The Relationship with Food in Eating Disorders

Eating disorders are common, frequently severe, and often devastating pathologies. Biological, psychological, and social factors are usually involved in these disorders in both the aetiopathogeny and the course of disease. The interaction among these factors might better explain the problem of the development of each particular eating disorder, its specific expression, and the course and outcome. This book includes different studies about the core concepts of eating disorders, from general topics to some different modalities of treatment. Epidemiology, the key variables in the development of eating disorders, the role of some psychosocial factors, as well as the role of some biological influences, some clinical and therapeutic issues from both psychosocial and biological points of view, and the nutritional evaluation and nutritional treatment, are clearly presented by the authors of the corresponding chapters. Professionals such as psychologists, nurses, doctors, and nutritionists, among others, may be interested in this book.

The research was held in Florianópolis (Santa Catarina, Brazil), involving seven female teenagers diagnosed with ED's, according to DSM-IV-TR (2002), of whom four of them with AN and three of them with BN, aged between 17 and 20 years old, attended in Joana de Gusmão Childhood Hospital, at Regional Medical Clinic and in private clinics. The interviews were conducted from March to May of 2006, until reaching the criterion of saturation, which is the phenomenon that occurs when a number of collected data fail to present something new to the phenomenological understanding (Mucchielli, 1991, as cited in Coppe, 2001.
The inclusion criteria in this study were age, sex and diagnosis of the disorder in question. In addition, participants should allow the understanding of the guiding question, take up the case, communicate without hindrance or limitations, have the consent of parents or guardians to participate and accept the condition of having their interviews recorded.
The interviews were conducted according to a predefined script, consisting of an objective part, trying to collect data for characterization of the interviewees, and a subjective part, with questions that varied according to the course of the interview, trying to capture the lived experience of the interviewees about the ED's. The interviews were conducted by the researcher, at the location where the adolescents received care, and lasted 37 minutes on average, ranging from 23 to 58 minutes.
The interviews were recorded and transcribed verbatim by the researcher. Confidentiality and anonymity were guaranteed for the content in order to preserve the identity of the interviewees who chose a cognomen to be used throughout the interview and signed a Free and Informed Consent Form for participation in this research.
After the transcription, to begin the analysis of the interviews, the steps outlined in the proposal of Amedeo Giorgi were followed (Amatuzzi, 1996;Coppe, 2001;França, 1989;Holanda, 2002Holanda, , 2003Martins & Bicudo, 2003;Moreira, 2002), divided in: 1) reading the interview transcripts, with the intention of capturing the sense in all, before the object of research, 2) new reading of the text, with the specific objective of discriminating signification units with a psychological perspective, capturing the moments of sensitive psychological change of each situation, 3) transformation of units in psychological language, in order to reach the most straightforward and explicit expressions as possible to the perceptions contained in the expression of the subject, 4) synthesis of all the signification units, turning them into a consistent report on the experience of the subject, reaching the structure of the experience.
Having finished this step, in order to continue with the analysis of the data, the following methodological paths described by Coppe (2001) were performed: 1) creation of a table containing the identification data of each participant, a description of the signification units and the psychological understanding of each one, allowing us to observe the specific synthesis of each participant, 2) categorization of the signification units in order to comprehend the overall structure of background, then extracting the structure of the lived experience, 3) development of a general synthesis, consisting of the analysis of all reports, to obtain an overview of the material. From this summary, we had a reflexive dialogue, linking empirical and theoretical content that guided our investigation.
The research project was approved by the Ethics Committee in Human Research of Universidade Federal de Santa Catarina 1 (Project No. 013/06) and of Joana de Gusmão Childhood Hospital (Project No. 016/2006). 3. The relationship with food in the perception of the adolescents 3.1 Brief profile of the adolescents interviewed Table 1 presents a brief profile of the seven teenagers interviewed, trying to list some information considered important for a better understanding of the phenomenon studied.
The current age of the adolescents interviewed ranged between seventeen and twenty years old. The World Health Organization (WHO, 2005) considers adolescence the period between ten and nineteen years old, but some authors consider that there are many individual variations, influenced by both genetic and sociocultural factors that make age limits of the stages of adolescence approximate. Thus, for these authors, the increasing complexity of the teen phenomenon goes beyond the second decade since the technological development of Western society has led it to an extension of this transitional process. They therefore consider that the final or tardy phase can go up to twenty years of age (Chipkevitch, 1995;Vieira, 2002).
Regarding the type of ED and the treatment phase, of seven adolescents interviewed, four had diagnosis of AN (Gabriela, Carolina, Camila and Paula) and three had diagnosis of BN (Daniela, Helena and Julia). One of them is under treatment, but does not admit she has an ED and is in critical condition (Gabriela), three are under treatment and admit to having an ED (Daniela, Julia and Helena), two are under treatment in the recovery phase (Caroline and Paula) and one is not under treatment, and admits she has an ED and needs treatment (Camila). With respect to the treatment location, one of them (Gabriela) came from Joana de Gusmão Childhood Hospital (HIJG), four (Daniela, Carolina, Julia and Camilla) from Regional Medical Clinic and two (Helena and Paula) from private clinics. Although the teenagers interviewed were found at the age between seventeen and twenty years old, the disorder manifested between eleven and eighteen years old, and the duration of disorder was between one and nine years. As to education, all of them are between high school and incomplete higher education. Table 2 presents data related to the anthropometric characteristics of the interviewees, regarding height, weight and body mass index (BMI). One of the most common criteria used in ED's to determine whether a person is below the expected minimum weight is the BMI, calculated as weight in kilograms divided by height in meters² (DSM-IV-TR, 2002). Although this criterion presents some limitations, it is the most practical and the least costly one to analyze individuals and populations, and thus widely used (Conde & Monteiro, 2006 (Appolinário & Claudino, 2000;Cordás et al., 2004).

