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Jornal Brasileiro de Psiquiatria

Print version ISSN 0047-2085

J. bras. psiquiatr. vol.62 no.4 Rio de Janeiro Oct./Dec. 2013

http://dx.doi.org/10.1590/S0047-20852013000400005 

ORIGINAL ARTICLE

 

Current and previous eating practices among women recovered from anorexia nervosa: a qualitative approach

 

Práticas alimentares atuais e pregressas em mulheres recuperadas da anorexia nervosa: uma abordagem qualitativa

 

 

Mariana Dimitrov UlianI; Ramiro Fernandez UnsainII; Priscila de Morais SatoI; Patrícia da Rocha PereiraI; Isis de Carvalho StelmoI; Fernanda SabatiniI; Fernanda Baeza ScagliusiI

IUniversidade Federal de São Paulo (Unifesp), Campus Baixada Santista
IIUniversidad Nacional de Buenos Aires, Facultad de Filosofía y Letras, Cátedra de Antropologia, Buenos Aires, Argentina

Correspondence address to

 

 


ABSTRACT

OBJECTIVE: The aim of this study was to analyze qualitatively how women, who have recovered from anorexia nervosa, perceive and describe their current eating practices, as well as the ones developed during the eating disorder period.
METHODS: Seven women were interviewed individually with the objective of investigating their eating practices, transition phases and all relevant aspects that somewhat contributed to the habit-forming; experiences, feelings and perceptions related to mealtime and the influence that food has had over the present subjects' life. The interviews were analyzed by the discourse of the collective subject method.
RESULTS: The results brought up the following topics: a) control; b) concerns and feelings; c) deprivation d) beauty dictatorship; e) eating competence; f) importance of food; g) food cacophony.
CONCLUSIONS: What stands out is a multiplicity of eating practices, which during the eating disorder were similar to and characterized by restriction; however, after recovery, part of the subjects seem to have developed a higher eating competence, whereas others show a practice similar to the one acquired during the anorexia nervosa, such as the difficulty in realizing when they are satisfied and a feeling of discomfort when facing social interactions.

Keywords: Eating, eating practices, eating disorders, anorexia nervosa, qualitative inquiry.


RESUMO

OBJETIVO: Este artigo teve como objetivo analisar qualitativamente como mulheres que se recuperaram da anorexia nervosa percebem e relatam suas práticas alimentares atuais, bem como as práticas vigentes no período do transtorno.
MÉTODOS: Foram feitas sete entrevistas individuais com mulheres que vivenciaram a anorexia nervosa. Estas abordaram: hábitos alimentares das entrevistadas; mudanças e fatores importantes para a formação destes; vivências, sentimentos e percepções associados ao momento da refeição; e a influência que a alimentação exerce na vida das participantes hoje. A análise dessas deu-se a partir da técnica do Discurso do Sujeito Coletivo.
RESULTADOS: Os resultados trouxeram os seguintes temas: a) controle; b) preocupações e sensações; c) privação d) ditadura da beleza; e) competência alimentar; f) importância da alimentação; g) cacofonia alimentar.
CONCLUSÕES: Destaca-se nesses a multiplicidade das práticas alimentares, que durante o transtorno se assemelham e se caracterizam pela restrição; no entanto, após a recuperação dos sujeitos, alguns parecem ter desenvolvido maior competência alimentar, enquanto outros apresentam práticas semelhantes às vigentes na anorexia nervosa, além de dificuldade de perceberem quando estão satisfeitos e sensação de desconforto em situações de interação social.

Palavras-chave: Alimentação, práticas alimentares, transtornos alimentares, anorexia nervosa, estudo qualitativo.


 

 

INTRODUCTION

Anorexia nervosa (AN) is an eating disorder (ED) characterized by an intense and intentional weight loss resulted from a restrictive diet and by body image disturbances1.

Eating is essential for the construction of our identity since it is built biologically, psychologically, and socially through what the subject decides to incorporate2. The different meanings associated to food deprivation have changed over the years and are specific to the cultural moment on which it occurs3.

