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University Rovira i Virgili

Learning to Eat

Mabel Gracia Arnaiz

ESTABLISHING DIETETIC NORMALITY IN THE

TREATMENT OF EATING DISORDERS

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ABSTRACT

: :This article argues that the biomedical logic behind the treatment of eating disorders

attempts to substitute many of the economic, adaptative and symbolic reasons that have

historically and ethnographically conditioned eating habits in all cultures for exclusively

dietetic reasons.Thus, when nutritional rehabilitation is used as a therapeutic tool,

rather than restoring food culture (i.e. the set of food representations and practices

learned and shared by the members of a particular social group), it involves an

enculturation in dietetic normalization largely devoid of the sociocultural functions

attributed to food. Because of their normative parallelism with the following of any diet

(e.g. the use of highly-specific competencies, mechanisms and protocols), these

prescriptions hinder not only the therapeutic success of the treatment but also the

social integration of the people undergoing treatment due to the partial interruption

and routinization of daily life that they involve.

Keywords: eating disorders, culture, gender, food socialization, dietetic normalization

Introduction: :

As discussed in the medical literature, eating disorders are characterized bythe coexistence of social, psychological and biological factors. Principallyaffecting young women in Western societies, eating disorders have beenvariously attributed to genetic predisposition, family conflict, a lack ofpersonal autonomy or, often, a natural inclination to following slimmingdiets. Although the list of possible causes for anorexia nervosa is extensive,clinicians understand that restrictive dietary practices result from a desirenot to put on weight and consequently treat the mental imbalances whichlead to these practices. They agree that the psychological and physicalaspects should be treated with a combination of nutritional rehabilitation,weight gain and long-term psychotherapy. However, very few proposals aremade to address the sociocultural aspects. Indeed, when clinicians reducethe causes explaining the triumph of thinness and accept that, socially, littleor nothing can be done about it, they instead treat patients according to theirindividual circumstances and symptoms, rather than considering otherpossible reasons why people stop eating.The recovery figures for anorexia nervosa are not very encouraging and

although the reasons may be manifold, the present article will look at whatwe consider to be one of these reasons. The article takes into account theextent to which the neglect of cultural factors in areas such as diet isinfluencing the relative success of therapeutics. Emphasizing the nutritional

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functions of food, as is often done, at the expense of its relational functionsgenerates at least two problems. The first problem consists of avoiding thingslearnt from the restrictive practices which, instead of being seen asconsequences of wider social processes (e.g. the medicalization andcommercial exploitation of health), are seen as inappropriate individualdecisions. The second problem consists of applying a nutritional educationprogram based on the so-called balanced diet, during and after the therapy,which imposes control and a routine on daily life which are difficult tofollow. This difficulty increases when the patients leave the care centers andhave to face various social pressures.This ethnographic research approaches the problem of eating disorders

from a position outside healthcare intervention, separate from the interestsand opinions of the professionals involved. Critical distance is important inmanaging a qualitative toolkit, and is reinforced with comparativemethodologies which observe people affected by the different afflictionswithin the sphere of eating disorders; professional and healthcareinstitutions from the public and private sector; the perspectives ofpsychiatrists, clinical psychologists, social workers, nurses and managers;and the data from clinical and socio-sanitary research.1

Regulating Food, Normalizing Weight: :

Because of improved access to and greater abundance of food, nutritionalrecommendations in industrialized countries have over the last four decadeschanged from “eat more” to “eat less” (Nestlé 2002: 38). The fear of nothaving enough food has receded and has been replaced by concern abouthow to restrict food. The relationship, established in the 1950s, between theconsumption of certain foods (animal fats and simple sugars) and theincrease in morbidity and mortality due to non-transmissible chronicillnesses such as hypertension, diabetes, heart attacks and cancer, hasopened the doors to hygiene/sanitary campaigns against “bad” food andexcess weight. Normal weight standards have been fixed, and health expertsconsider obesity to be symptomatic of industrialized society’s failure tofunction properly (Gard and Wright 2005: 2) because it is the victim ofabundance and disorganized lifestyles. These unhealthy lifestyles are alsocited as a reason for the increase in eating disorders. According to Zimarrón(2003: 161): “the causes seem to be bad social habits … and hectic lifestyleswith little time to go and eat at home.” The need to restructure theselifestyles is thus considered urgent.According to Ascher (2005: 174), there is a three-pronged argument

underlying this sanitary and productive system: if you are healthy, you havea better quality of life, you work more efficiently and you cost society less.

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Any behavior which deviates in style or content from established standardsmay be interpreted as abnormal, not only because it disrupts dietary andweight rules, but also because it is a risky behavior that must be regulatedby health policies based upon prevention. Following this logic, medicalizingdiet helps to establish “dietetic normality” in people’s behavior. Thisnormality has gradually taken shape, particularly in those contexts in whichfood is relatively abundant, around the concept of the “optimum diet.” Thisis a dietary pattern based on restricting and/or promoting the consumptionof certain foods and nutrients (that is, what and how much to eat) and whichprescribes a set of guidelines about how, when and with whom to eat, withthe aim of minimizing the risk of contracting avoidable illnesses.The medicalization of food is based on a set of collective dietary rules and

regulations that act simultaneously on the need to acquire real dietarycompetence, on one’s responsibility to look after oneself, and on the feelingof guilt for not doing so (Ascher 2005: 173). In numerous public healthcampaigns there are moral recriminations related to dietary behavior whichmake people feel they lack judgment or competence: “when we are unhappywe compensate by eating or drinking despite the fact that we may not behungry and contrary to our own reasoning and health” (NAOS 2005: 12).Regarding the dietary behavior of the majority of the population asproblematic means that medical advice becomes a lifelong guide tomodifying and regulating this behavior and turns nutritional education intoa mainstay of the healthy lifestyle.In Spain, the model for promoting health proposes that to change the

incorrect habits and eliminate the frequent irrational impulses that guidefood preferences, it is both necessary and a priority to provide the populationwith scientific information and expand their dietary education: “The family,as the principle transmitter of messages, should have a basic knowledge ofwhat constitutes a healthy diet which in turn allows it to create varied andbalanced meals” (NAOS 2005: 21). All dietary guides point in the samedirection. If it is accepted that dietary habits “begin around three or fouryears of age, are established by the age of eleven and consolidatedthroughout the individual’s life” (NAOS 2005: 12), the act of exercisingcontrol over food is legitimized at a younger age and begins with the firstmeal of the day, breakfast. Thus, “Breakfast should be eaten at home, in noless than 15 minutes, in company, eating fruits, cereals and homemadepastries” (SENC 2004: 92).However rational this model may be, to what extent is it being effective?

