Waging Holy War with the DSM-5

CW: fatphobia, eating disorders, IWL/diet talk

Introduction

“Nothing tastes as good as skinny feels”; this was the oft-repeated mantra of the doctor who once helped me lose over 30 pounds (after having already lost 40) in a little under three months by dramatically restricting my diet. Her words are symptomatic of a larger trend that is deeply entrenched in the medical industry, namely, an underexplored and oversimplified conflation of health and wellbeing with weight. The automatic attribution of poor health to body size has led to an emphasis on reducing body mass, often to the detriment of health. By identifying fatness as a problem in and of itself, the medical industry has made itself a complicit player in the size-ism and weightism that run rampant in U.S. and other developed societies, lending professional credibility to the “fatphobic” attacks of the diet, fitness, and fashion industries on fat individuals. Eating disorders, particularly anorexia nervosa and bulimia nervosa, are a logical consequence of this rampant weightism and size-ism, a natural response to the medically reinforced notion that thin = good and that fat must be avoided at all costs.

The church has resources that can help heal our society’s disordered and unhealthy relationship to both food and body. These resources date back to the early centuries of Christianity; in particular, this paper will explore the relevance of the writings of Evagrius Ponticus, a fourth century Egyptian desert monk, and Gregory the Great, a sixth century Roman pope. Both of these Christian figures wrote extensively about the ancient church’s understanding of gluttony, and about how the relationship between self, neighbor, creation, and God is properly to be understood. Two other key tools in the ecclesial toolkit are a theological affirmation of the inherent goodness of creation, and a robust theology of incarnation. Together, these resources present a countercultural and life-giving alternative to our eating disordered society that is deeply rooted in God’s love and promises.

Modern Classification and Understanding of Eating Disorders

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) identifies six kinds of eating disorders, plus other specified and unspecified feeding and eating disorders. The two of these disorders most immediately relevant to this paper are anorexia nervosa and bulimia nervosa. The factor uniting both of these disorders and providing the driving force behind them is an extreme fear of gaining weight and becoming fat. Sets of criteria are given for identifying and distinguishing each disorder. For a diagnosis of anorexia nervosa, a person must have “significantly low body weight” as a result of a “restriction of energy intake relative to requirements,” an intense fear of becoming fat, or persistent behavior that deliberately inhibits weight gain, and a “disturbance” in their perception of their own body and weight: “undue influence of body weight or shape on self-evaluation.” (American Psychiatric Association, 2013, pp. 338–339) The primary criteria the DSM-5 lists for a diagnosis of bulimia nervosa are: recurring incidences of binge-eating, repeated behaviors like inducing vomiting or diarrhea to prevent weight gain, and once again, self-evaluation that “is unduly influenced by body shape and weight.”(American Psychiatric Association, 2013, p. 345) The manual also distinguishes bulimia nervosa from anorexia nervosa by stating that those suffering from the former maintain a weight that is at or above normal levels.

The DSM-5 and related resources identify a number of potential risk factors for developing an eating disorder. For example, women – particularly younger women – carry a much greater risk than men for developing either anorexia nervosa or bulimia nervosa. According to the DSM-5, the female-male ratio for developing one of these disorders is approximately 10:1. (American Psychiatric Association, 2013, pp. 341, 347) No data is given about the prevalence of these disorders among transgender, gender nonconforming, or other gendered people. In Ministry with Persons with Mental Illness and Their Families, the authors of the chapter about eating disorders note that, “in addition to female gender, obsessive and perfectionist personality traits confer an increase in risk for anorexia nervosa,” further claiming that “it is felt that this characteristic may predispose individuals to an overly-valued low weight idealization.” (Albers, 2012, p. 136) Having a first degree relative who develops an eating disorder like anorexia or bulimia increases one’s risk of developing such an eating disorder; there likewise may be a possible correlation with incidence of bipolar and depressive disorders among relatives. (American Psychiatric Association, 2013, pp. 342, 348) Finally, the DSM-5 mentions briefly among environmental risks for eating disorders the “internalization of a thin body ideal” and an “association” specifically of anorexia nervosa “with cultures and settings in which thinness is valued.”(American Psychiatric Association, 2013, pp. 342, 348)

Picking a Fight with the DSM-5

The DSM-5 diagnostic criteria for both anorexia nervosa and bulimia nervosa state multiple times that people susceptible to or showing characteristics of eating pathology self-evaluate in a manner that is “unduly influenced by body shape and weight.” Such phrasing begs the question: how does one determine whether a level of influence is “undue”? What does that constitute? And what determines a normal or acceptable level of influence? If, say, one lives in a culture that is saturated with images of a thin ideal, in which fat people are actively ostracized and underrepresented, even underpaid, in which anti-fat bias is unquestioned, repeated, confirmed over and over again by family members, friends, media, even their own doctors, surely any attention to such a culturally privileged aspect of one’s being could hardly be called undue!

