Religious and spiritual factors in childhood and adolescent eating disorders and obesity.

Eating disorders transcend medical specialty boundaries, unlike other conditions of body and mind. Given the significance of food, fasting, and eating customs in world religions, religious and spiritual issues figure prominently in the development, assessment, and management of anorexia, bulimia nervosa and obesity.

Anorexia Nervosa, Bulimia Nervosa, and Obesity

An individual with anorexia nervosa harbors great fear about becoming fat or gaining weight, even if underweight. She does not maintain the minimally accepted weight for individuals of her age, height, and gender. All organ systems and physiologic processes may be adversely affected by this self-imposed starvation state; anorexics commonly have one or more comorbid psychiatric illnesses. Bulimia nervosa entails recurrent episodes of consuming amounts of food substantially greater than what others would eat in a comparable time period, accompanied by lack of control over the eating. Compensatory behaviors to prevent weight gain are enlisted, including self-induced vomiting, excessive exercising, fasting, and misuse of laxatives, diuretics, enemas, and other medications. Common psychiatric comorbidities include mood disorders with suicidality, substance use, personality, and impulse control disorders. (1) Eating-disordered patients experience medical complications that bring them to the attention of the primary care physician (PCP). Due to the medical and psychiatric complexities of anorexia and bulimia nervosa, treatment is multidisciplinary and long-term. Excellent treatment guidelines are available that summarize these disorders, medical complications, and treatment strategies. (2)

In children and adolescents, overweight means the individual's body mass index (BMI) is at or above the 95th percentile (BMI = kilogram weight divided by the square of height in meters). According to 2003 to 2004 Centers for Disease Control statistics, 12.5 million, or 17.1% of Americans age 2 to 19 years were overweight. (3) Obesity predisposes young people to multisystemic disease throughout their lives if weight is not managed properly. Early detection of increased BMI, regular monitoring, and early interventions are critical. (4)

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Food, Fasting, and World Religions

Food as sustenance for life and context for religious expression pervades major faith traditions and sacred texts. This is true especially in the Judeo-Christian tradition. Food supported physical life, was used to seal covenants and social relationships, and served as gifts and tributes. People celebrated with abundant food and drink at celebrations and feasts. Worshipers brought food as religious offerings. Food was integral to sacred communal meals. The lack of food was interpreted as separation from God, or the result of disobedience to God. Food served as a reminder that God was the ultimate provider--"man shall not live by bread alone, but by everything that proceeds out of the mouth of the Lord" (Deuteronomy 8:3; Luke 4:1-4). (5) In Christianity, eating and drinking attain the utmost significance in the Lord's Supper, also known as communion or the Eucharist. (6,7)

Fasting also appears in sacred writings. In the Hebrew Bible, public fasts accompany mourning and penance rituals. Prophets warned against misusing fasting for nonreligious purposes. Jesus fasted for forty days and nights at the beginning of his ministry. Early Christians fasted during times of trial and before the consecration of church leaders and teachers. (8)

Food and fasting are integral to other world religions as well. In Islam, the Quran forbids certain foods, and the Hadith and law books offer instructions on etiquette and contexts of meals. Daytime fasting is central to Ramadan, during which refraining from eating and sexual activity demonstrates self-discipline and faithfulness. (9,10) Fasting has a role in orthodox Hinduism as well, alongside instructions for bathing, eating, posture, clothing, and specific acts of worship. Fasting is observed by faithful Hindus and may be prescribed for violations of codes of conduct. (11,12) In Jainism, an ascetic religion, the conclusion of each year is commemorated with a penitential fast. Native American religions include fasting, particularly in rituals marking life transitions. In many faith traditions, fasting is a time-limited means of self-control that facilitates contemplation and frees the spirit to serve God and humanity. (12)