It is constantly surprising that obesity and eating disorders should haveincreased at the same time that the health authorities have made an effortin schools, the media and health centers to teach people how to lead ahealthy life. Furthermore, it is surprising that this increase should happenwhen people are able to demonstrate that they know what they should and

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should not be doing (Contreras and Gracia 2006: 82). This model, however,contains two contradictions, one which is external in nature and anotherwhich is internal. On the one hand, current medical and political rulesdesigned to favor normal weight and optimum diets seem to be able to dolittle in the face of the economic performance of therapies for treatingobesity and the buoyant personal care market. This market has broughtabout profound cultural changes and is a driving force behind numerousbusinesses (food, fashion, pharmaceutical), which, to promote their goods,do not hesitate to use rhetoric regarding wellbeing and thinness as signs ofhealth and distinction (Gracia and Comelles 2007: 15). “Being on a diet” hasto form part of our lives and is imposed, above all, on women, as a rationalact for those who take care of themselves. Following a balanced diet meanswillpower and competence; not following one means carelessness andnegligence.On the other hand, nutritional recommendations are based on a fairly

inflexible dietary pattern, as applying them not only affects behavior duringmeals, “we insist on at least 4 or 5 meals a day, not too slowly, not too quickly,in the company of others, a balanced diet” (CP3-D), but also throughout theday. The times, number and structure of meals, eating companions,manners, and even where we should and should not eat, demand a dailyroutine which is difficult to carry out. Although health is an important factorin the decisions made regarding food intake, it is only one of many of thevarious circumstances that condition everyday eating. People’s lives areirregular. To change diet it is necessary to modify living conditions, which isalways difficult and often impossible.

Losing Weight, Gaining Weight, Getting Ill: The Emergence ofEating Disorders: :

Dietetic and bodily normality have coincided with the increase in clinicaldefinitions of eating pathologies.2 Eating disorders have been described asan epidemic3 that became increasingly prevalent through the twentiethcentury. This coincided with medical and social value being given to the thinbody—especially in women—and with the problematization of therelationship between food, health and gender.The way illnesses are characterized cannot be separated from either the

social settings in which certain phenomena turn into a problem (Hepworth1999) or the medical assumptions regarding which social aspect (when thisis recognized) has influenced the emergence of an illness. In the case ofeating disorders, the social aspect is gender. The context is one thatconsiders which behaviors are appropriate, deviant or pathological, so thatsimilar attitudes towards food, be they fasting, binging, purging or vomiting,


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do not always have the same ends or acquire the same meanings. Thesemeanings depend on how and when the behaviors manifest themselves, oron who instigates them. For this reason, during the Middle Ages, thosewomen who fasted for religious reasons received social recognition (Bell1985).The first systematic descriptions of anorexia nervosa or hysteria by Gull

(1873) in Great Britain and Lasègue (1878) in France alluded to a specialfeminine sensitivity (Knibielher 1983). These doctors tried unsuccessfully tofind the organic causes of these afflictions. Thus they moved their attentionto the psyche, attributing the afflictions’ origins to the mental state of thepatient. By placing anorexia in the discourse on women, they were able topresent it as a mental perversion in young women who, after all, wereirrational and emotionally unstable. Disturbances in marital, sexual andemotional life caused this species of “madness” to manifest itself in noteating. During the nineteenth and twentieth centuries, first anorexia andthen bulimia became mental illnesses and those fasting or gorgingthemselves were regarded as sick. This came about because of theintellectual framework and the increasingly specialized nosological exertionsof Western medicine at the time.4

A century after Gull and Lasègue introduced the term anorexia nervosa,modern psychiatry, influenced by scientific debate, included cultural,psychological and biological factors in the etiology of eating disorders. Theexplanation as to the greater prevalence of eating disorders in womencontinues to be closely related to a particular and limited vision of theinfluence of society. Eating disorders are thus based on the obsessive desireto be thin, resulting from the pressures exerted on women by consumersociety. The latest versions of the Diagnostic and Statistical Manual ofMental Disorders (DSM-IV-TR) and the International Classification ofDiseases (ICD-10) describe anorexia nervosa as a mental disordercharacterized by a significant and usually voluntary loss of weight (more than15 percent), by amenorrhea in women and by an intense fear of putting onweight.Despite this perception of anorexia nervosa being the most common in

psychiatry, the debate on how to treat it continues because of its recognizedtherapeutic, diagnostic and etiopathogenic difficulties (Chinchilla 2003: 1).If the medical theories have made anything clear, it is that we are facingailments that are highly malleable, and that their signs and symptoms varyunder changing social circumstances. The fact that these practices can beseen in different contexts and to different degrees is a serious argument forconsidering them as a continuum, rather than as separate and isolatedproblems (Apfeldorfer 1994).The explanatory models include eight hypotheses divided into three

groups, depending on whom and on what they focus: the individual, the


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family or the social context (DiNicola 1990). The first group of hypothesesconstructs eating disorders as a personal dysfunction and focuses therapy atthe individual level. In this case, the subject stops eating or eatscompulsively because something is not functioning in the organism due tobodily changes related to puberty or due to the negative influence of thesubject’s immediate surroundings. The second group widens the etiology,situating the illness in the family environment, which can often bedysfunctional, conflictive, overprotective or neglectful. Here, extremedietary practices show problems existing between people who are close toone another. Finally, the third hypothesis group, focusing on the socialcontext, suggests that eating disorders increase as women feel pressure fromboth a society that demands that they are artificially thin and from thecontradictions which derive from their supposed emancipation. In this case,restrictive diets are followed in order to achieve a certain idea of femininity.These ideas were expressed by the first sociological feminist critiques,