An extensive synthesis of research studying the cause and role of body dissatisfaction in eating pathologies found that the research affirms that we live in precisely such a culture, confirming that “appearance is a central evaluative dimension for girls and women in Western cultures,” and that a fat appearance is considered unacceptable. (Stice & Shaw, 2002, p. 987) These studies found that the pressure to be thin – or even the perception of pressure to be thin – has an adverse effect on body dissatisfaction. They also found that exposure to the thin-ideal perpetuated by the media results in “acute increases” in body dissatisfaction, as does social pressure from peers to be thin. (Stice & Shaw, 2002, p. 987)

The internalization of the thin ideal and bias against fat also leads to body dissatisfaction. However, “body dissatisfaction” may be a mild term for the response it actually provokes in those who experience it. The title alone of a study about participants’ internalized weight bias says it all: “Exploring stigma of ‘extreme’ weight gain: The terror of fat possible selves in women’s responses to hypothetically gaining one hundred pounds.” (Fahs & Swank, 2017, emphasis added) This study first pointed out that about a quarter of American women of reproductive age will gain significant weight, and that gaining 100lbs or more over an adult lifetime is actually “relatively common and mundane.” (Fahs & Swank, 2017, p. 2) What is truly “extreme” about this weight gain is the stigma surrounding it. Researchers describe the “visceral, desperate, intense emotional reactions” participants had to simply being asked to imagine themselves 100lbs heavier. (Stice & Shaw, 2002, p. 5) The “unconditional acceptance and mimicking of mainstream fat shaming messages” resulted in a “wide range of reactions that connect fatness to dread, disgust, terror, fear, abjection, and disability.” (Fahs & Swank, 2017, p. 6) Some participants went so far as to state that life would not be worth living if they were 100lbs heavier, and even implied that they would kill themselves if they ever got that fat.

As noted above, the messages that elicit such responses are, regrettably, mainstream. According to the authors of the hypothetical 100lbs study cited above, “the ‘war on obesity’ and its rhetoric have been deployed to injure, insult, and degrade fat people, especially women, and continues to treat fat bodies as ‘the enemy,’ with a host of public health campaigns and reforms targeting food and drink consumption and eating practices.”(Fahs & Swank, 2017, p. 1) The inclusion of weight bias in public health messaging is perhaps the most insidious of all. Promotion of the thin ideal as a health ideal by medical professionals leads naturally to fixation on that ideal as a measure of health and worth, and also leads people to work to attain such an ideal, often to their detriment. The research synthesis referenced above also discovered compelling evidence that dieting significantly increases one’s risk of developing an eating disorder. (Stice & Shaw, 2002, p. 988)

In summary, mainstream messages of weight bias, which are promoted by society, media, and medical professionals, directly influence body dissatisfaction, which often leads to dieting, which leads to disordered eating. In fact, the argument can be made that dieting is disordered eating; it relies on a similar philosophy of restricting energy intake, just on a less extreme scale. Yet, as the Albers text so aptly notes, there’s no such thing as “’just a little’ eating disordered.”(Albers, 2012, p. 148) Dieting – by which is generally meant calorie restrictive dieting – is a means to the end of achieving the thin ideal (and an ineffectual one at that). What, then, are eating disorders but the logical conclusion of such a system? In a culture that places such a high value on thinness, aren’t those who develop eating disorders simply attempting to conform to the standard better than anyone else? In this case, a correlation with perfectionist and obsessive traits makes perfect sense; they are characteristics that enable people with eating disorders to sustain a pattern of behavior implicitly suggested by the rampant weight bias in western society.

This weight bias is evident in the DSM-5 itself. According to its diagnostic criteria, the primary factor for distinguishing between a diagnosis of anorexia nervosa and bulimia nervosa is the weight of the person being evaluated. “Both” disorders are characterized by a deep-seated fear of and aversion to fat, by eating restrictive behaviors, and by binging and purging behaviors. Notably, individuals in the “obese” range and above who present with symptoms of anorexia or bulimia are excluded even from bulimia; they are instead lumped into the “Other Specified Feeding and Eating Disorder” category. (American Psychiatric Association, 2013, pp. 347, 353) Such weight-based distinctions between disorders constitute a reprehensible erasure of fat experience and fat suffering. Arguably, this is due to the fact that, above a certain weight, the cultural demand for thinness trumps genuine concerns for a person’s health, and so many questionable “dieting” practices adopted by desperate fat people fly under the radar, or in many cases are even lauded. Instead of receiving help for patterns of disordered eating behavior that would be considered harmful in thinner people, these disordered patterns are all too often praised and encouraged when performed by fat people. And the medical industry bears a significant amount of the blame for perpetuating these harmful behaviors. 

