The Painful Truth about Dieting

The term diet originally meant the different types of food a person ate each day. The concept described a factual list of foods rather than a prescribed or limited one. 

A diet has clearly become something different in our current world. Today dieting implies intentional food restriction in order to lose weight. The act of going on a diet means one needs to lose weight and will make a concerted effort to do so. It means judgment about one's body and weight. It means someone is taking a supposed virtuous and health-minded step towards wellness. It means something is wrong and a diet will somehow fix the problem. 

Although dieting originates with concerns about weight, by and large the result of dieting is to attempt to fix the ills in one's life. 

The result of any temporarily successful diet is widespread praise. Others comment on changes in weight and compliment on a regular basis. Dieting is a public act that warrants public attention. This is often the main reason people diet. 

Paradoxically, hard data about dieting shows that 98% of them fail. In fact, the large majority of people end up gaining weight after a diet. Despite a plethora of evidence against the benefit, people regularly attempt to diet. There is nothing else to replace the collective desire for the praise that attends short-term weight loss. 

With this background, it's clear to see why adolescents, who are constantly searching for an identity and praise, easily latch onto dieting and weight loss as a marker of personal success. No wonder dieting has become a rite of passage in high school. But exposing most teenagers to dieting looks more like a horrible experiment in the effects of widespread starvation than an introduction to adulthood. 

Chronic food deprivation triggers the biological survival mechanism of starvation. Humans are genetically programmed to respond to food restriction in very specific ways to survive. Symptoms include obsession with food, all consuming hunger, the desire to overeat and focus on all things related to food, to name a few. Specifically, these symptoms look suspiciously like eating disorder symptoms.

In other words, most eating disorder symptoms are the biological response to starvation gone awry. Our diet culture has in large part caused the sharp spike in the incidence of eating disorders. 

As long as dieting is a central part of our general ethos, eating disorders are here to stay. I'll write about some thoughts on how to combat dieting in the next post.


Dieting is the Most Important Risk Factor for Developing an Eating Disorder

Clinical literature, academic research and personal memoirs about eating disorders all ignore one crucial and salient fact about these illnesses: they all start with a diet. 

This seems like an obvious point. The inception of an eating disorder is right in front of us. Dieting is an integral part of our culture, a rite of passage for all adolescents. Weight loss and the compliments that ensue are a sign of the ultimate gold star of success. 

What is lost on the communities that condone dieting is the inherent risk of this ritualized practice. For most people, dieting is one of a few things: a short-term lark, a series of new beginnings which always fail or a misstep in how to eat healthily. But for a small percentage of people, it is the start of a chronic, severe illness. 

Dieting is essentially self-inflicted starvation. The goal is to eat a limited amount of food, significantly less than one's body needs, in order to lose weight. Dieting is somehow considered safe and healthy, largely due to the influences of the cultural norm of thinness and a powerful diet industry. The consequences are almost completely ignored. 

To state the dangers of dieting as clearly as possible, the number one risk factor for developing an eating disorder is dieting and restricting calories over a significant period of time. If people didn't diet, there would be no public health problem of eating disorders in this country. Prior to the late 1960's, eating disorders were a very rare phenomenon. The increase in dieting has in large part spurred the skyrocketing incidence of eating disorders. 

This fact remains unheralded and ignored despite the explosion of public information about eating disorders. Parents will follow a doctor's or nutritionist's advice to put a child on a diet. Most parents won't bat an eye when a teenager diets and loses weight. The willful collective ignorance about dieting continues to leave children unprotected from this growing problem. 

The next post will address more clearly why dieting causes eating disorders.


Why is Coaching a Viable Part of Eating Disorder Treatment

The last post explored the role of coaching in eating disorder treatment but left one question unanswered: how can untrained paraprofessionals safely participate in treating a severe mental illness?

There are parallels in other fields where less extensively trained people treat illness: optometrists vs. ophthalmologists or chiropractors vs. orthopedists, to name a few. These options generally reflect a cheaper form of care when the patient seeks help for more basic problems. But the increase in coaching as a viable alternative or addition to traditional eating disorder treatment reflects something different.

Eating disorder treatment is often successful, but the underlying reason for improvement is elusive. Although different types of therapy can give a patient the choice to find the right fit for them, even seeking the supposed best care doesn't guarantee full recovery. Finding the motivation or reason why one person can take steps in recovery is typically very individualized. Progress depends less on education or training and more on the nature of the therapeutic relationship and the ability to tap into a desire for wellness otherwise unknown to a patient. If successful treatment depends largely on the relationship, then it's possible that the best person for someone may not be a professional. 