Cognomen
Concerning the maximum weight reached, only one of the adolescents (Julia) reached a rate considered overweight (above 25 kg/m²), while the others (Daniela, Helena) had, as well as the adolescents diagnosed with AN, normal BMI, also quite far from the upper limit of normal weight, and the maximum rate achieved was 21.63 kg/m², lower than the one found in the maximum rate of anorexia.
Regarding the weight loss of these adolescents diagnosed with BN, we found a drop of 9.26 (Helena) to 25.76% (Julia) weight, being that the minimum amount of weight loss was 5 kg (Helena) and the maximum was 17 kg (Julia), confirming that there is a significantly greater weight loss in AN rather than in BN .  Table 2. Anthropometric characteristics of the adolescents

The content of the interviews and signification units
With respect to the guiding question of how female adolescents with ED's perceive and experience their relationship with food, the analysis of the interviews brought out nine signification units, namely: what food represents, eating habits, foods that are no longer eaten, food that came to be consumed, the consumption of soft drinks, food choices, meal composition, the family's eating habits and healthy food.

What food represents
The term food, in the vernacular sense, means: "1. What you eat or is suitable for eating. 2. Action of eating" (Ferreira, 1993, pp.131). But for the teenagers interviewed in this research, in most cases, food had a very different meaning, referring to something negative, as we found in the reports below: "Hum, well, torture." (Daniela) "It represented fear, so I was afraid." (Carolina) "I think it is a very bad thing." (Gabriela) www.intechopen.com "Escape, a decadence, drugs." (Helena) For some of the teenagers interviewed, the food was an obligation, something that would take their freedom, described as follows: "It is necessary, mandatory, but I did not want it to be like this." (Julia) "If I were not forced to eat, perhaps it might be good." (Gabriela) "I feel freer when I do not eat." (Helena) Others commented on the positive side of food: "While that is good. [...] The foods that you like." (Daniela) "Food that makes you feel good. [...] The food is good for me today, it's tasty." (Carolina) With a view to what food represents to these teenagers, we can observe their eating habits.

Eating habits
The development of eating habits is influenced by several factors -physiological, psychological, sociocultural, economic -and occurs as the children grow, until the moment when consciously and independently they will choose the food that will be part of their diet. While a child, usually parents determine their food, but as they go to school and socialize with other children, they get to know other foods, preparations and habits (Bandeira et al., 2000).
During adolescence, due to the rapid physical growth and development, there is an increased need for nutrients, but at this stage there is also a change in food preferences, which puts these individuals at a nutritional risk group (Bandeira et al., 2000).
In the interviews that made up this study, we observed, from the adolescents, a concern with food control, both alone and with nutritional counseling, as described below: It is also interesting to note that many of these teenagers interviewed stressed the fact that they are eating, according to the excerpts below: To proceed with the subject related to food, we may observe then, the foods that are no longer consumed by the adolescents interviewed.

Foods that are no longer eaten
Nutrition and diet play an important role in the development and maintenance of ED's, and should thus be taken into account during the treatment plans of such disorders.
People with these disorders have severe dietary restrictions, eating patterns and wrong eating habits due to a number of factors such as myths and false beliefs, feelings of incompetence to deal with food, fear of putting on weight (Alvarenga & Larino, 2002).
The main foods that are no longer consumed by the adolescents interviewed were those they considered "junk" -chocolate, for example -regardless of whether they liked it or not: In the study by Dunker & Philippi (2003), the types of food that were least consumed were soda, chocolate, pasta and potato chips, and those that they least liked were vegetables, meat and fat, consistent with what was found in our research about what was no longer consumed, with the exception of soda. We describe below, the type of food that started to be consumed.

