Community Influence on Eating Disorders

One aspect of eating disorders I don't write about frequently is the influence of community. Where someone lives and the general expectations and norms for the community have a significant influence on how someone's eating disorder manifests. 

In some communities, a person's value is largely dependent on looking a certain way. Children will learn from parents and peers at a young age that body and looks are paramount for identity and confidence. In the concrete mind of a child or adolescent, these facts transform into black-and-white rules about living. Suddenly, the overvalued ideal of weight and shape become the only important thing in a child's life. This situation opens the door to dieting and obsessive thoughts about food and weight, a significant risk factor for an eating disorder. 

Some communities take this ideal to an extreme. For example, many adolescents or young adults discuss learning how to purge food as a rite of passage. Children openly discuss and teach each other the tricks. In others, Adderall is widely available and shared among all peers as a way to enhance studying and inevitably curb appetite. 

The openness around these dangerous activities among those susceptible to eating disorders is very risky. Some people are at much higher risk for eating disorders based on genetic predisposition and emotional vulnerabilities. However, simply living in these communities increases the risk of an eating disorder based on the accepted and taught practices and overvaluation of weight and food. 

The underlying fix for this distortion is through education, but the difficulty is the means of education that will get through to an age group programmed to feel invincible. Seeing the effects of these destructive behaviors going haywire on peers can have an impact, especially when those peers are only a few years older. Shifting the ever changing sense of what is cool to this impressionable age is just as effective. Focusing on trends for eating locally or body positive movements can energize a new trend quickly in susceptible ages. 

The issue is to raise awareness of these risks in communities where the incidence of eating disorders is high. Doing so can trigger a backlash against the norms and start to change behaviors.


Binge Eating Disorder: A Need for Parity

The societal understanding of Binge Eating Disorder (BED) has had an impact on medical diagnosis and treatment. Binges are seen largely as a clinical term to describe overeating rather than the symptom of eating very quickly an amount of food much larger than a meal in a very short period of time. The distinction is very significant. Even though BED is now one of only three eating disorder diagnoses, most people mistakenly view this illness as justified gluttony. 

The increase in binging in recent decades stems from two changes in our daily lives: sanctioned starvation through dieting and the abundance of addictive, processed foods. Starvation through restricting leads to excessive, uncontrolled hunger in many people. Even once better nourished, the hunger frequently takes months or years to diminish, and regular dieting without cease can mean the intense hunger never goes away. Also many people are susceptible to the addictive qualities of processed foods, namely added sugars and fats, which increase the likelihood of binging. 

In a society searching for a pharmaceutical cure to human limitations, many people seeking help for BED simply want a medication to fix what most people call the "chemical" cause for their illness. The pharmaceutical industry has added to this belief by viewing BED as a new frontier, approving Vyvanse last year despite minimal evidence of long-term benefit. Rather than look for a treatment plan for recovery, people with BED more than any other eating disorder have been primed to only seek a quick fix, as if their symptoms are just a chemical deficit rather than a full-fledged eating disorder. 

The reality is that people with BED need a comprehensive treatment plan including therapy, nutrition counseling and medication just as anyone else with an eating disorder. Distorted views about binging and about the fantasy of a magical cure seem more accepted for BED, but that belief leaves these patients much more hopeless and without reasonable expectations for treatment. It's crucial for patients with BED to be treated as thoroughly as anyone else with an eating disorder.


The Psychiatric Symptoms Caused by an Eating Disorder

People with eating disorders are often diagnosed with comorbid psychiatric illnesses including depression, panic disorder, and obsessive-compulsive disorder in addition to many others. Clinicians do not often attempt to differentiate between the diagnoses and clarify the interplay between them, much to the detriment of the patient. 

It is rare that another diagnosis is the primary diagnosis; usually the eating disorder is the central issue. People with other primary diagnoses may have eating symptoms as a part of their struggle, but a full-fledged eating disorder inevitably takes over a person's life. 

A list of diagnoses, rather than just one, only makes someone feel sicker and untreatable. An explanation of what the diagnoses mean and how they reflect the person's current state and likelihood of successful treatment is a much kinder and more helpful way to approach the path to recovery. 

What is rarely discussed with patients is that starvation and binge/purge cycles themselves can cause psychiatric syndromes. In other words, one effect of chronic eating disorder symptoms is to create a new psychiatric diagnosis hat resolves with normalized eating. 