Recovering a Christian Relationship with Food and Body

As shown above, the problems surrounding weightism and the factors influencing eating disorders operate on a massively systemic scale. It will take time and motivation for this society to unlearn its virulent hatred of fat and its unhealthy preoccupation with food. Fortunately, the church has much to offer this conversation, if it’s willing to overcome its own internalized weight biases. This section will explore three key things that the church can bring to the table: a rediscovery of ancient understandings of the “deadly sin” or “thought” of gluttony, an affirmation of the absolute and inherent goodness of God’s creation, and a rich theology of incarnation that speaks directly to the preciousness of bodies in God’s sight.

The first systematic writings about the concept of gluttony in the ancient church’s writings can be traced back to Evagrius Ponticus. Evagrius Ponticus was a fourth century monk who took up residence in the deserts of Egypt and wrote extensively about the life of discipleship. Among his best-known works is the Praktikos, famed for its discussion of the eight logismoi, that is, eight kinds of evil thought, which later theologians condensed into the “seven deadly sins” more familiar to modern readers. These eight thoughts consisted of impurity, avarice, sadness, anger, acedia, vainglory, pride, and of course, gluttony. Of gluttony, Evagrius writes,

The thought of gluttony suggests to the monk that he give up his ascetic efforts in short order. It brings to his mind concern for his stomach, for his liver and spleen, the thought of a long illness, scarcity of the commodities of life and finally of his edematous body and the lack of care by the physicians. (Evagrius Ponticus, 1972, p. 17)

Later theologians following in the vein of Evagrius’ work unpacked this presentation of gluttony and began to break it down into different “types” of gluttony or different ways that gluttony could be understood. Evagrius’ student, John Cassian, developed the concept of gluttony into three subtypes in the fifth century, and then in the sixth century, Pope Gregory the Great further developed this into a system of five kinds or ways of understanding gluttony, which is what shall be explored in more detail here. Gregory’s five kinds of gluttonous eating behavior are: eating praepropere (too soon), eating laute (too expensively), eating nimis (too much), eating ardenter (too eagerly), and eating studiose (too attentively). (Bringle, 1992, pp. 68–70)

Eating praepropere, too soon, referred initially to the canonical hours by which monks ordered their days. Monks were to break their fast at none – the ninth hour after daybreak, or noon. To eat sooner meant to eat in solitude, away from the community, when eating was understood to be a communal activity. Even more broadly, the idea of praepropere eating speaks a word about priorities, that eating ought to be done in proper relationship to others and to gratitude for the gifts of God. Eating ardenter reflects some of these concerns as well. Mary Louise Bringle, in her book The God of Thinness: Gluttony and Other Weighty Matters, classifies the binge eating with which she herself as struggled as eating ardenter. She contrasts this binge eating with the concept of feasting; while both may involve consumption of large quantities of food, only feasting privileges the community, gives loving attention to the pleasure of eating and enjoying God’s creation, and holds celebration and gratitude to God in a central place. (Bringle, 1992, pp. 69–70)

Eating laute, too expensively, reflects a distaste for nutritious elements of the creation which God has declared good. Even more seriously, laute eating raises the ethical issue of money that is spent on one’s own particular consumption when so many people in this world don’t have enough to eat. Bringle aptly points out the irony of the vast sums of money Americans pour into the diet industry every year, when so many children go to bed with empty bellies. (Bringle, 1992, p. 70) Eating nimis, too much, raises similar concerns about having enough to go around. Bringle stresses repeatedly that this kind of gluttony traditionally had nothing to do with any individual’s own physical shape or health. Rather, especially in the desert, food supplies were often limited, and eating more than one’s fair share could have serious consequences. Living on a planet with limited resources, the traditional idea of eating nimis rather raises questions about a consumer capitalist society that accumulates too much material wealth, at the expense of others.

Finally, eating studiose is probably the kind of gluttony that modern readers will find most surprising. Gregory the Great names eating with too much studied attention a particularly dangerous pattern of gluttonous behavior. Studiose eating, with its fastidious concerns about the food one puts in one’s body, makes an idol of both food and body. It is the gateway to more serious sins, like pride and vainglory, which lord the slender self over and against other people. Eating studiose betrays a lack of belief in the goodness of God’s creation, a lack of gratitude for the gifts of God, a disregard for the importance of sharing in community eating, and above all, a completely disordered set of priorities. Contrary to all popular contemporary understanding of gluttony, it is arguable that this is the true sin of gluttony that plagues our culture. Obession with calorie-counting, BMI, clothing sizes, weight, and other quantified measurements of a person’s worth and being are in and of themselves gluttonous patterns of behavior around eating.