Food from Biblical Times to Present

Religious understandings--or theological misunderstandings--have also fostered unhealthy eating behaviors. Gnosticism, a religious movement stemming from early Christianity, held that salvation comes from knowledge ("gnosis") and that matter is evil. This engendered a dualism in which the body is sinful and self-denial leads to holiness or spiritual superiority. (13) A list of "seven deadly sins" arose as early Christians attempted to live faithfully as directed by scripture. The seven sins are: lust, avarice, envy, anger, accidie or sloth, pride, and gluttony. (14)

Asceticism refers to the practice of extreme disciplines, with the goal of spiritual growth. Expressions include sexual continence, solitude, prayer, vigils, restricting fluid intake, and fasting. Catherine of Sienna (1347-1380) was a mystic renowned for radical holiness. She had a vision in which she was joined to Jesus in mystical marriage, ministered to the poor and sick, and developed a following as a teacher of mysticism. Catherine fasted as part of extreme asceticism, not unlike modern restricting anorexics. For Catherine, fasting was fundamental to female holiness, and her writings demonstrate a profound preoccupation with food, eating, and drinking. (15) Though we would be ill-advised to pass judgment on Catherine, her writings describe undeniable elements of modern eating disorders--food and fluid restriction, self-induced vomiting, and gastrointestinal dysfunction. Catherine of Sienna has remained influential over several centuries, verifying the overlap and potential confusion between religious piety and ascetical practices gone awry. (15-17)

Case Example

Fifteen-year-old Courtney and her family had been treated by their PCP for over a decade. Her mother had been a postulant in a Catholic order when she became pregnant with Courtney and left the order to marry her father. She suffered a psychotic depression after Courtney's birth, and had recurrences with numerous suicide attempts over the years. Courtney's parents divorced when she was 10 years old, and she went to live with her father. Her father blamed the Catholic Church for her mother's difficulties and raised Courtney in an environment antagonistic to religion and spirituality. Her mother committed suicide when Courtney was 13. As her mother had spoken fondly of her postulancy, Courtney became curious about the Catholic Church, its customs, rituals, saints, and mystical theology. She began observing Church Holy Days, fasting on Fridays and during Lent, and eventually embraced the strict ascetical practices of the medieval mystics. Her father brought her to the physician after being horrified by her emaciation when he accidentally walked in on her while she was undressing. The attention to her weight loss paradoxically motivated her to increase her ascetical practices. She fasted, limited fluid intake, self-flagellated, and slept with nails under her sheets--all with the nearly delusional belief that such self-denial would absolve her of the sin of her birth, which had forced her mother to leave the bliss of religious life to suffer recurrent, painful depressive episodes and suicide. Her father and PCP forced psychiatric hospitalization when her behaviors became increasingly dangerous to herself. The psychiatrist and PCP coordinated a multidisciplinary treatment plan that included a priest who addressed Courtney's religious and spiritual issues.

Religion, Spirituality, and Psychodynamics 

Religion, spirituality, and eating disorders have long had the attention of clinicians and researchers. Several scholarly reviews exist in this area, (18-26,29) with the work of Richards, Hardman and Berrett being the most recent. (26) This literature supports the importance of considering religion and spirituality in clinical case formulation and the development of treatment plans for patients with eating disorders. Anger, control, anguish, despair, perfection, unworthiness, shame, and guilt are common themes in both eating disorders and religious belief. Many patients attribute spiritual meanings to their pathologic attitudes and behaviors, and use unhealthy religion and spirituality to justify ongoing illness. Families are the primary social context of many eating disorders. (27) In some cases, religious beliefs can fuel patterns of interaction, such as over-protectiveness, which impede full patient responsibility for healthy eating. (28)

The Role of the PCP

The first obligation of a primary care physician is to help recognize an eating disorder. PCPs are in a key position and should appreciate the importance of religion and spirituality to their individual patients and families, picking up on hints that belief systems might be misleading or even failing them, and noting when attention to religion and spirituality might be helpful. Their recognition of the roles of food and drink in major religions, in daily life, and in the communal lives of religious gatherings can all contribute to the early identification of eating disorders in patients of faith.

