Everything in moderation: including good advice

There’s been some interesting pieces written about coronavirus recently, from Ashley Fulwood’s advice for people experiencing OCD on how not to let the news be a trigger, to Dr Jo Daniels’ piece on how to prevent anxiety about the virus from spiralling out of control.

If mental health is a spectrum, how do we give advice that doesn’t inadvertently harm people at the pointy end of it? Good advice can tip into something harmful if worries around it get out of control.

It was also Eating Disorder Awareness Week last week, and amongst the tips for how to spot an eating disorder, I recalled some research on food labels published last year.

The research, published by Professor Amanda Daley from Loughborough University and colleagues, investigated ways to increase healthy eating in the general population. The study found that packaging which outlined how much exercise would need to be done to counteract eating that food reduced the amount of calories that people ate. “We found that when you put our labelling against foods or menus it seems to reduce the amount of calories that the public select for consumption,” Professor Daley explained to me. The Royal Society of Public Health suggested replacing calorie labels with exercise labels, although Professor Daley thought it would be better to include both types of label on packaging.

The research suggests this small change could help people make healthier choices, but having worked in adolescent inpatient mental health wards, it also made me think of the excruciating minutiae of decision-making and agonising trade-offs between exercise and eating that I witnessed there in young people who were in the grips of the eating disorder anorexia nervosa.

Professor Daley acknowledged the difficulty of trying to help a population eat healthily when for some that will mean reducing intake and for others increasing it. She said: “I guess there’s negative aspects to lots of things but that doesn’t mean that we don’t do it… We know much of the population is obese and that this has severe health impacts. We’re focussed on trying to reduce those diseases. That’s not to say that we’re not concerned about eating disorders but there’s no evidence that physical activity campaigns lead to eating disorders. And our focus is population health and impacting the majority of the population.”

This feels like one of those problems that gets bigger the more you follow where it leads. Access to information about healthy habits and to healthy food are related to socio-economic status too. In the current climate of proliferating food banks some families can’t afford to be making healthier choices, if those choices require more time or more money to achieve them.

Professor Daley acknowledged the difficulties in trying to have an individual approach in the face of bigger social influences: “There’s a lot to be answered for in terms of how food is manufactured, advertised and promoted to the public. Until we do something about that we’re struggling against a very vast force.” She hopes for more primary care involvement in promoting healthy lifestyles but thinks more training is needed to help people feel comfortable tackling conversations about food, exercise and weight.

I still wonder whether we want to encourage a tit-for-tat attitude to food and exercise though. Aren’t there better ways in which we could try to encourage a healthy relationship with food and exercise from an early age? Not all calories are nutritionally equal and constantly weighing up exercise against food takes the joy out of both.

It’s not that I think the exercise-equivalent advertising would lead to an eating disorder by itself, more that I think it could exacerbate an existing problem or be part of a perfect storm of contributory factors. Despite the focus on losing weight that eating disorders such as anorexia nervosa include, the young people I’ve worked with who’ve experienced this problem have mostly talked about it not really being all about the food. It’s usually about something else as well: the control that not eating represents, the effect losing weight has on relationships with people around them, how they feel about themselves and what they deserve…. Nonetheless the focus on losing weight does come from somewhere, and that somewhere is often at least reinforced by social attitudes to weight and shape that we see all around us.

Dr Josh Wolrich, NHS surgeon with an interest in nutritional advice, has written about what he thinks would help, pointing out that dieting is consistently found to be the biggest predictor of eating disorders in adolescents: “Children are a product of their environment, and their environment is currently doing them a disservice. Harmful language around food, constant dieting messages, aggressive weight stigma in the public sphere all mean children start imitating the behaviour they see from a very young age,” he writes.

There are lots of psychological drivers which occur not only in the context of eating disorders but in many people’s relationship with food. Eating for comfort, restricting as self-punishment, eating without stopping to savour but more for fuel… Real change in public health will come when as a society we address our relationship with food and exercise, rather than relying on direct calorie-for-exercise comparisons on food. This advice might help some people to understand how energy-dense a food is, but I’m not sure on its own it will be helpful enough, or worse, could encourage unhelpful attitudes. Food for thought. 

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