In summary, Gregory the Great’s systemization of gluttony shows clearly that the early church’s understanding of gluttony had nothing to do with fatness or physical size. Instead, gluttony had to do with priorities that set up material things as idols over and against God, with behaviors that detracted from life in community with neighbor, and with a lack of gratitude or appreciation for the good things of creation. Resisting gluttony means healing relationships with God, neighbor, creation, and self.

Gregory’s systemization of gluttony relies on a mostly unspoken assumption that is worth drawing out and mentioning here as well: that creation is good. The church can utilize the creation narrative from Genesis 1 to affirm God’s declaration of creation, including the creation of human bodies, as “very good.” God gave humans every good thing to eat, without stipulation, and the long story of the bible begins in a garden of fruit trees and ends with the feast of the Lamb in Revelation. Genesis 2 offers the beautiful image of God molding humankind from the soil of the earth with God’s own hands, an act which reveals the preciousness of humans to God. Surely a body formed by hand by the Creator has a much greater purpose and destiny than conforming to an arbitrary societal standard of beauty or thinness.

And God’s love and care for humans did not stop with creation. God became physically incarnate, was born human, and grew and ate and digested and defecated, just like regular humans do. It’s a striking image. God elevates the human body to the level of the divine by dwelling physically among us, and God likewise dignifies the act of eating. Jesus is shown eating in the bible over and over again: fish and bread and wine and figs and so on. In fact, both the gospels of Matthew and Luke record a very telling statement of Jesus: “The Son of Man came eating and drinking, and they say, ‘Look, a glutton and a drunkard, a friend of tax collectors and sinners!’” (Matthew 11:19, Luke 7:34, NRSV) No mention is made anywhere in the bible or in the life of Jesus of maintaining a certain body shape or weight, but plenty is made of Jesus feasting and enjoying the good things of creation in the flesh.

Conclusion

Contemporary society’s fixation on fatness and its pervasive ideal of thinness have a deeply detrimental effect on health, especially that of women. It is a medically reinforced bias that leads to intense body dissatisfaction in many people, behavior which forms a significant risk for the development of eating disorders. Disordered patterns of eating are a logical consequence of the overwhelming emphasis western society places on the thin ideal, at the expense of health. The DSM-5 itself illustrates how patterns of eating that are considered harmful when performed by thinner people are completely disregarded as pathological in heavier people, leaving open the suggestion that these behaviors might not be seen as negative in fat people. This is a wide-reaching systemic issue that will be difficult to resolve. However, the church has resources that can enable it to contribute meaningfully to the conversation surrounding food and bodies. Chief among these are the church’s historical understanding of the “sin” of gluttony, its affirmation of the goodness of creation, and its belief in the divine incarnation. The church can and must counter the intense negativity surrounding bodies and eating with an alternative and life-giving vision that is deeply rooted in God’s love and care for humankind. The church can help guide society and the individuals in it toward a place of healing, one which restores right relationships between self and God, self and neighbor, self and creation, and self and self.

Bibliography

Albers, R. H. (2012). Ministry with Persons with Mental Illness and Their Families. (W. H.    Meller & S. D. Thurber, Eds.). Fortress Press.

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental          Disorders (5th edition). Washington, D.C: American Psychiatric Publishing.

Bacon, L., & Aphramor, L. (2011). Weight Science: Evaluating the Evidence for a Paradigm    Shift. Nutrition Journal, 10, 9. https://doi.org/10.1186/1475-2891-10-9

Bringle, M. L. (1992). The God of Thinness: Gluttony and Other Weighty Matters. Nashville:           Abingdon Pr.

Durso, L. E., Latner, J. D., White, M. A., Masheb, R. M., Blomquist, K. K., Morgan, P. T., &       Grilo, C. M. (2012). Internalized weight bias in obese patients with binge eating disorder:         Associations with eating disturbances and psychological functioning. International        Journal of Eating Disorders, 45(3), 423–427. https://doi.org/10.1002/eat.20933

Fahs, B., & Swank, E. (2017). Exploring stigma of “extreme” weight gain: The terror of fat     possible selves in women’s responses to hypothetically gaining one hundred pounds.          Women’s Studies International Forum, 61, 1–8.        https://doi.org/10.1016/j.wsif.2016.12.004

Stice, E., & Shaw, H. E. (2002). Role of body dissatisfaction in the onset and maintenance of eating pathology: A synthesis of research findings. Journal of Psychosomatic Research, 53(5), 985.

Uchoa, F. N. M., Lustosa, R. P., Rocha, M. T. M., Daniele, T. M. C., Deana, N. F., Alves, N., &   Aranha, A. C. M. (2017). Media influence and body dissatisfaction in Brazilian adolescents. Biomedical Research (0970-938X), 28(6), 2445–2451.

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