There are very few situations in life where one answer is right for everyone. Dietary patterns are definitely not one of them. We all come in different sizes and shapes and have different nutritional needs and goals. One dietary approach cannot accommodate every person’s situation. Fasting might serve to improve mental health in one individual and might be part of the problem in another. It’s complex.
The goal with any diet is to support human flourishing. We want to optimize energy, vitality, strength and wellbeing. The trouble is our counseling about weight and diet are taking place in the context of a highly judgmental population, a rigid educational framework around diet and a very unhealthy national food culture.
The recent increased popularity of intermittent fasting has brought greater awareness to society of something that people who have struggled with anorexia have discovered for themselves: withholding food causes weight loss. It is not hard to see how inappropriate use of fasting could be detrimental to people already struggling with their body composition in a society that places high valuation on thinness.
The Struggle is Intense
People today, especially younger people, have tremendous pressures on them regarding body image between media, social media and peer culture. Yet given the decline in healthy food options, confusion about healthy eating patterns and a general decrease in activity it is harder than ever to maintain a healthy weight. These conflicting pressures can be part of a process that leads to binge eating or purging behaviors.
I have found disordered eating to be one of the most difficult issues to address in medicine. It has been eye opening how much more willing people have been to talk about their experiences once I start thoughtfully asking about meal frequency. Many are very hesitant to bring these experiences up with healthcare professionals and I think we need a much more open and nuanced discussion about these issues.
I especially want my patients to know that we can talk about any of these experiences. As anyone who has struggled with an eating disorder or who has friends or family members who struggle knows, this can be a very difficult and painful discussion to have. Hopefully these words can provide a place to start.
One Potential Framework
I find it helpful to think of eating disorders on a spectrum with normal eating. If we imagine severe undernutrion and anorexia on the left and significant over nutrition on the right we can see that we would pass through levels of undernutrition and overnutrition with a center area of balanced eating in the middle. Where exactly that “normal” balance point is may be different for each person.
The distribution of our population across this spectrum is definitely skewed to the overfed side. Much of what is considered normal eating in our society could very well be described as a type of eating disorder. I think a case can be made that a dietary pattern that has a high probability of causing obesity, diabetes, heart disease, fatty liver and premature death should also be called disordered in some fashion.
Appropriate use of fasting regimens should aim to help the group of people whose diet is shifted right to center themselves in a more balanced dietary practice that improves their life. There is no role for using these concepts to push people who are left on the curve even further toward undernutrition.
People who are undernourished need to eat more and more frequently. I am very much opposed to many online resources around fasting that promote the practice as “for everyone”, “the best” or “the optimum human eating pattern.” Any hype does not help. I hope I am accomplishing that on this site.
I certainly want to encourage anyone struggling with an eating disorder to refrain from a fasting practice. That would include people who might not be underweight but find that trials of fasting lead to binging behaviors. It’s not worth it.
One Specific Scenario
One pattern I have seen a number of times is a person who struggled with anorexia and related eating problems in their teens and in order to escape that cycle basically let go of restraint and overate for most of their twenties. As they were underweight this worked fairly well for the better part of ten years. An initial gain of 30 pounds didn’t necessarily make them significantly overweight but a second 30 wasn’t welcome and brought significant frustration. As they progressed through their thirties and forties further weight gain lead to depression and started them back on a difficult cycle of dieting and food struggles.
Complicating things further, at this point people may start running into chronic weight related health issues like blood pressure and diabetes along with joint pain and difficulty keeping up their activity. On a few occasions I have had discussions with overweight patients who have struggled with anorexia earlier in life who did not appreciate discussion of intermittent fasting regimens. But most of the time I have this conversation people are open to the discussion and are at least appreciative of the ability to discuss it even if they are not interested. People are confronted with discussion of intermittent fasting in society and it can be awkward for them to try to navigate these conversations especially if it is friends or coworkers practicing it and possibly “encouraging” them.
A Good Outcome
Some of the most rewarding experiences I have had helping people lose weight have been from overweight patients who used to be significantly underweight due to an eating disorder. Many have found a level 1 fasting practice to be like a breath of fresh air. It can be a simple, sustainable routine that lets them eat food they like, attain a healthy weight and stay far away from disordered patterns that previously troubled them. Patients have told me they wish they could have had a balanced talk about this issue years ago but that any time they brought up their eating disorder history they were discouraged from any kind of dietary modification from their health provider.
Intuitive Eating
With an issue as complex as this it is definitely a good thing to analyze multiple viewpoints. A perspective that seems at first glance to be completely the opposite of fasting would be the concept of intuitive eating. I have had a number of patients who have struggled with eating disorders report finding benefit from this practice. Certainly if you are underweight please stay away from fasting and check out intuitive eating.
Fasting definitely can be a discipline. For some people psychologically that might not be a good fit. I am for whatever works and if the opposite of what I generally recommend works for someone I am all for it.
I actually resonate with most of the pillars of intuitive eating. Although I do find benefit in the regimentation of time restricted eating as far as controlling huger patterns, even from a fasting perspective, once hunger is under control the regimentation is much less of a concern and what particular regimen someone participates in can become much more fluid and intuitive.
In conclusion
I hope some of these thoughts can be helpful. If you are struggling with an eating disorder please seek out help from a health care professional or an eating disorder specialist. These are really difficult and complex issues and it can be very helpful to have knowledgeable people to come alongside and help you.