Thus, eating can trigger innumerous feelings2-4. Especially, when considering women who suffer from AN, it is documented that they show an extremely dysfunctional relationship with eating3. However, little is known as to how this relationship unfolds during the disorder and after recovery. Moreover, many consider eating and dieting as simple and set factors, and there is not enough description of how they are construed, understood and contextualized5, especially among individuals with ED.

Regarding the remission of the disease little is known about its nutritional aspects and whether they may influence its maintenance6. Schebendach et al.7 found that diet energy density and variety predicted outcome in recently weight-restored women with AN. Crisp et al.8 investigated the relationship between sleep, nutrition and mood of patients with AN before and after restoring a normal weight. They concluded that changes in sleep patterns were associated with disturbances in nutritional status caused by the disease, but did not investigate which nutritional aspects might have influenced such finding. The abovementioned studies bring important findings about nutritional aspects of the post-recovery period of AN, but they evaluated only objective and quantitative parameters, which may limit the full exploration of the subject. It is hypothesized that eating practices*, when better developed, might exponentially affect patients' recovery and avoid relapses. The present study would be an initial step towards researches in this area. Exploratory qualitative researches could be hereafter conducted in order to better describe eating practices during the remission period, allowing quantitative studies to later investigate if these practices are associated with a better outcome.

Thus, the aim of this study was to analyze how women, who have recovered from AN, perceive and describe their current eating practices, as well as the ones prevailed during the ED.

 

METHODS

This research was a qualitative inquiry. It was held in the city of São Paulo (Brazil) and involved seven women who recovered from AN. The inclusion criteria were: a) to be female; b) to state to have recovered from AN; c) not to be engaged in any treatment for AN, and; d) to agree to enroll in the study.

Regardless of the treatment received (or not) during the AN period, all subjects reported that the initial diagnosis was made by a psychiatrist at the time. In this study, recovery was considered as the presence of normal body mass index (BMI, calculated as weight/height2, the cut-off point was BMI > 18.5 kg/m2 – data of weight and height were self-reported) and the absence of the following symptoms (self-reported and evaluated before the interviews): refusal to maintain weight within an adequate range, and the presence of purgative practices.

Information-rich cases were selected, resulting in "insights" and in depth understanding rather than empirical generalizations10. Thereby, the "snowball" and "emergent" samplings were combined.

The sampling process involved making contact with the coordination of the Network of Encouragement of Health, Body Satisfaction and Food (RISSCA), which provides information about the disease and discusses related issues. The discussions are conducted mainly by a digital platform, but also by face-to-face meetings, which are scheduled monthly. The Network provided the contact of potential participants, which were approached by e-mail or telephone. One subject interviewed had bulimia nervosa, hence was not included in the study sample. The final sample was made up of 5 participants of the network and 2 non-participant individuals that were appointed by other members (snowball sampling). To establish the total number of respondents the saturation criterion was used: when additional information no longer generates new understanding10.

Data was collected by a semi-structured interview. This type of interview is characterized by the previous development of open-ended questions, which should encompass all the content of interest and flexibility as to allow other questions to emerge from the dialogue between researcher and subject11,12. The interview aimed at collecting information that characterized the interviewees, and at raising issues that could contrast the ED period to the recovery stage13, addressing: the eating practices of the respondents, as well as changes and factors considered important to its formation; experiences and feelings related to the mealtime; the relationship between the respondents with family and friends; situations which involved food, and its influence on their lives.

The interviews, recorded and transcribed verbatim, were conducted individually by the first author of this study (MDU), who had previous experience with qualitative interviews. When approached, participants were informed of the objective of the study, but otherwise, relationship between researcher and interviewees was not established prior to interviews. They were conducted in a place selected by the participants and lasted from 50 to 90 minutes.

From the transcribed material, the questions that best met the objectives of the study were selected to compose the final analysis. For data treatment, the Collective Subject Discourse (CSD) technique was used. It consists of a synthetic speech, derived from the analysis of the material collected by the interviews13. The technique allows finding common ideas among the selected responses. These are given a summing name, called central idea (CI), which are later grouped when expressing the same meaning and coded, forming the CSD13. Seven CSD were built, and then grouped into 5 tables.