which in turn influenced the explanations and therapeutic approaches ofpsychiatrists and psychoanalysts such as Selvini (1974) and Bruch (1978).Since the 1970s, feminist ideas have evolved within critical social theory(Orbach 1986; Wolf 1991). Bordo (1993) goes further than psychoanalyticalexplanations based on the link between mother and daughter andintergenerational problems of identity (Chernin 1985), and explores thecomplex intersections present in eating disorders. She considers generalsocial attitudes such as the value placed on thinness, the role of consumersociety, social representations of women, abstinence and food, and themedicalization of food, and proposes a dialectic process to identify mutualinteractions in contrast with the dualistic causal models of biomedicine(based on the concept of normal/deviant). Bordo criticizes the medicalmodel, as its excessive concern for the bodies and diets of the non-clinicaladolescent population leads to a partial and superficial understanding of theillness:

most women in our culture, then, are “disordered” when it comes toissues of self-worth, self-entitlement, and comfort with their ownbodies; eating disorders, far from being bizarre and anomalous, areutterly continuous with a dominant part of the experience of beingfemale in this culture. (Bordo 1993: 56–7)

Chernin and Bordo challenge the view of eating disorders aspsychopathologies. They emphasize the aspects learnt and incorporatedfrom these behaviors and reclaim the roles of culture and gender as primaryfactors in their inception and evolution, forcing individual dysfunctionalcauses to be reassigned to social factors. The interaction betweensubjectivity and objectivity or between microsocial and macrosocial factorshas become the axis of recent feminist theory, highlighting the importance


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of both historical and political processes and individual experience(MacSween 1996; Hepworth 1999; Gremillion 2003). They focus on thediversity of interpretations and answers generated by people in the face ofcomplex and dynamic phenomena. Given the particular connections womenhave with food in our society as producers, nourishers, servers, consumersetc, dietary and bodily behaviors have served as a medium for expressingcomplex and contradictory emotions and relations (Gracia 1996; Allen andSachs 2007). For many women, eating or not eating can be, depending onthe experience, painful and unpleasant. For others it can be a way ofmeasuring their strengths and abilities (Van Dongen 2000) by using food andthe body to respond to material and symbolic structures that their culturerepresents at a given moment (Rubio 1999: 77).

The Role of Food in Treating Eating Disorders: :NUTRITIONAL EDUCATION AS A THERAPEUTIC TOOL

: :The majority of psychiatric manuals on eating disorders published in Spain(Fernández and Turón 2001; Chinchilla 2003) emphasize the bio-psycho-social etiology of eating disorders and support interdisciplinary andmultimodal intervention from different fields, taking into account social,affective, behavioral and cognitive factors, among others. The care team,made up of psychiatrists, psychologists, dieticians and nurses, recommendstreating four areas: the medico-psychiatric, the psychological-educational,the environmental and the familial. Although the causes of anorexia nervosaare usually established in these four areas, following a slimming diet is oftenthought to be the main precursory factor. This puts the focus of attention onthe individual’s “extreme” behavior: “It all starts with a diet … They getobsessed with losing weight” (HP1-PQ). To consider following dietsindiscriminately as the result of an “obsession” with losing weight not onlypathologizes the patient’s practices by separating their causes from political,economic and social agents (whose function is more difficult to trace andevaluate), but also makes them responsible for their own illness: “they havebrought it on themselves” (CP3-PS). For this reason, whereas hospital oroutpatient approaches are centered on the first two areas, only somesystemic approaches include the family and no approach deals with patients’environments. Thus, treatments aim to deal with individual aspects (such asmalnutrition and the psyche) by means of cognitive-behavioral therapies(both one-to-one or in groups) or psychodynamic therapies, combined withdrugs and special nutritional care (Vázquez 2003: 68).Choosing an effective psychological treatment for anorexia nervosa is

problematic given that there is insufficient empirical evidence to


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demonstrate the superiority of one treatment over another. The figures arenot encouraging: 50 percent of patients are cured, 30 percent are partiallycured and 20 percent do not respond.5 To date, nutritional rehabilitation isthe only treatment to have proven its efficacy (Saldaña 2001).The general acceptance that patients must be returned to their normal

weights has given transversal importance to nutritional therapy. Restrictingfood in an extreme way can cause serious harm to health and many of thephysical and psychological symptoms associated with anorexia nervosa arethe result of malnutrition (Toro 1996: 9). When life is at risk, the first aimof treatment is to stabilize physiological and cognitive functions. Themajority of clinicians understand that “recovering weight is one the principalaims in the initial phase of treatment, while the patient is in a state ofcachexia or is at a dangerous weight” (Fernández and Turón 2001: 88) andthat this is the first step in psychological and psychotherapeutic treatments.Achieving normal weight by recovering and maintaining the weight that hasbeen lost, has a double objective: it allows psychotherapies to be betterapplied and prevents relapses. For this reason, many clinicians consider itcrucial to include a step dealing with nutrition: “weight is paramount,normal weight levels must be achieved by making them eat well” (C2-PS).Achieving this is also important so that they can be discharged: “when theirweight is at a normal level or during menstruation, when they start eatingbetter, they are at the correct weight, they accept a normal diet naturally; wedon’t expect them to be cured” (HP3-PQ). Because the therapeutic aim isnot just about re-establishing normal weight but also maintaining it,nutritional therapy usually continues throughout the treatment, although inthe second phase it is more oriented towards “teaching the patient how toeat,” that is, towards providing teaching related to healthy nutritional anddietary patterns.However, bearing in mind that serious cases of anorexia nervosa are

fortunately in the minority in normal clinical practice (Ruiz 2002), we doubtwhether it is appropriate to apply a psychoeducational approach based onnutritional education, given the limitations of this model. These limitationsare due to the emphasis on the biological functions of food and the rigidityof the dietary pattern proposed. Oriented exclusively towards improving thestate of health, this pattern forgets that food decisions are made, eitherindividually or on a group scale, in response to the different aims of differentoccasions — pleasure, convenience, sociability, appetite, emotion and health— and they do not always use the same logic. In affirming that the principalaim of eating is to obtain nutrients and that sufferers of anorexia need to beclosely watched, nutritional education is oriented towards inculcating astrict dietary model in the patients as to what they must eat, in whatquantities, where to do it, who to do it with and how many times a day theymust do it:


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We set up training groups for eating behaviour to teach them howthey should eat, the correct posture at the table … we try to teachthem how to control the negative symptoms of the illness from boththe psychological and the educational points of view. (HP1-N)

This approach makes it difficult to effectively apply the treatment inhealthcare institutions and for patients to subsequently readapt to theirsurroundings.