While the goal is not for physicians to become religious scholars or practical theologians, there are some general indicators of healthy and unhealthy religious and spiritual beliefs and practices that PCPs should keep in mind. One helpful scheme of unhealthy and healthy religious systems is Bowman's model (Elizabeth S. Bowman, personal communication, January 6, 2007.), which she in turn has based on the work of Howard Clinebell (31) and Wayne Oates. (32) Bowman describes theological characteristics that foster healthy religious systems--and hence good health practices--including: an openness to searching, to learning, and even to doubting; toleration of ambiguity; and an understanding of God that balances God's requirements with God's beneficence. Healthy religious and spiritual growth permits and encourages multidimensional growth, responsible personal decision-making, self-acceptance, and is encouraged by the religious community.

In contrast, theologies that do not permit doubting or questioning are rigid, tending to emphasize punitive images of God, and may contribute to religious belief systems that hinder physical and emotional health. Similarly, religious and spiritual traditions are potentially damaging to individuals if they induce intractable individual guilt, make forgiveness of self or of others difficult, are unaccepting of human shortcomings, discourage personal growth, lead to or perpetuate feelings of helplessness, reinforce low self-esteem, offer limited pathways for individual growth and development, or cast illness as the result of spiritual inadequacy or sinfulness.

The second obligation of a PCP treating a young person with a suspected eating disorder is to evaluate, diagnose, treat and manage acute and chronic medical problems. Depending upon one's training, experience, and local resources, this may or may not involve consultation with medical subspecialists.

Third, the PCP needs to make sure that the identified patient is referred to the most qualified and appropriate mental health clinician available. That is to say that the clinician in question should be one whom the patient can afford on a continuing basis, who is in close geographical proximity, and who can schedule flexible appointments. Periodic psychiatric evaluation is crucial for identification of comorbid psychiatric conditions and treatment with psychotropic medications, if indicated. Many treatment plans work best when there is one clinician in charge of coordinating treatment, which may include regular weigh-ins, working with a nutritionist, negotiating behavioral incentives or consequences, and facilitating communication among all professionals involved in treatment.

Religious professionals should be well-informed and competent in the discipline of religion and spirituality. (33-35) They should have enough knowledge of eating disorders and general psychiatry so that they have some experience and insight into how religious/spiritual lives and practices are affected by psychiatric illnesses. They should be open, receptive, and nonjudgmental enough in their approach so as to be helpful to the patient and not compound pre-existing issues with religious and spiritual overtones, such as guilt, shame, and conflict with authority. They should be free of significant personal investment in the "conversion" of the patient, or adding them to the membership roster of a particular congregation. They should be healthy enough themselves to withstand the negative projections that a patient and family may place on them of a punitive, angry God or the negative associations of religion in the past. While there are local church pastors who can do this work well, the time demands of congregational work and the emotional drain of eating disordered patients and their families often limit their availability. Well-trained pastoral counselors are often helpful, for they wed religious/spiritual knowledge and authority with training in psychotherapy. (36) Again, the PCP is in a unique position to listen for religious/spiritual themes that perpetuate eating disorders and may benefit from periodic sessions with a religious professional sensitive to the psychopathology of this diagnostic entity.

Spiritually-oriented programs specifically targeted toward the treatment of eating disorders do exist. There is limited data as to treatment outcomes, and some data that do exist may suffer from both negative and positive biases. The authors' anecdotal experience is that patients who report being helped by this approach have a religious and spiritual worldview that is similar to that of the program, are fairly motivated to become healthy, and generally feel supported in their treatment programs by family and significant others. Families are well-advised to investigate the program's ability to accept various insurance plans, and, if possible, to speak with those who have completed the program.