The project was approved by the Ethics Committee of the Federal University of São Paulo and by the RISSCA. All participants signed the Free and Informed Consent Term before the interview.

 

RESULTS

Box 1 shows the socio-demographic characteristics of the interviewees. Box 2 shows information regarding the anorexia nervosa period.

 

 

 

 

Tables 1 to 5 demonstrate the CI and the respective discourses obtained for each question.

 

DISCUSSION

The discourses brought up the following topics: a) control; b) concerns and feelings; c) deprivation d) beauty dictatorship; e) food competence; f) importance of food; g) food cacophony.

Control

Among the etiological aspects that make up AN, the psychological ones stand out with relevant characteristics, such as perfectionism, need for control and organization. Those can be exemplified by the intense focus on details, the establishment of rules related to food, like extreme diets and calorie counting14.

Not surprisingly, the need for control stood out in the reports regarding the ED period; nonetheless, it also appeared in the period after recovery. However, there were differences in the way this control was exerted: while during the ED control was done through the quantity of food and the calories consumed (CI 2F), after recovery the focus shifted: it turned into a need to establish a routine and a pattern related to eating practices (CI 1D).

Even though some individuals considered the mealtime as "a really calm, a pleasant moment" (CI 1A), a certain control can still be noticed in terms of quantity of food consumed (CI 1A). CI 3A also showed this control by means of concern related to the amount of fat contained in the food, which became an avoided component and source of aversion.

Control is a well-established characteristic of the AN dynamic. It gives a sense of certainty and security. It calls our attention that most of the subjects have received nutritional treatment, which is essential for AN. Nevertheless, depending on the kind of nutritional treatment, the biological aspects of the food are over emphasized, meaning that the need of control might persist and, also, that there might be a switch between the rigid, restrictive diet to a rigid, but adequate diet15.

As observed in the discourses of our study, control still plays a part on participants' life even after they have recovered, which suggests that recovery does not mean losing the impetus of control. Lee et al.16 examined the relationship between control and the intermediate term outcome of patients with AN. Individuals with a good outcome had the least negative modes of control and the least desire for control. They suggest it might be necessary to better address control aspects during treatment. Such approach could have eased our participants' willingness to establish routines and a diet, and also their discontentment when not meeting certain expectations.

Concerns and feelings

During the ED, subjects were not concerned about having a satisfactory food consumption (CI 2B). CI 2D reports their food intake during this period, reinforcing their lack of concern with food itself, since it was regarded as something to be suppressed in order to lose weight. Differently, after they have recovered, both frequency and quantity of food improved (CI 1B). A concern with food quality could also be noted (CI 3B).

The discourses above-mentioned highlighted negative feelings related to certain kinds of food and the consequences to the body. Besides, guilty also appeared in both moments studied (CI 1G and 2G). The same guilty feeling is repeated in both phases: that eating would represent irreversible consequences to the body (CI 1G).

This feeling was observed in the study of Souto and Ferro-Bucher17: it was reported that one grain of rice or one piece of candy would be enough to trigger the feeling of weight gain. Long et al.18 found an ongoing concern with food during the disease period. Furthermore, food was visualized in a fragmented way: a cake was seen by its ingredients (eggs, butter and sugar), refraining the respondent from eating it. Still in this work, the speeches showed feelings of physical discomfort, identity loss and inadequacy during the meals. Anxiety, panic, confusion and shame were also described. Apart from panic, reported in a speech just during the illness period (CI 2C), the other feelings described could also be observed among our subjects even when recovered.

Espíndola and Blay6 argue that, in the long term, the disease involves limitations and restrictions, which may influence the level of adjustment of the individuals, even when recovered. As observed in our results, participants did not show a relaxed attitude regarding food or eating. Thus, the reported concerns and feelings may trigger an eventual relapse. An alternative would be to shift the treatment focus to the use of more meaningful therapeutic tools, such as restoring patients' food culture and investing on the emotional and social functions that permeates eating. That would be important not only to empower patients' role during the treatment but also to contribute to a more effective result after recovery15.