Food that came to be consumed
Looking at the most consumed foods in the study by Dunker & Philippi (2003) among the students with symptoms of AN, we found the presence of some special foods, which by their own qualities , reflect the concern in making a balanced diet, having mainly a variety of fruits and vegetables. In the interviews of this survey we also found the approval of consumption of vegetables by some of the teenagers, whether they like it or not, as shown by the statements below: "Although I don't like them (vegetables), I have to learn to love them." (Daniela) "Vegetable is one thing I learned to eat that I don't, I don't, I never realy liked it." (Carolina) "One thing I started to eat that I didn't use to eat much is vegetable." (Paula) One of the adolescents surveyed also reported an increased consumption of sweets, as described below: "I started to eat more sweets" (Helena) In addition to these foods, the consumption of soda is also notable in the case of adolescents with ED's, as will be seen below.

The consumption of soft drinks
Excessive consumption of soft drinks by teenagers is a common problem across the globe (Bandeira et al., 2000), also occurring in adolescents with ED's, as noted in the statements below: We found that soft drink, for these teenagers, sometimes end up replacing meals or water itself, becoming thus one of the food choices made by adolescents. This process of food choice will be observed in the sequence.

Food choices
Several factors may be involved in the choice of food, both from signals originated in the brain or on the outer edge when out of habit (Bacaltchuk & Appolinário, 2005). In our study, some of the factors mentioned by the adolescents interviewed for the food choices were the amount of calories or what is less filling, as described below:  (2009), where they analyzed the diets chosen by forty-four anorectic patients and thirty-four people without ED, they also found that anorectic patients have a lower fat intake than healthy people, and also the content of carbohydrates, proteins and fats were lower among these people.
Other factors mentioned about their food choices were the cravings, flavor, or taste, as testimonials below: During episodes of binge eating that occur in ED's it is possible to happen considering food choices when these episodes are planned. But in most cases, they are not planned, so there is no choice of foods to be eaten (Devoraes & Fagundes, 2005), which can be confirmed by the testimonies below: One of the professionals needed in a team that works with people with ED's is a nutritionist. His role is closely linked with the factor of food choices, since the nutritional advice is important to clarify and demystify inappropriate beliefs as well as enabling the establishment of a proper relationship with food (Alvarenga & Larino, 2002). The statements below show the influence of this specialist in food choices on some of the adolescents interviewed: "The nutritionist who chooses. She also lets me choose, but I prefer her to choose because it is difficult, I don't know what I like." (Gabriela) "We (she and the nutritionist) tried to make a balanced menu, in the first month I followed a menu strictly, later we started adapting to make some modifications." (Paula) "I didn't know how to do this before I went to the nutritionist, I didn't know how to eat and stop feeling hungry." (Helena) We can not unlearn that food choices are complex decisions related to social conditions, cultural traditions and irrational elements, and that eating is also a social activity and food is an emotional issue (Alvarenga, 2004). Furthermore, since the beginning of our lives, food is intertwined with emotions, symbolisms and socioeconomic and cultural influences. Thus, eating infers, for sure, in making choices. But it also involves establishing relationships, relating or not with models and values from the family or others , adapting well or poorly to the established standards and living with habits, schedules and several lifestyles (Eisenstein et al., 2000).
To carry on the issue of food choice, we describe the meals made by the adolescents interviewed, as well as the meal composition.

Meal composition
According to the Guia para Escolha de Alimentos 2 (Philippi, 1999), the eating habits of an individual should be distributed in six meals, arranged as follows: breakfast, morning snack, lunch, afternoon snack, dinner and evening snack. In our survey, the number of meals ranged from 3 to 8 a day. According to Philippi et al. (2000), breakfast should be between 6 and 9 o'clock and make up 25% of total calories of the day. The teenagers interviewed described their breakfast as follows:

"It's a fruit and some yogurt, or a cup of coffee and two pieces of toast, or a small cereal bar, then it depends on if my weight is okay, it depends." (Paula)
"After breakfast I eat a fruit, or a cheese roll during the recess." (Helena) Lunch should happen between 11 a.m. and 1 p.m., constituting 35% of total calories of the day -the largest meal of the day (Philippi et al., 2000). With respect to foods consumed for lunch by the adolescents surveyed, we highlight the following statements: Dinner should happen between 7 p.m. and 9 p.m., comprising, as breakfast, 25% of total calories of the day (Philippi et al., 2000). With respect to foods consumed for dinner, the following were the testimonies of the adolescents: It is also recommended to have a third snack, commonly called supper, composing, like the other snacks, 5% of total calories of the day (Philippi et al., 2000). Some of the teenagers interviewed have this meal, as described in the statements below:

"She (nutritionist) recommended that I eat supper, sometimes I eat it, sometimes I don't, because it is an apple or any fruit." (Carolina)
"Supper is also milk and fruit." (Gabriela) "And for supper usually a cup of coffee with skimmed milk, a banana, it's always something like that." (Paula) Looking at the descriptions of these meals made by the adolescents interviewed, we found that they actually have a very big concern in maintaining a healthy diet, they eat food that they consider healthy, although sometimes in small quantities or even skipping some meals. Two factors stood out about the weekends. First, waking up late and spending the rest of the day eating "crap", even though many of these teenagers interviewed said that they don't eat, changing thus the pace of all other days of the week, as evidenced by the statements below: In addition to the meals, there are also the so-called "extras" that would be eating anything that is caloric and different than what they are used to eating in their daily diet , as exemplified in the story of this adolescent: "Jaque ( nutritionist) kind of forced me to eat an 'extra' during the week as well. An extra, anything like this, a piece of cake, or more over the weekend. [...] But it's so tricky, I always feel kind of guilty." Once observed these meals contents, we will describe, then the perceptions of these teenagers about the eating habits of their families, as well as the influence of these habits on the eating habits of these adolescents. It is noteworthy to stress that the opposite may also occur: the eating habits of adolescents influencing the family's eating habits.

The family's eating habits
From birth, parents have a fundamental role in the development of the eating habits of their children, either by the type of food they offer to their children, or through the food concepts that they express, and all these factors influence the formation of eating habits of children .
The way the family organizes their diet -the type, quantity and quality of food -may constitute a risk factor for developing ED's. But in addition, another factor that plays a central role is the relationship that the family establish with food (Cobelo, 2004).
According to a study hold by Prieto (2011), in which fifty-seven relatives of patients with ED participated, the feeding of relatives of these patients with ED wouldn´t be healthy either, being in general hypocaloric. The study also showed that when the feed of the patient is compared to the feed of the relative, not big differences are found. In our study most of the adolescents interviewed also found their way to eat similar to their families', as these statements show: "It is (the family's eating habits similar to hers). A lot of fat, my father is more concerned, you know, but my mother is not, well, she is not fat, but she feels like eating the same things as I do, a lot of pasta, she can't eat only one roll of bread for the afternoon snack, she's always overeating, and sometimes she also spends hours without eating, she eats very little, well, three meals, she wakes up in the morning, she does not eat in the morning, she eats lunch, she eats more for lunch, then she drinks coffee at 6 o'clock, she goes up to 6 p.m. with no food, and then at night she eats something, always a snack, some crap." (Julia) "My brother has always been into martial arts and this stuff, then he's already been into healthier food, as well, but he eats a lot, he eats a fried egg every day, but he makes a lot of physical activity then. [...]  The family's relationship with food is important because the timing of meals goes beyond its nutritional aspect. It is a time to share, beyond food, information, daily activities, messages, etc.. (Cobelo, 2004). According to Cordás et al. (1998), eating and emotions are closely related, so meals should be happen, whenever possible, with all family members, with set hours and a friendly and pleasant atmosphere.

Healthy food
To be considered a healthy diet it is necessary to be present a variety of foods according to the dietary habits, food availability and nutritional needs of each individual. It should also be considered the calorie intake and the inclusion of all macro and micronutrients in adequate quantities and proportions (Philippi & Alvarenga, 2004).
According to the Ministry of Health of Brazil (Brasil, MS, 2005) a healthy diet should be based on "dieting practices taking social and cultural significance of food as a basic conceptual foundation", having the main characteristics: the respect and appreciation to the culturally identified dieting practices, since food has different cultural meanings; access guarantee, taste and affordability, because contrary to what has been socially constructed, a healthy diet is not expensive and should be tasty, it is varied: so it can provide different nutrients that the body needs; it is colorful, to ensure the variety especially in terms of vitamins and minerals, it is harmonious, with regard to quantity and quality of food consumed to the extent of appropriate nutrition considering the cultural, affective and behavioral aspects, and it is safe: from the physical chemistry and biological contamination standpoint and possible health risks.
In the description of the adolescents interviewed, the concept of healthy food seemed to us much more restricted. This is how they described it: We see thus that these adolescents have an understanding of the principles of a balanced diet, although in most cases, they have attitudes that do not correspond to this understanding, since, as it was previoulsy seen, eating goes beyond nutritional dimensions, also involving emotional factors, being both socioeconomically and culturally influenced (Alvarenga, 2004).