Coaching offers a new way for people who have experienced their own struggle with food and body, or even their own eating disorder, to help others without seeking formal training. The risks of seeing someone less trained are clear: a lack of complete understanding of the power of the therapeutic relationship and the nature of recovery can be damaging. However, exposure to the right person can be exactly what someone needs to find their own path to recovery. 

Due to the risks of seeing someone less trained, I would suggest a patient see an experienced therapist as the foundation of treatment, but seeking guidance from a coach whose writing and messages are meaningful can augment recovery in significant ways. In the end, the goal is recovery in any way one can find it.


The Role of Coaching in Eating Disorder Treatment

A relatively new but growing component of the eating disorder treatment community is coaching. Although this industry is generally becoming more popular, helping people with eating disorders is its most significant foray into mental health. 

In general, coaching provides many more options and much more flexibility than traditional clinical treatment. Not bound by the same professional and ethical constraints, coaches can provide not only one-on-one meetings but group online chats or discussions, weeks or months long courses, an assortment of blogs and podcasts and more flexible meetings and hours. 

As I have written many times in this blog, successfully treating someone with an eating disorder demands flexibility. The eating disorder thoughts are present 24 hours per day. An appointment a few times per week may be helpful in the moment but is often insufficient to stave off the power of the eating disorder meal after meal after meal. 

The inherent flexibility in the coaches schema allows for much more accessibility to counter the relentless eating disorder thoughts. 

The rise in coaching people with eating disorders also reflects two facts about these illnesses in our society. 

First, there is still a conflict between the concept of disordered eating/food obsession and an actual eating disorder. The internal struggle with food and weight that is pervasive in our current ethos masks the severity of full-blown eating disorders. Coaching spans all these issues, and many people with eating disorders many not be aware how severe their problem is. That leaves room to research and seek help from non-clinical care. 

Second, the limitations of clinical and often overly medicalized treatment for eating disorders leaves a lot to be desired. Many people are frustrated after seeking out help and are turning to coaching for another avenue for recovery. Coaches are more free to individualize treatment and forge new theories of practice. They also aren't as well regulated and certainly aren't trained to diagnose an eating disorder or identify concurrent problems. But the desperation of struggling with an eating disorder certainly makes another option worth pursuing when clinical treatment has been a bust. 

It would behoove the eating disorder treatment community to embrace the coaching movement. The flexibility of support, positive, creative messages and alternative approaches to countering the eating disorder thoughts can all help someone in the throws of recovery. Since there is no clear path to wellness, any support that is useful to someone struggling to get well can have real benefit. 


The Realities of Nutrition Science

A recent article about nutrition studies by a renowned but at times misleading health writer cast a spotlight on an often hidden reality. Research into nutrition science is almost completely useless. 

The article points out that these studies cannot possibly take into account the myriad effects of many other external causes into various diseases or health concerns. The complexity of singling out any direct link between a diet change and a medical or health outcome is almost impossible. 

The omnipresent diet and exercise industries would have us all believe otherwise. They insist that any number of decisions about food choice is essential for long-term health and weight loss. These supposed experts have no guidelines and regulations about their advice and can continue to spread misinformation to build business. As long as the media covers nutrition studies as if it is science, most people will attempt to follow these often contradictory suggestions and remain adrift about any dietary decisions they make. 

The real experts have provided guidance about how to interpret nutrition information for years. However, their thoughts are so basic and obvious that they tend to drift quickly into oblivion. No one wants to hear that diet advice is completely unfounded. It's not interesting copy to report that the best diet is a variety of foods in a moderate amount with as much real food as possible. 

The limited amount if knowledge we do have about food and nutrition doesn't come close to satisfying our collective appetite for a magical way to approach eating. Everyone wants a quick fix that is proven to promote health, longevity and weight loss. Since nothing of the sort exists, American ingenuity creates an endless assortment of fabricated solutions to food, and the public gobbles them all ignoring the obvious fact that no approach is proven to be effective. 

The first step to find a peaceful and knowledgeable way to approach food is by accepting the clear evidence that nutrition science is extremely limited. Any desire to find a quick fix represents an emotional attachment to food and a need to manage those emotions through manipulation of one's diet. Acknowledging this reality is the first big step forward for anyone with a difficult relationship with food.


Common medical problems associated with Chronic Bulimia

The medical problems associated with Bulimia are largely due to the process of compensating for binges most commonly with purging or laxative abuse. Both behaviors are very traumatic to the body. Most people will be able to adapt temporarily but the long term consequences are severe. 