LEARNING TO EAT WELL: A PROPOSAL FOR “NON-DIET MEALS”

: :The aims of introducing a dietary routine arise from the belief that patientshave destructured habits and they follow self-imposed food restrictionswhich have no rational foundation: “they have so many whims and fanciesthat some of them have not even tried some foods, and that’s why they saythey don’t like them … here they have to eat all kinds of food” (HP1-N).Nutritionists demand that they improve their dietary knowledge and changetheir erroneous dietary practices: “we teach them the abc of nutritionbecause otherwise they would believe any old nonsense” (CP2-PS). Theirhabits must include “a normal diet, ingested over a correct period of timeand accompanied by civilized habits” (Fernández and Turón 2001: 123).However, in the case of eating disorders we find a paradox when making

comparisons with other forms of deviation. The fact is that the more or lessorthodox application of an institutionalized diet—based on restriction andmoderation—is considered to be the starting point of the “deviant slide” intoanorexia (Darmon 2003: 143–6). There is an extraordinary parallel betweendiets of anorexia patients and the commitments taken on by women whenfollowing a slimming diet. In both cases they limit their intake of fats andsugars, they do not eat between meals, and they reduce the amountconsumed or the number of meals. In fact, the techniques used by manypatients (counting calories, weighing food, restricting food) have beenadopted, with greater or lesser wisdom, from the fields of dieting andnutrition:

the doctor gave me a diet limited to 1200 calories and a schedule fora month. I had to weigh everything I ate. Permitted foods werecolored in black, such as vegetables. Grilled meats and fruit, and thethings I couldn’t eat were in red. (HP1-BN-W)

Adjustments and measurements are constantly made in order to make sureweight is lost. This means that, according to Darmon (2003), we can speakof a rationalization of eating practices in terms of what to eat, when to eatand why:


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I asked my mother to buy 0% skimmed dairy products, with no sugar,no fats … That way I was eating more or less a bit of everything,compensating for any excesses, because some of these foods had nosugar or were light, or I relied on sachets. (CP1-AN-W)

The informants reveal their laborious search for both qualitative andquantitative information in books, journals and the internet:

I kept a diary and made a plan. I pinned up the BMI chart next tothe calorie chart for the foods and different diets that I had got frommagazines, friends or the doctor … I stopped doing this when Istarted my nursing training … there was much more information inmy text books. (HP2-AN-W)

The suppression of meals and foods is gradual, not drastic, and the intentionis to combine dietary convenience with esthetic considerations and,simultaneously, to take into account individual preferences: “I preferred toeat less meat and vegetables … That was no problem. The problem was noteating chocolate, which I love … so I only ate that” (HP3-AN-M). Thus, itis through a rational attitude towards diet that dietary practices move awayfrom the original medical prescriptions and are interpreted according toother criteria.Nutritional rehabilitation is seen by doctors, psychologists and

nutritionists as being fundamental to ensuring that patients recover from theillness not just physically and psychologically, but also socially (Zamarrón2003: 170–1): “The diet must be followed to the letter … over months ifnecessary. The diet makes them feel secure, provides order in their lives andhelps them to combat the obsessive fear of getting fat.” To do this, variousactivities are used to assess the patients’ information and beliefs aboutnutrition. A training program is used which establishes and maintains abalanced diet and gives information about the types of ideal diet and therequired daily amounts: “set point theory and the risks of dieting areexplained” (CP3-PS).What is surprising, however, is that health professionals who define

patients diagnosed with anorexia nervosa by their “obsession with dieting,”use the same strategy, dieting, to treat the illness. The paradox lies in thatthe patients’ exaggerated predisposition towards dieting (non-optimum)should find its solution precisely in putting them on another diet (optimum).From the therapeutic point of view, it is less a question of stigmatizing thediet itself than of rejecting those facets which, by their content or form,deviate from the biomedical nutritional model. This model is the only onecapable of rationally establishing who is dieting or not:

a non-diet meal is a meal which a neutral observer would concludeis not part of a diet or designed to save calories … This food must


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be varied and be in sufficient amounts … [Someone who doesn’tdiet] eats according to their biological needs, more than according tohow much they want to weigh. They start to eat when they feelhungry and stop when they feel full. (Fernández and Turón 1998:281)

According to this model, in order to be able to eat “non-diet meals,” one hasto learn to eat in an almost mechanical manner. This can be seen in materialused in psycho-educational group sessions. For example:

• have breakfast no later than one hour after getting up;

• do not let more than 3–4 hours pass between breakfast and lunch;

• have a light snack between lunch and dinner;

• do not have dinner too late (between 8.00 p.m. and 9.00 p.m.);

• eat according to a predetermined plan (first course, second course anddessert) and not whether or not one feels more or less hungry;

• do not skip meals.

It can be seen that the educative proposal to restore “food normality” in usersis limited to reordering their habits regarding eating times and the numberof intakes while also turning the act of feeding in into one which holds littleattraction. It is not surprising, therefore, that of all the activities proposed,nutritional education sessions are the least valued.These programs are based on two beliefs that need to be revised. On the

one hand, the sessions offer “didactic information about lesser knownaspects of the illness … including dietary information” (HP2-PS), when thisis not always necessary. Although there are people who, effectively, need torevise their dietary knowledge, the majority of patients are already aware ofthe basic recommendations: “this is our daily bread … I’ve been listening tothe same story for fifteen years; so many carbohydrates, so many mineralsand so many vitamins” (CP2-BN-W); “these are the most boring sessions outof all of them, and all of us just switch off. I feel bad because the therapistis making an effort but I already know everything she is telling us” (HP1-AN-W). For this reason, urgent reconsideration is required of both the contentsof these sessions and the way they are given.On the other hand, by prioritizing nutritional education, the sessions

eliminate both the opportunity to work on the emotional and socialfunctions which accompany the act of eating and the chance to use these astherapeutic tools. Furthermore, when healthcare professionals resort to thenotion of pleasure and personal satisfaction, they do so in a reductionistmanner: “you have to eat well to be healthy and feel happy with yourself forhaving managed to resist what you like best” (HP1-N). It seems fairly


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unpedagogical to promote the optimum diet using ideas of renunciation,sacrifice or self-control which ignore the related functions of food.