Case Example

Kathleen was a 13-year-old girl seen by her PCP for right hip and knee pain of six months' duration. Always overweight, she was now 5 feet, 4 inches tall, weighed 225 pounds, with a blood pressure of 156/92, hyperlipidimia, and hypercholesterolemia. An evaluation of her joint pain by an orthopedic surgeon revealed no fractures or underlying pathology. Her musculoskeletal complaints, as well as her hypertension and abnormal laboratory studies, were attributed to obesity. Kathleen's father, a local church pastor, was 5 feet, 8 inches tall, weighed 275 pounds, and had not seen a physician for over a decade. Her mother and two younger siblings likewise were over 150% of their ideal body weight.

The PCP met with Kathleen's parents, with Kathleen alone, and then with the entire family, and explained the effects of obesity on Kathleen's health. He referred the family to a nutritionist and exercise programs in the community, and followed them monthly. After one year, all five family members continued to gain weight, and blood pressure and cholesterol continued to increase. Upon further inquiry, the PCP learned that the family ate at least two meals per week at the church, and an average of two additional meals were of banquet proportions prepared either by the pastor's wife for entertaining church members in their home or by church members inviting the pastor's family for meals. There were also donuts, pizza, and chips at the numerous community events.

It was clear that losing weight and adopting a healthier pattern would only be possible with the aid and support of the family's tight-knit religious community. The pastor asked the PCP to serve as the congregation's medical consultant. Menus at the all-church dinners were chosen to conform to American Diabetes Association guidelines, donuts and sweets were eliminated and replaced with and fruits and diet sodas. The congregation sponsored a chapter of Overeaters Anonymous, healthy cooking classes under the theme of faithful stewardship of God's body, and started combination Bible study/exercise clubs. The PCP offered free quarterly blood pressure clinics at the church. After one year, Kathleen had lost 10 pounds and her hip and knee pain and hypertension were improved.

The degree and scope of the program adopted by this particular congregation at the urging of its pastor was extensive and would be very difficult to maintain over time. However, just as religious gatherings may unwittingly perpetuate unhealthy habits and lifestyles, so they can promote healthy eating and exercise if given the proper education, leadership, and encouragement. Many PCPs are part of faith communities themselves, and can provide such a nudge from the inside. Even from the periphery, however, physicians generally will find religious organizations to be interested and willing partners in public health endeavors.

Closing Caveats

Primary care physicians are in the unique, even enviable, position of knowing patients and multiple family members over the course of years, walking with them through times of joy, illness, and even death. PCPs often live in the same communities and are familiar with the prevailing religious and spiritual beliefs and practices, and may have helpful insights regarding the role of religion and spirituality in medical matters, especially eating disorders and obesity. In conclusion, the following suggestions may be helpful:

1. Religion and spirituality impact significantly on health and illness. The PCP should ask routinely about the role of religious belief in a patient's life, especially where eating disorders are an issue. Most patients will appreciate the concern and insights such questions convey, and a few will be relieved at the opportunity to talk about it.

2. Regardless of the PCPs own familiarity with the religious faith in question, it is important to inquire what specific beliefs, teachings, and customs mean to the patient and how her life is affected.

3. Remember that religious and spiritual aspects of food, drink, fasting, and communal meals may affect a patient's lifestyle, even if she does not realize it. Similarly, remember that eating and food can be associated with powerful memories and strong emotions, especially guilt, shame, and senses of well-being and self-worth.

4. Develop a cadre of religious professionals from different faith traditions in your community that you can rely on for further insight.

5. Cultivate a list of well-trained, well-educated, well-credentialed secular mental health professionals whose aid can be enlisted.

6. Never be afraid to consult or to refer to qualified others for second opinions about the roles of religion and spirituality in any patient's medical or psychiatric health.

References

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After all is said and done, more is said than done.
--Aesop

Mary Lynn Dell, MD, MTS, ThM, and Allan M. Josephson, MD

From Emory University School of Medicine, Atlanta, GA.

Reprint requests to Mary Lynn Dell, MD, MTS, ThM, Emory University School of Medicine, 492 Ponce de Leon Manor NE, Atlanta, GA 30307. Email: [e-mail]