Deprivation

Deprivation, a well-established characteristic of the disease, after recovery, slowly makes room to situations when there might be moments of exaggeration: "sometimes I think it's healthy to exaggerate" (CI 1A). During the ED, this would be unthinkable: CI 2A and CI 1C showed the restriction and exclusion of foods considered "fattening" during the ED.

Thereby, the use of light products could be considered a way of excluding "fattening" food, an artifice used by the subjects during the ED (CI 6D). CI 6A highlighted the difficulty of the subjects in stopping using light foods with specific allegations after they have recovered. The concern to maintain a lean body is also featured in this discourse, explaining its continued use. It is then possible to suppose that our respondents' desires, feelings, expectations, as well as the use of light/diet products are evidence of the restrictive practices established during the disease. Accordingly, Schebendach et al.19 found that persons recovered from AN who had a later poor outcome consumed less non-diet and other kinds of food considered "fattening", which highlights the importance of studying such behaviors. Surprisingly, literature referring to eating practices and choices made by persons who have recovered from AN is very scarce.

Beauty dictatorship

Food choices can be made based on what is considered more appropriate for the body size and its modulation. Such practices are "written" in the body, forming and shaping it in a specific way3. In this scenario, the dictatorship of beauty gains ground. It involves the need to be thin, setting aside individualities as well as biological and genetic limitations. It is assumed that those who fit the pattern are valued, and those who do not, are rejected20; also, it reinforces the idea that the body can be a source of pleasure, when consistent with the expected pattern, or a source of anxiety and shame when it does not3; accepting this fact directly influences food choices, as will be further explained.

The excessive amount of information conveyed regarding food and dieting and the fact that we live in a society which encourages hyper consumption of food creates a duality: eating can represent a banal act, and it can also lead to irreversible consequences2,3. Such situation contributes to individuals' anxiety and insecurity related to their food consumption. Consequently, movements of reaction are induced and may manifest, for example, the concerns with diet, increased interest in cooking and greater individual discipline regarding food2. These movements are easily described, especially by women; however, those who experience AN reflect an important extreme. For them, contradictions regarding body dissatisfaction and deviations on eating practices are significantly enlarged and intensified20.

Accordingly, the discourses illustrate the respondents' desire of reaching a greater discipline regarding their diet, even after they have recovered, and a greater expectation to be healthier and natural (CI 4A). Besides, their discourses show concern with a balanced and nutritionally adequate diet, as illustrated by CI 1B, 1D and 3B. It is important to point out how those concerns with healthier eating habits merge with the discourses of the beauty dictatorship; as Sudo and Luz21 assert, esthetic becomes the socio-cultural criteria to determine "being healthy".

Food competence

Studies evidence the existence of inner and outer clues which establish different responses when faced with food exposure. The first refers to hunger, satiety and appetite; the second includes food availability and social interactions22. The speeches illustrate the subjects' reaction when confronting these experiences.

Regarding the inner experience of satiety, it was observed the respondents' difficulty in realizing when they were satisfied (CI 5B, 5C and 5D). Differently, CI 5A e 5E showed a contrary statement: "I stop when I'm satisfied".

It is known that food restriction represents a shift in the homeostatic processes that moderate food and body weight23. It is well established that, in such cases, one eats higher amounts of food when available24. It is not possible to assert that the individuals ingest an amount of food higher than usual nowadays, but, a great fear of feeling hungry was observed (CI 1C).

In turn, the perception and managing of hunger are important elements that lead to a normal appetite25. From CI 2E, it was seen that, during the ED, there was a connection between pleasure and hunger feeling. During AN, hunger is experienced as a temptation to lose control: its denial becomes a symbol of triumph and purity, and its control a source of euphoria, accomplishment and pleasure3. Yet, CI 1C showed that after recovery this association was lost, making room for a negative feeling linked to hunger.

