neutral approaches promote. Rather, weight-neutral approaches encourage engagement in health-seeking behaviors from a place that is free of restriction, guilt and shame. We should not discount the validity and importance of these principles (many of which can be encouraged regardless of the approach we take) based on dogmatic views of an extremist minority.
It is not the "what" of weight loss that is under question, but the "how" and "why" behind it. Precisely how we go about change, is a nuanced question indeed.
Rigid Control vs Flexible Control
Eating restraint is a form of cognitive control engaged in by those who are trying to lose weight or prevent weight gain. Simply put, caloric limitation requires a certain degree of attention.
Eating restraint is not a homogenous construct and can be divided into two forms: rigid control (RC) and flexible control (FC). Dietary restraint is distinct from dietary restriction engaged in by pseudo-dieters, since calorie restriction can be achieved without the avoidance of specific food or food groups. Dietary restraint, when engaged in appropriately, may not lead to increased levels of eating pathology and can be a beneficial strategy for those looking to control their weight.
Whilst some form of dietary restraint is necessary, not all forms are beneficial. It follows that a deeper understanding of dietary restraint is key for facilitating a healthier approach to fat loss.
We can distinguish between two primary forms of restraint:
Rigid Control: An all-or-nothing approach to eating characterized by the avoidance of calorie-dense foods, regimented calorie counting, and fasting.
Flexible Control: A balanced approach to eating characterized by conscious and intentional food choices, monitoring portion sizes, eating to satisfaction, and compensating by eating more or less when needed.
Flexible control is considered a "healthier" form of dietary restraint, yet it has not consistently been linked to positive health outcomes or well-being. As a matter of fact, flexible control has been associated with increased levels of disordered eating and promotion of weight gain. The relationship between rigid control and flexible control is nuanced; it is evident that these forms of dietary restraint can, and likely do, correlate. Despite our best intentions, we may be unintentionally promoting rigid control through our endorsement of flexible dietary strategies.
Let’s use fasting as an example.
The manipulation of timing of food intake has received great interest as a strategy for achieving negative energy balance. Intermittent energy restriction (IER) can take many forms including time-restricted feeding windows, alternate day fasting or 5:2 protocols, among others. IER has been associated with a significant decline in BMI, fasting glucose and insulin levels in those with overweight and obesity. On the contrary, fasting can be a catalyst for disordered eating and is highly associated with binge eating. It is likely that the disordered eating risk associated with fasting is derived from the behavior’s interaction with other individual difference variables. When the available evidence suggests that IER results in equivalent weight loss when compared to continuous energy restriction, it pays to be prudent in our encouragement of these strategies, or at least define an appropriate target population.
Macro-tracking is typically promoted as another form of flexible control. When "Clean Eating" failed, If It Fits Your Macros (IIFYM) was established to fill the need for a more flexible approach to dieting. Macro-tracking gives an individual greater control over their dietary intake, but it is not without risk. Increasing one’s attention to detail can lead to preoccupying cognitions and attentional bias to food and shape-related stimuli, thus facilitating rigid restraint. Macro-tracking is not the panacea it is claimed to be and may not be appropriate for all populations. A diverse range of tools are needed to facilitate healthier eating styles. The adaptive properties of flexible control require further elucidation and caution is required.
Disordered Eating In High Risk Populations
Disordered eating behaviors, although distinct from eating disorders such as anorexia nervosa, bulimia, or binge-eating disorder (BED), are associated with many health problems. These behaviors affect both the psychological and physical domain, leading to depression, anxiety, reduced quality of life and overweight and obesity. The prevalence of disordered eating tendencies is far more common than disorders reaching clinical significance and warrants a great degree of care and attention in light of this.
Certain populations are more susceptible to developing psychopathological behaviors than others. Awareness of risk can inform our approaches.
Bodybuilding can be characterized as the use of progressive resistance exercise to control and develop one’s musculature for aesthetic purposes, competitively or recreationally. High levels of dietary restraint are required to manipulate food intake in accordance with periods of overfeeding and underfeeding, synchronizing with periods of muscle gain and fat loss.
1. Predispositions to develop eating disorders or body image concerns
There is a greater likelihood that competitors have previous experiences of psychopathology related to food and body image. A study looking at a population of female weightlifters found that 42% female bodybuilders used to have a diagnosis of anorexia nervosa, 67% reported being terrified of becoming fat and 50% had uncontrollable urges to eat.