Discussion
In recent years, AN and BN have become important topics of discussion in the Brazilian and world media. Characters in soap operas of the main open TV channel in Brazil carrying pictures of AN and BN, headlines from the covers of magazines, newspapers and central theme of several shows, both on TV and radio, contributed to the increased audience flow.
This whole discussion brings a positive aspect: the dissemination of information about ED's by these vehicles of mass communication, because the earlier one detects an ED, the greater the chances of a good prognosis. As people's attention is called to the ED and the population becomes aware of its existence, symptoms and consequences, the more likely it is to be discovered in less time. Often seen as a teen mania, because of lack of information, the episodes reported by the media leads knowledge to the outsider public that AN and BN can kill.
In our research, we believe that the best people to provide information about ED's were the individuals affected by these diseases. Thus, in order to understand the meaning of the lived experience of people with ED's, particularly adolescent girls, we looked for them. This contact allowed us to know their experiences and feelings directly and indirectly related to their ED's.
Discovering what ED's are is not a very hard task, once there are numerous scientific articles and several books describing them. Our proposal was to show how these disorders are in the view of who is going through them.
In the contact with the interviewed teenagers, the availability to open the doors of their existence and share the history of their disorders and lives called our attention, even in the presence of suffering that emerged so many times in form of a deep silence or of tears that almost, or sometimes, were shed. The contact with these teenagers was enriching. The interviews allowed us to describe behaviors, attitudes, feelings and perceptions that guided our research.
An exacerbated concern with eating control is the common base of ED's, according to literature. This concern was also evidenced in our interviews, both with the teenagers that were having nutritional counseling and the ones that were not. There is still the intention of a diet considered healthy by them, which is not always their favorite, but it is, even though, adopted.
We observed in our interviews that eating choices are usually done according to the amount of calories or with what gains less weight, but, besides these, the flavor, taste and desire also influence this choice. Some testimonies showed us that choices are made according to the guidance of the nutritionists, emphasizing the importance of this professional in the success of the treatment. However, in the episodes of binge eating, we observed that there is no rule for choosing.
Regarding to the number of meals had by the teenagers in our research, they quoted between three and eight a day, being distributed in breakfast, morning snack, lunch, afternoon snack, dinner, night snack, supper and "extras". Most of the interviewed teenagers considered their way of eating similar to their family's; some that the family's way of eating is similar to their own way, being different only to the amount. Others that their current eating habit had influence from the family's eating habit and one of them that she has influenced the family's eating habit, making it healthier.
This research allowed us to contemplate ED's by the prism of the relation with the food, confirming how this relation is connected to emotional matters. It has also shown us how it is to live with ED's in the view of the teenagers, trying to see these disorders according to their understanding and feelings. And, despite the theoretical knowledge and clinical practice with people with ED's, this "intersection" between nutrition and psychology led us also to see something relatively popular with a new vision.
In addition, this study, during its execution, caused significant changes in both personal and professional aspects, opening questions for future consideration.
With regard to the method adopted in this study, we believe that the choice of qualitative methods, focused on a phenomenological approach, was confirmed in fact to be the most appropriate according to the proposed objectives. The method adopted allowed us access to the content in a profound way, not generalized nor interpretative, as described by Heidegger (1989) " to let that which shows itself be seen from itself in the very way in which it shows itself from itself ".

Final considerations
This research, as noted, sought to understand the meaning of the lived experience of ED's instead of explaining them, since through the adopted phenomenological perspective, it is the understanding of the phenomenon that enables us to cover a whole in its multiple dimensions. Thus, it provided us to show you how it is to live with ED's in the vision of each of the seven adolescents interviewed.
But we can not stop here: it is essential to have more studies on this topic, especially providing space to people with ED's who have so much to say. Of great importance also is the information and disclosures about these ED's, as well as about the appropriate treatments and the right professionals to help in these cases, in an attempt to prevent that the suffering of those affected go unnoticed and last for too long -or even worse -lead to a tragic outcome. Alvarenga, M. & Larino, M. A. (2002). Terapia nutricional na anorexia e bulimia nervosas. Revista Brasileira de Psiquiatria, Vol.24, No.3, (December 2002) www.intechopen.com