Among ordinary individuals, the outer experience of social interaction seems to promote higher food ingestion5,26, to increase the time spent at the table and to promote disinhibition27. Differently, the discourses showed that the social interaction during the mealtime was, and still is, an inciting of discomfort to the subjects: "I didn't feel pleasure staying at the table" (CI 2C). Likewise, CI 1E showed that the subjects' preference for having the meals alone remains even after they have recovered. This reinforces the need for approaching the emotional and social functions of food during treatment, and for promoting the social integration of the patients15.

Satter22 developed the eating competence model, based on food behavior and attitudes. According to the model, competent eaters are positive, confident, comfortable, and flexible when it comes to eating practices. Such attitudes allow them to be attuned to outer and inner experiences related to eating22. Inner experiences determine feelings of comfort or conflict when exposed to food; outer experiences, which include food availability and social interactions, interfere on the eating practices inherent in those experiences.

Thus, competent attitudes are based on the individual ability to trust on feelings, and to accept and be comfortable with the pleasures of food and the satiety experience22. Thereby, it is possible to state that some individuals have developed a higher degree of eating competence after recovery, but overall, that seems to be low, considering that few speeches reported a positive, comfortable and flexible attitude towards food.

Importance of food

Food is central to individuals' identity, and is, at the same time, a source of ambivalence, since food intake implies not only a risk, but also hope to become different based on what is eaten2-4.

Thus, the decision of what to eat can be entangling not only for embodying aspects as convenience and responsibility, but for representing identity conflicts4. It is a complex process that permeates social interactions; it influences health, and it is a source of pleasure, but also of anxiety and fear5.

Nunes and Vasconcelos28 observed that for patients with AN food represented torture, terror, fear and decadence. Moreover, they reported it as being a drug, an obligation, something that takes their freedom away. Long et al.18 reported their interviewees wished to escape and disappear during the mealtime.

In the present study, the discourses demonstrated a transition from an indifferent (CI 7A and 6D) or negative feeling related to food (CI 2A and 2B), into something that became a tool to live well and to accomplish future projects (CI 7C) after recovery. Conversely, it was also possible to notice that it is a phase of adjustment (CI 7B), and that food still is a source of anxiety; the need for controlling and choosing different kinds of healthy food still remains (CI 7D).

Some of these findings could also be observed by Jenkins and Ogden29: the interviewees reported ambivalent feelings during the recovering process; this was a difficult moment, which involved feelings of distress and anxiety, but also positive ones, since their self-awareness was enhanced, and they were feeling stronger, and enjoying life, as observed in the present study in the speeches after recovery.

Besides, the subjects reported that recognizing the disadvantages caused by the disease was also fundamental for their recovery. In this study, the speeches met such considerations (CI 7C), implying that when sick the subjects could not accomplish many of their projects.

A review on qualitative studies involving the treatment of AN30 found that the fear of changes, ambivalence and anxiety limited the recovering process, which was also observed in the discourses of this study (CI 7D). While in the review these feelings were related to a subjects' wish to remain thin, in the speeches of the present study they were related to the need to strictly eat healthy food, following a routine.

Lamoureux and Bottorff31 noticed that the AN was the solution found by the individuals to deal with daily challenges and demands; therefore, restriction and weight loss were the way found by the subjects to establish control and identity32,33. Among the challenges cited when in recovery, a feeling of abandonment and exposure were observed, considering that once recovered, the familiar feeling of security made room for insecurity and fear, making them feel vulnerable and susceptible to relapses.

Accordingly, CI 7E of the present study meets the challenges described. The line implies that food has no influence on the subjects' life, what may suggest that the contact with food equals vulnerability, insecurity and fear. Not listing food as a priority may be the way they found to feel safe and protected against the unknown and possible relapse. Furthermore, it may indicate a low eating competence, since their distance from food exemplifies a negative, inflexible and not comfortable attitude towards it.

Food cacophony

Currently, there is countless information about food: public health policies, nutritional prescriptions and prohibitions, medicalization and individualization of food and eating, every­thing amplified by the media. Thus, Fischler34 proposed the concept of food cacophony: the combination of those multiple discourses creating a "noise" for their understanding and, frequently, leading to contradictory data34.