Eating within the Healthcare Network: :MEALTIMES: WHEN FOOD IS ALMOST EVERYTHING

: :In the majority of day centers, the dining room is a singular andmultifunctional area. While mealtimes are principally aimed at feedingpatients, they also end up achieving other objectives. They help instillnutritional education, teach manners, sanction behavior and establish socialrelations. Just as in non-healthcare environments, dining rooms become asocial space where patients, despite the rules, share experiences and expressemotions.There is a therapeutic contract between the center and users, which

obliges users to meet a series of conditions in order to guarantee apermanent place. Patients agree voluntarily, in theory at least, and mustpromise to eat. In particular, these conditions include the rules that must beobserved during mealtimes, which are usually displayed in visible locations,either in the dining room or in adjacent corridors. These are guidelines relateto the duration, order and quantity of meals, attitudes at the table andtowards food, and even subjects of conversation. For example:

• you must eat food in a particular order;

• you have a limited amount of time to prepare meals;

• chew your food properly;

• finish all the food on your plate;

• drink the recommended amount of water;

• do not talk about food;

• do not talk about sizes or weight;

• remain active at the table, do not become engrossed in looking at yourplate;

• do not compare dishes;

• do not tamper with the food, mixing liquid and solid foods;

• maintain the correct posture in the chair (back straight, legs uncrossed).

Although the table rules are similar in all centers, the way they are followedvaries from center to center. In the healthcare network, the role that food


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plays also varies according to the therapeutic models. In hospital units wherea cognitive-behavioral and multimodal approach prevails, nutritionalrehabilitation is a priority. Healthcare personnel, even though they say theytry to avoid it, closely monitor the food behavior of users, their daily weightand possible vomiting or binging. The aim is to know whether their behavioris being modified in the right direction:

I do not supervise. I establish limits because someone has toestablish them in order to organise the lives of these girls … I do notconsider myself a supervisor, I provide overall care to the patients, soI check everything they do. It is part of the nursing function. (HP1-N)

The integral care from the nurses directly involves inculcating dietary rules:

Did you notice that during the meals I took advantage of some oftheir questions to teach them about the different food groups anddifferent nutrients? … I advised them to eat all sorts of food … Theydon’t like some of the foods, but while they are here they must eateverything, even if they don’t like it. (HP2-N)

Often, the conversation centers on the nutritional content of foods and thequantities which they should eat:

N: Water is not compulsory and you can drink up to two glasseswith each meal … So Magda, what is the nutritionalcomposition of the set meal?

U4: I have food from the vegetable group (lettuce and tomato),proteins (tuna), starch (the rice) and fruit (the peach)

N: Do you all agree?All: Yes! [unanimous response]N: Very good, Magda.

Preventing patients from not eating or eating too much is one of the mainaims. This can be seen in the importance given to the number of daily mealsand in the establishment of a rigid three-course structure for the mealsconsisting of a first course, a second course and dessert. It can also be seenin the establishment of fixed mealtimes and in the obligation to eat at thetable with other diners. The patients play a passive role, as they are notallowed to participate in planning the weekly menu, or in preparing thedishes or choosing the set meal: “this is like a hotel, everything is done foryou, but with the difference that you cannot choose and you have to eat itwhether you like it or not” (C1-AN/BN- M). Although there is some varietyin the food offered according to the complaint diagnosed and the therapeuticobjectives—weight gain or weight loss—there is no flexibility. Wheneverusers are allowed to choose from two products, they are always foods within


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the same group. If users refuse to eat any of the dishes offered or only eatpart of them, they will be given a dietary supplement.The diversity of the menus usually follows two criteria. In special cases, in

other words, when users cannot eat a certain food owing to health problems(allergies, intolerance, etc), the foods are substituted with others withsimilar nutritional characteristics. Set menus recommended by thenutritionist may also vary in content (but not in form) when users celebratebirthdays. In general, dishes are rotated every four or five weeks. Althoughfrom a healthcare and therapeutic perspective it is necessary to establishmenu planning without taking the preferences of users into account, thelatter are critical of the meals system, considering it too rigid andunappealing:

the dining room smells of non-specific food. They asked me what mytaboo foods were to find out what types of obsession we have withfood. I told them that vegetable purée makes me feel sick and thefirst day there was purée on my plate” (HP2- EDNOS-W).

Only one of the centers gives the patients broad dietary training, in otherwords, the others only provide basic dietary information. They do not dealwith the processes prior to or concomitant with the act of eating, such as,for example, choosing how, where and what to buy, preparing food, adaptingto the constraints of everyday life, etc. Neither do they analyze the possibledifficulties in these areas. Healthcare personnel acknowledge that the skillsand abilities of users vary considerably. Some users, in spite of being young,cook very well, but on other occasions, the exact opposite may occur. In anycase, these care centers do not have adequate space to teach such skills, asthey are not regarded as a priority in the therapeutic objectives (HP2-N&D):

N: One of the activities that remains pending is teachingthem how to cook, but we don’t have a place to do thisat the moment.

D: Many of them don’t have a clue about quantities,what to cook…

Researcher: In general they don’t cook anything?D: Some do…N: …Some of them make exquisite dishesD: The thing is these people are never hungry…D: Yes. The thing is they don’t eat them, but cook them

for everyone else…N: It’s a way of concealing that you are not eating.