2. Exacerbating behaviors
Not only does the biological drive of cyclical energy restriction contribute to binge eating behavior, but monitoring and judgement of one’s physique can contribute to body image concerns.
Post-competition is a particularly vulnerable time: 81% of a sample of bodybuilders reported reinforced food preoccupations, binge eating and increased anger and anxiety. Female bodybuilders continue to adhere to strict diets post-comp to fit in with the muscular and lean ideal.
Weight and body pressures are rife in the sporting environment. In general, athletes display higher rates of eating disorders compared to the general population, and eating disorders are most commonly observed in athletes who engage in sports that favor a lean body type, particularly females. Athletes that participate in weight-class sports are particularly vulnerable due to the necessity of bodyweight awareness, self-monitoring, preoccupation, weight-cycling, and rapid weight loss techniques.
Pathological behaviors and cognitions can take the form of:
- A preoccupation with food, energy intake and body weight
- A distorted body image and body weight dissatisfaction
- Undue influence of body weight on self-evaluation
- Intense fear of gaining weight even when at or slightly below (approximately 5%) normal weight.
Despite appearing to be healthy, the athlete may display symptoms of RED-S, an impaired physiological functioning caused by relative energy deficiency. The mismatch between an athlete’s energy intake (diet) and the energy expended in exercise is often, although not always, underpinned by disordered eating. Perfectionism, competitiveness, pain tolerance and the perceived performance advantage of weight loss all influence an athlete’s risk of disordered eating.
Poor Body Image
For many people, the relationship with food is closely tied to their relationship with their body, and body image disturbance predicts future levels of disordered eating. Popular media emphasizes a muscular ideal for men and a thin ideal for women. Internalizing these ideals leads to a lack of body appreciation and many go to great lengths to change how they look.
Unfortunately, body image has little to do with how one actually looks. It is a multi-faceted construct that has far more to do with how one feels about how they look. Changes in body composition do not necessarily correlate to improvements in body image. Body image flexibility, the ability for one to openly and freely experience thoughts about the body without acting on them or making efforts to avoid or change them, is protective of disordered eating tendencies. For some, perhaps, it is their thoughts that need addressing first and their diets second.
The Path To Progress
Athletic performance, manipulation of body composition, and optimization of physical health are worthy pursuits which need not be discouraged. We simply cannot ignore the fact that these pursuits often lead to the neglect of psychological health and result in maladaptive eating behaviors. Harm might manifest in individuals with "normal" bodyweight who are chronically dieting because they hate their bodies, but also in athletes who internalize strong athletic identities. Despite our best intentions, rigid forms of dietary restraint are common and can lead to psychological inflexibility and counter-regulatory eating. Whilst caloric restriction is the only form of restriction necessary for fat loss to occur, we must not forget that eating is a behavior with deeply rooted biological drives, and our relationship with food often reflects our relationship with our bodies.
In order to do no harm, we must empower our clients with adaptive eating styles, defined as eating with the absence of disordered behaviors.
Intuitive Eating (IE), distinct from both rigid control and flexible control, is one approach that does exactly that. IE has been branded as the anti-diet diet - a rather unfortunate label. A more accurate conceptualization of IE is that of a flexible and adaptive approach to eating, operating under a framework of self-care. Those who eat intuitively are attuned to their hunger and satiety cues, relying on these signals to guide their eating. Intuitive Eaters are less likely to be preoccupied with food or think in black and white terms. Instead, they choose foods that are satisfying and provide valuable contributions to one’s health, energy and performance.
Not only is IE inversely related to eating disorder symptomatology, disinhibited eating and BMI, but also related to positive psychological factors that are often neglected by less adaptive forms of dietary restraint. These include lower levels of food-related anxiety, thin-ideal internalization, body preoccupation, body dissatisfaction and negative affect. Intuitive Eaters display higher levels of body appreciation, self-compassion, positive affect, proactive coping and self-esteem, all of which may get pushed aside in our pursuit of fat loss or body weight regulation.
Whilst in the midst of goal attainment, there may be times in which an effortful process of recalibration is required to keep both physical and psychological health in check. We can liken this to the need for rehabilitation of physical injury for longevity in sports. Perhaps a more graded approach, determined on an individual basis, is needed. Whilst one’s physiology is predictable and simple to manipulate, one’s psychology is not. The next article in this series addresses how conscientious coaching methods can help to bridge the gap between weight-neutral approaches and fat loss or performance outcomes, paving the way to positive change.
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