Consequences of this cacophony were noticed in our discourses, mainly in the period after the ED. There was a great association between food and negative feelings when related with possible injuries to the body and expressed the respondents' wishes to establish a more natural, healthier and nutritionally adequate diet. One example refers to meat. While some subjects reported they would like to eat less meat (CI 4B), others reported they would like to eat more meat (CI 4D). The same occurs with light and diet food (Table 4), which were seen as positive by some (CI 6A), as not healthy by others (CI 6B) and as "relative" (CI 6C) and "markers" of the ED (CI 6D). In short, it was noted that there were contradictory discourses about food, especially regarding "what is necessary to eat", which is, according to Poulain35, the core of food cacophony. It stressed how dietetic rules are currently rooted in the speeches above-mentioned. Apparently, subjects experience a duality between a remaining AN voice, which urges them to restrict their food intake, and a remaining treatment voice, which requires them to balance and adequate their food intake.

Some of the study limitations comprise the small sample size and the fact that the majority of the respondents had participated of the RISSCA. Nevertheless, the sample size fulfilled the saturation criteria, a crucial aspect of qualitative inquiries. It was also a varied sample, stressed by respondents' age amplitude, diversity of treatments received, duration of the disease and years of remission. That also reinforces the idea that, although the majority was part of RISSCA, they were a heterogenic group. The "snowball chain" methodology is sometimes criticized by some authors; however, it is appropriate when the target population is rare, interconnected and hard to be approached directly, as is the case of those who experienced the AN36.

 

CONCLUSION

This study analyzed how women recovered from AN, perceive and report their current eating practices, as well as their eating practices during the ED.

An important result is the diversity of eating practices after the recovery. While during the ED these practices were similar, marked by dietary restriction, after the ED they became diversified; some participants seem to have developed a higher eating competence, others still present similar practices to the ones developed during the AN, marked by control and restriction, even though not as intense as before. Furthermore, interviewees reported difficulty in noticing when satisfied, and social interaction still is something bothersome, meaning shame and discomfort.

While aspects regarding consumption need to be taken into account during the AN treatment, strategies that access eating practices aspects should be addressed as well. In the present study, some participants seem to have unchanged perceptions or a perception extremely supported by a biological and normative perspective. Understanding their eating practices could be important to empower treatment outcome and also understand and predict relapses.

Thereby, perceptions regarding eating practices could be addressed by professionals during their patients' treatment. Further studies could develop strategies to help increase food competence throughout the treatment and analyze aspects regarding the mealtime considered important by patients.

 

INDIVIDUAL CONTRIBUTIONS

Mariana Dimitrov Ulian – Collected the data and conceived the study, analyzed the findings and wrote the article.

Fernanda Baeza Scagliusi – Conceived the study, analyzed the findings and wrote the article.

All authors read, reviewed and approved the final version.

 

CONFLICTS OF INTEREST

There were no conflicts of interests.

 

ACKNOWLEDGMENTS

The authors acknowledge the participants for putting their trust on our work, the RISSCA (and specially its coordinator Natália Bonfim) for helping in the subjects' recruitment and the colleagues Roberto Manoel dos Santos and Marilia Zanella for helping in the text review and in the translation review, respectively. We also acknowledge the funding conceived by the Fundo de Auxílio aos Docentes e Alunos da Universidade Federal de São Paulo (FADA) and by the REUNI program.

 

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Correspondence address to:
Mariana Dimitrov Ulian
Universidade Federal de São Paulo, Campus Baixada Santista
Av. Ana Costa, 95
Telephone: (13) 3878-3700
11060-001 – Santos, SP, Brazil
E-mail: mari_dimi@hotmail.com

Received in 5/22/2013
Approved in 11/23/2013

 

 

* Eating practices were conceptualized as a set of objective and subjective data that enable description and understanding of the eating phenomena. Thus, eating practices could be defined as the way individuals relate to food in different spheres9.

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