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STAYING ON A DIET

: :Health officials assume that patients are dietetically incompetent, and sothey call on families to help share the responsibility of the “new” dietarysocialization and to offer proposals to promote healthy habits at home:

As this is an out-patients hospital, we also give them a guideexplaining what they have to do at home and during the weekend.Then there are cases in which they ask us for menus to provide themwith recipes for the weekend. (HP2-N)

It is often thought that the de-structuring of users’ eating habits originates inthe home. This is because disorder is a habitual characteristic of thedomestic environment or because insufficient attention is paid to children’snutrition: “their behaviour had probably already been altered before theonset of the illness, and even the dietary behaviour of a large part of societyhas also probably changed” (Correas, Quintero and Chinchilla 2003: 293).Therefore, some health professionals call for a degree of family co-responsibility:

It is the responsibility of parents to prepare meals and to ensure thatthey (the children) eat what they should. But the moment thechildren sit at the table the arguments begin and in the majority ofcases, not to say all, the family ends up giving in to the whims andfancies of the child. (HP1-N)

The dietary guidelines that users have to follow in their domesticenvironment are very similar to those applied in the clinics: “the lunch anddinner menus must always consist of a first course, a second course and adessert in normal quantities” (C1-PS). If possible, the members of thefamily are all advised to eat the same: “when they gave us the menus, thenurse said that, if we wanted, to make things easier, we could also followthem, as they were healthy maintenance diets, designed neither for gainingnor losing weight” (HP1-P). However, although they usually follow theinstructions, the strict application of these rules often makes patients feeluncomfortable not only because they have to continue with the hospitalroutine “diet in the hospital, diet at home” (HP1-AN-W), but also becausethe changes directly affect their families: “So that I didn’t feel ‘different,’ inthe evenings we all ate the same, even my poor brother, who was in no wayto blame for the situation, whether they liked it or not. It was sheer misery”(HP3-AN-W).The most recommended patterns of what, how much and how to eat

rarely coincide with the general behavior of the population at large. Theyalso make it difficult to adapt to the different social contexts in which eatingbecomes meaningful. Evidence of this is the almost inexistent flexibility


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inherent in medical prescriptions, even on public holidays, when a certaintype of meal—copious and lengthy—acquires a distinctly social significance:

On Christmas Day and Boxing Day, if lunch has been copious, theevening meal should be a bit lighter, but should always comprise afirst and a second course and a dessert … On New Year’s Eve, thegrapes6 eaten to symbolise the farewell to the old year don’t replacethe dessert. So the meal will include a dessert and the grapes willcome later. (C3-PS)

What benefits do these obligations bring to the patients, and whatpsychological and nutritional dangers are there in not observing them? InSpain, the structuring of the evening meal into three courses occurs less andless, so what sense is there in maintaining this practice after a sumptuousmain meal?After the patient has been discharged, these difficulties increase for two

principal reasons. The first is that while they were in care they were mere“consumers of food.” The users’ contract only obliged them to eat, withoutproviding them with the tools to carry on with “good” dietary practices:

when they did everything for you, from breakfast, tea and supper, ifyou wanted, it was much easier. It is hard enough having to be awarethat you must put the food on your plate into your body, withoutbeing told “now go home and make it yourself…” (CP2-AN-W).

The second reason is that the prescribed guidelines do not take real life intoaccount: “I work shifts in a factory; yes, I know how to cook, but combiningmy hours with eating three dishes five times a day, without missing ameal…” (HP1-EDNOS-W). Neither do these guidelines fit in with therhythms of family life:

at home, we all have different working hours. My mother leaveseveryone’s food prepared for them and opts for a single dish, becauseshe is rushed off her feet and it’s the easiest way … When I comehome from school at midday I’ve got half an hour to have dinner andso just eat what I find in the fridge. (HP3-AN-W)

It is hardly surprising that after they have been discharged, patients end updoing what everyone else does, that is, organizing their meals according totheir daily needs, and not the other way round. Unfortunately, in the case ofrelapses, not following the prescriptions is interpreted as “voluntarily”abandoning the treatment and not as inadequacy or failure on the part of thetherapy.


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MEALTIMES: WHEN FOOD IS NOT EVERYTHING

: :The emphasis on bilateral and trilateral negotiation depends on thetherapeutic orientation and the role played by the family in the appearanceand maintenance of eating disorders: “it is a question of reaching agreements… They hold family meetings with them and with the parents or brothersand sisters or boyfriends or husbands. They make proposals, and so do we”(HP2-N). The same happens with food. The center with a systemicapproach believes that food behavior is an expression of the users’ discomfortin their immediate environment, and that this is where attention should bedirected. Hence they consider it essential that the people closest to thepatient are committed to the psychological and nutritional therapy. Theyassure us that the girls are not supervised, even though subtle monitoring iscarried out, diluted in the close relationships that are developed:

we do not get on top of them, I do not act like a police officer, in otherwords I’m not going to rack my brains wondering if they are hidingfood. There is supervision, but it is not my primary role. (HP2-N)

At mealtimes, in the dining room of this center there are usually two, andsometimes three nurses, while there are only seven or eight diners.Whenever a patient has a problem with the set meal, they try to resolve thisby reminding the patient that prior agreements exist and have to be observedand that one of the activities of the unit is to provide emotional support thatavoids authoritarian attitudes during mealtimes. Nurses reproach thepatients with glances and find that nonverbal communication is a highlyefficient tool: “We have managed to create a close environment … we haveestablished that when they have an issue, they get up and come and speakto us separately” (HP2-N).This is the center that personalizes the set meals the most, by gradually

introducing foods that users consider taboo. Each patient has a file that listsher nutritional aversions and preferences, so that the nutritionist knowswhat to include or leave out in each case when preparing the meals. It is themost participatory scheme: “these rules have been established with themover time, taking their requests into account, if someone has a specificdifficulty” (HP2-N). These more flexible practices, which according tonurses make the patients feel “more human,” reflect a certain way ofunderstanding this affliction and the diversity of patients: “the treatment isindividual … and they have different trays adapted to their preferences andrequirements. Such individual attention creates many problems, but thereare advantages: they feel like they are being treated like people and takennotice of…” (HP2-D).Such greater flexibility does not mean that the ultimate objective is not to

achieve a normal diet:


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I don’t start working with them on all of this at once; instead wecollect all the information and reach an agreement on the diet, whatthey will and will not eat and the quantity. Afterwards we startintroducing new things. Sometimes things they have never eatenbefore. (HP2-N)

In spite of this increased adaptation to the preferences of users, thenutritionist at the center establishes certain clear limits with regard tomealtimes and contents:

The only thing we respect is something they really do not like at allor if somebody is following a vegetarian diet …At first you give themhalf a portion. We do this for a few days, and then full portions thefollowing week. (HP2-D)

Mealtimes are also valued differently at the other healthcare service thatcombines psychoanalytical and systemic guidance: “Issues related to foodhave to be treated with total normality” (CP1-PS). Only when the users areat risk of death, does food become the most important objective:

if a patient refuses to eat then she must be made to, especially if herweight is putting her at risk, but if this is not the case, the mostimportant thing is to treat her personality problems using individualpsychotherapy. (CP1-PQ)

This clinic believes there is no need to place emphasis on food behavior,given that it is only a vehicle for expressing problems of the unconscious.This private center, which operates as a day center, offers four meals a dayincluding, unlike the majority of centers observed, dinner. Despite having amore extensive nutritional offer and timetable, it

does not have its own kitchen and the food is supplied by a cateringcompany. Dining room staff are responsible for serving food andcleaning the dining room… The catering company has a nutritionistwho writes the menus. The nutritionist takes certain foods intoaccount which, owing to intolerance or allergy, certain patientscannot eat, this being the only reason they are substituted for others.Exceptions are only made on major feasts, such as San Juan orChristmas. (CP1-PS)

The lack of importance placed on food within the therapeutic facility meansthat less stringent dining room regulations are applied and there is somefreedom regarding mealtimes, leaving larger quantities of food and choosingwho to dine with. But, as in the other centers, there is no flexibility regardingthe form and content of the meals: “they cannot choose dishes and there isa first and a second course and dessert” (CP1-AN-M).


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This clinic encourages patients to look after one another in repressing orproviding incentives for normalized behavior at mealtimes: “it is not ourproblem. They have their leaders, and our job is to serve and collect” (CP1-Cook). It is believed, furthermore, that medical staff should not be present:

There is no supervision. At each table there is a monitor and thisperson makes sure that her colleagues do not stop eating. The girlshave their own record of meals, which is checked with the kitchenrecord. The groups are self-regulating by means of the supervisionthey exercise over their fellow colleagues … The new arrivals are themost problematic with the food, which they do not want to eat, andhide … They improve quickly and these are isolated incidents.(CP1-PS)

The emphasis on self-regulation among users is even more evident in the so-called therapeutic apartments. This health service, privately run andexpensive, has been created recently as a complementary alternative toexisting services. The objective is for patients to continue to havepsychotherapeutic support once they have been discharged from thehospital or day center and have to face up to the demands of everyday life.Users are attended by psychologists who go to the apartment at certain timesof the day. They also act as social educators and even nutritionists:

The apartments are like an intermediate step. They are aimed atusers with unstructured families or a high risk of developing achronic condition … so they can establish themselves.Rehabilitation in dietary habits, autonomy, hygiene … we try tonormalise at all levels here, both nutritionally and socially. (CP2-PS)

In this therapeutic area, they work on food education in the broader sense,in other words, they relate the culinary knowledge and skills of users tosocial constraints. The choice of set meals, where to buy food, thepreparation of the food are issues that the occupants of the same flat dealwith collectively:

one day a week they get together and have a meeting. They write aweekly menu with the psychologist. They also share out the tasks,whose turn it is to cook and wash the dishes each day. They make ashopping list and go round supermarkets or food shops and do theshopping. They contribute some money every week. We try to getthem to observe the times for lunch and dinner. If they are able tofind a job that allows them to come home for lunch, even better.When they are at a more advanced stage, obviously we want them todo the opposite. If it is necessary to eat at work, they will now beready to do this. This is precisely what we want to encourage, for


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them to go out, meet people, become independent on all levels.(CP2-PS)

The ultimate aim of this facility is for patients to be able to re-enter societyin family, work and educational environments. The aim is for these people toacquire, in cases where they do not possess them or do not apply them,adequate nutrition skills—and not just food skills—in order to adapt these,as applicable, to the dynamic social context in which they have to live theirlives. The psychosocial complexity that surrounds food and eaters must beas the starting point for giving what should be a broad education, taking intoaccount any possible restrictions that affect food consumption, includingfinancial ones. A user explains that of all the therapeutic proposals she hastried, this is the best, since it is the one which is closest to “real life:”

We cook properly here, but not special treats … you learn how toeconomise and that’s useful. I think it’s the best project because it isreal, you are participating in life, it hurts, but you know … this is adifferent option, where they also listen to you. (CP2-AN-W).

The pedagogical content of this last method differs substantially from thepsychoeducational programs proposed in the majority of the centersstudied. It is true that this method means lengthening the patients’institutional dependence and increasing the cost of treating them, and itcannot be said that it is more effective than other techniques because,among other reasons, the way it currently works is as a complementarytreatment rather than as an alternative. Furthermore, the majority ofanorexic people have undergone a variety of treatments and the diversity ofthe criteria used to define and evaluate their recovery is extraordinary.However, it is useful to show the holistic character with which it “thinks”about the patients and their relation with food and incorporate this into thedifferent levels of intervention. As the woman in the last quote says, thepeople treating these women must learn to listen to them and give voice totheir experiences. Those patients who, for different reasons, have tried allsorts of different treatments provide solid arguments in favor ofreformulating the current clinical concept of nutritional rehabilitation andits therapeutic functions when, beyond normalizing physiological andcognitive functions in serious cases, it tries “to teach people how to eat.”Among other things, this reformulation in the area of food would also meana general reconsideration of the social aspects in understanding eatingdisorders.