When we vomit in any way, the body loses a large amount of potassium at one time. Just being sick over a period of several hours or a day is a state we can overcome quite easily after a day or two of rest and replenishment. Regular purging over months and years leads to a constant norm of low blood potassium concentration. This electrolyte is necessary for normal human function, so the medical consequences of low potassium are great. The two organs most affected are the heart and kidneys.

The heart conduction system initiates each and every beat and is very sensitive to low potassium which can cause irregular beats or even lead to cardiac arrest. Although the body can adjust to chronically low potassium, this new state leads to a continued risk of cardiac abnormalities or even death. 

Constant low potassium also causes chronic kidney damage over time. At first this leads to kidney dysfunction, but since we can all survive with one kidney, the damage doesn't lead to a change in lifestyle. However, a decade of this new steady state can lead to kidney failure and the need for a transplant, something that is a real possibility for someone with chronic bulimia. 

Laxative abuse is another common form of compensation for binging for people with Bulimia. Laxatives draw water into the colon, the second main part of the gastrointestinal system, and cause the muscles of the colon to contract powerfully and thus evacuate the bowels. Overuse leads to addiction so that the GI system slows down and eventually cannot function without laxatives. Withdrawal then forces the colon to relearn how to function normally again. 

Laxative abuse causes damage to the GI system by slowing down normal functioning leading to symptoms of constipation and bloating. Short-term laxative abuse can be overcome fairly easily, but long-term abuse can cause permanent damage. The colon sometimes cannot resume normal function and is damaged by the constant trauma of these medications. The effect is colonic inertia or very slowed processing of foods and waste, constipation and constant bloating. 

After years of laxative abuse, the body becomes used to losing significant amount of fluid through multiple episodes of diarrhea per day. The human body is constantly working towards a way to survive any change in circumstances. Thus, it will adapt to the daily loss of fluid by retaining fluid in another ways. Once laxative use is stopped, people often experience fluid retention since the adaptation of holding onto fluid continues. Most often, the body adapts back to its typical way of managing fluid, but years of abuse can damage the system of maintaining normal fluid levels and it can take months or years to adapt back again. In this situation, fluid retention and swelling are common symptoms until the body resumes normal fluid management.

These last two posts highlight how anorexia and bulimia are medical as well as psychiatric diseases. Sufferers need to understand that medical evaluation and care are important parts of treatment and clinicians need to be sure all patients have regular medical follow-up.


Common medical problems associated with Chronic Anorexia

As a medical doctor treating almost exclusively people with eating disorders, I see a cross section of complex conditions in almost every medical field. This experience leads me to often have a very narrow band of knowledge to diagnose and treat unusual situations. This post will highlight some common medical problems with anorexia and the next post with bulimia. 

Anorexia frequently causes severe gastrointestinal issues. This system is essentially one long tube lined by muscles that moves food and then stool through the body. Like other muscles, disuse leads to atrophy. Anorexic patients experience a GI system that stops working, namely gastroparesis (slowed digestion) and colonic inertia (chronic constipation). The symptoms people experience are bloating, gas and often painful constipation, all of which makes it even more difficult to eat. Treatment has limited benefit and only eating truly heals the problem, a conundrum for someone with anorexia. 

Poor circulation is another common chronic problem, especially to the fingers and toes. It's not uncommon for people with anorexia to have blue or even white fingers and toes in the winter. Often it can take an hour to restore full circulation once someone comes inside from the cold. There are medications that improve these symptoms and stop worsening of the circulation. Malnutrition limits the body's ability to maintain distal circulation to parts of the body furthest from the heart and prioritizes the functioning of the most important organs. 

For many complex and not fully understood medical reasons, patients with anorexia have trouble managing fluids. What this means practically is that people can often get swelling in their legs and sometimes through their entire body. The body cannot manage where the excess fluid goes and so it can build up in various places, some of which are medically worrisome. At its worst, people can gain up to 20 lbs of fluid overnight only to lose it in a few days. The best way to manage this medical problem is to monitor symptoms carefully and not rush to any medical treatment. Typical treatment for swelling can be dangerous for someone with anorexia because the balance of health is precarious. It's best to let the body handle the fluid and just to watch the basic vital signs. 

These three medical effects of anorexia are relatively common although very different from healthy people of the same age. Knowing the best way to manage the symptoms is critical for someone sick with this illness to keep them safe. Following standard protocol may be dangerous because an anorexic body survives and functions very differently from a healthy one.