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Conclusions: :

The models of intervention which we have seen are uneven. Patients’ dietarybehaviors may or may not be modified. When it is decided to act, it is notonly because their lives are danger but also because it is understood thatdifficulties with food express solely psychological problems and that oncethese have been resolved, extreme dietary behaviors disappear. In thesecases, centers limit themselves to feeding the users, applying to the meals amodel similar to that followed in student canteens. By following astandardized menu, the patients carry out the role of modern consumers:they eat what they like or fancy and there is no authoritarian control in theirintake other than what they exercise among themselves. Insofar asnutritional education forms no part of the therapeutic objectives, there areno psychoeducational programs and mealtimes do not become tooimportant.When it is decided to act, in the majority of centers, the objective is to

inculcate healthy habits by means of an optimum diet which is administeredalmost as if it were a medicine. In these cases, the socialization of goodpractices is partial and insufficient. The model of the “non diet-meals” isbased on biology and centers nearly all its attention on the nutritionalfunctions of food, and hardly any on its relational functions. It is,furthermore, a type of diet which is scarcely pragmatic, insofar as itpromotes a decalog of decontextualized dietary rules. Even though thenutritional instructions try to encourage a healthy lifestyle, they are badlyadapted to the social necessities that patients have outside their treatmentand this makes it difficult for the patients to follow them.Reconsidering the social aspects of eating disorders requires an effort on

the part of clinicians that goes further than modifying or readapting theemphasis currently placed on nutritional rehabilitation. This effort meanspaying attention to the effects of the medicalization and commercialexploitation of health, as well as understanding that women’s involvementwith food constructs who they are in the world in complex and contradictoryways. If these processes were recognized, other phenomena could be seenwith greater clarity and a substantive change could be justified in some areasof clinical intervention.Furthermore, we could identify the effects of the encounters and the

misunderstandings between ideology, science and market on thepopulation’s dietary practices. It is true that today the reasons for slimmingdo not correspond to the advice of health professionals and, with the help ofthe market, they are radicalized independently of such advice. However, it isalso true that public health pressures to watch one’s weight and keep itwithin normal limits through the optimum (restrictive) diet and physicalexercise have only increased while obesity has been associated with multiple


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chronic pathologies. Doctors use scientific arguments to rationalize theproduction of values related to food and health in their attempts to becomesocial engineers of what some call biopower. However, the acceptance by thepopulation of biomedical wisdom has meant that the market uses expertdiscourses in its own favor, dispensing with professionals or using them aslegitimators to deconstruct and reconstruct permanently the meaningswhich feed the production of goods and services directed at caring for thebodies of people of all ages and both sexes, especially women: the lucrativeinterests of a great many businesses and activities are involved in “being” or“going” on a diet.It should also be accepted that following restrictive diets (“eating less”) is,

now more than ever, a rationalization of the recommendations regardinghealthy lifestyles and ways of social distinction and not, as is maintained, adeviation. This would mean recognizing that there is a collective rather thanindividual responsibility in the transfer from “good” to “bad” dietarypractices. If it is true that in the case of women, social mobility is passedthrough the filter of body weight, then we must go beyond this reason tounderstand the origin of the pain and pleasure expressed through food.There is a whole series of phenomena directly affecting the process ofsocialization and personal autonomy of both sexes. These phenomena canbecome problematic and manifest themselves through dietary practices ifthe process becomes incorporated and starts to seem normal. We should notforget that these behaviors are in part transmitted to women by their peers,families or other socializing agents, nor that there is a continuum between“normal” and “deviant” behaviors. Reconsidering the different coexistingreasons for “giving up eating” would allow us to relativize, definitively, theirrational or anomalous character attributed to self-starvation and toapproach it therapeutically as an experience which is learnt and which thusacquires sense among people and concrete contexts.

Notes

: :1 This paper is based on wider research conducted in Catalonia (Spain) between 2000 and2006. The study involved three different levels of analysis: (a) a literary review of studies ofthe anthropology of food, medical anthropology and transcultural psychiatry, (b) the analysisof guidelines and manuals on nutritional recommendations and disorders in eating behavior,and (c) ethnographic work conducted in six clinics specializing in eating disorders, three ofthem state-run (HP1, HP2, HP3) and three private (CP1, CP2, CP3).The qualitativeanalytical methods employed were direct observation in the dining rooms of the clinics, in-depth interviews with health professionals and other relevant people, such as relatives,partners and friends, and the life stories of the people diagnosed with eating disorders.There were a total of fifty informants: fifteen health professionals (psychiatrists [PQ],psychologists [PS], nurses [N] and dieticians [ND]), thirty patients (twenty-four women[W] and six men [M] with bulimia [BM], anorexia [AN] and unspecified eating disorders[EDNOS]) and ten others (relatives [R], partners [P] and friends [F]).

2 This evolution can be seen in successive versions of the Diagnostic and Statistical Manual


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of Mental Disorders created by the American Psychiatric Association and frequently usedin psychiatric consultations the word over.

3 Nevertheless, longitudinal studies over fifty years show growth in minor eating disordersand stability in the more serious ones. (Ruiz 2002). In Spain it is agreed that 4–5 percentof young people are affected by some kind of eating disorder and it is accepted that 0.5–1percent of them suffer from anorexia nervosa. The male to female ratio is one male for everyten females; in both sexes those diagnosed are mainly between 15 and 19 years of age (CEC2005: 4).

4 The different categories created throughout history to classify fasting and binging aspathological behaviors are an example of the difficulties faced by medicine in identifyingsymptoms and establishing diagnostic criteria. A revision of the history of such terminologycan be found in Chinchilla (2003: 5–10).

5 Due to the different methodologies used, treatment success rates in the literature tend tovary. There is much pessimism in relation to anorexia nervosa, where successful treatmentrates have been recorded below 50 percent (Fichter, Quadflieg and Hedlund 2006; Ruffoloet al. 2006), although some studies have found improvements in 75 percent of patients(Wade et al. 2006; Sisó 2007). Similarly, in 2007, an unpublished study of patients of theURTA—a specialized EDS unit in Tarragona (Spain)—recorded a success rate close to 75percent (A. García Siso, personal communication).

6 In Spain, on New Year’s Eve the old year is seen off and the new one is welcomed by eatingtwelve grapes as the clock strikes midnight.

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