Starvation and binging are known to lead to depressed mood. Chronic, severe hunger begins to feel like anxiety much of the time, especially because people who are starved lose the ability to identify hunger. In addition, low blood sugar, a common long-term effect of an eating disorder, creates the feeling of a panic attack. Anyone starved over time develops OCD symptoms no matter how susceptible they are to this illness. 

Having a series of psychiatric diagnoses is different from realizing that the eating disorder causes a host of psychiatric symptoms that mimic other diagnoses. This fact also explains why medications tend not to be as helpful in treating psychiatric symptomatology associated with an eating disorder. If starvation or binging causes the symptoms, then medication will be much less effective than food, the only real medication that helps with recovery. 

This idea also brings up the idea that food is a mind-altering substance. It can lead to emotional stability, clarity and mental acuity. Starvation can lead to volatility, confused thoughts and dullness. Eating disorders are illnesses that affect our entire bodies, our minds and emotions included.


The Meaning of Weight in Weight Loss

The concept of weight in medicine and especially in the diet and weight loss industries is very confusing. So much attention is given to the number on the scale and so little to the meaning of that data point in metabolism and health. 

Shifting the focus away from weight and to changes in daily routine around food and activity is much more effective for long-term change. If all importance is placed on the number on the scale, success is marked solely by continued downward changes. Any leeway based fluid shifts, metabolic changes and the many other things that affect weight is nonexistent: it is simply a failure. However, if success relates to consistent lifestyle changes, which also are a better marker of health, the person can embrace the positive, and weight changes will follow as one of several key markers. 

There are three ways to understand weight as a valuable source of data: the current weight, the local weight range and the set point. Each reflects very different information of varying usefulness. Understanding the nuances of body weight also makes clear the limited value of these data for health. 

It's most clear to start with set point, the most longitudinal information, and proceed to the more specific. The set point is a wide range of weight, typically about 15% of total body weight, that anyone can shift within quite naturally. The body is comfortable and not in danger anywhere in this range. Any pressure to go above or below this range leads to a strong metabolic response to attempt to stay within this range. The brain and hormonal system has determined that this range is ideal for health and will therefore protect the range for survival. If enough pressure through starvation or overeating persists, the range can shift down or up over a period of months to years. Then the new range becomes the norm. 

The local weight range is a variation of about 2-5 lbs that the body can vary day to day. This weight change is almost completely due to fluid shifts from retained water or dehydration. Fluid shifts can be significant. One salty meal may increase weight the next day by up to 5 lbs. Monitoring weight too often simply reflects these fluid shifts. Body mass changes rarely constitute more than a pound per week and typically much less. Very fast weight loss on diets is almost exclusively water loss. 

Any specific data point of weight has very little medical value. This number will rest in the current local range and will be up or down based on the current fluid state of one's body. 

Weight data only has value longitudinally. This information over a period of weeks to months will clarify the general set point and range for someone and further history can clarify how long it has been set. Recent eating history and weight change can give a clinician an idea of where the person's weight lies in that range. Longer term history will dictate a plan for lifestyle improvement and how health and then weight may change over time. 

A true shift in the concept of weight loss needs to reflect the limited utility of weight data and take attention off of the number on the scale and instead to sustained lifestyle changes.


Diets Don't Work 101

The news this week about the Biggest Loser contestants gaining back most if not more of the weight they lost is no surprise to clinicians who treat people with eating disorders, nor is it surprising to anyone who has read this blog. 

The initial cause in the rise of obesity is related to several changes in lifestyle over the last few decades. The abundance of processed, non-nutritious foods which are highly caloric and also quite addictive has wreaked havoc on the average person's diet and exposed weaknesses in the human ability to navigate hunger and fullness. In addition, changes in transportation and careers have led to much more sedentary lives. These two facts have led to a spike in obesity and diseases that follow such as diabetes, high blood pressure and heart disease. 

Treating obesity, however, is not about changing these variables but instead addressing a metabolic disorder caused by excessive weight gain. Attacking the problem head on with swift weight loss is never successful, as decades of research have shown: nothing new in the Biggest Loser data. The only form of success involves long term, permanent lifestyle changes and slow, steady weight loss. The key is that the changes are not temporary: the diet paradigm does not work. 

The psychological manifestations of weight gain in our current society make weight loss seem urgent. Many people feel that obesity must be fixed before facing any challenges in life, professional, personal and emotional, a condition I have called pathological obesity. These people spend years focusing solely on quick fixes for weight loss and forgo all other components of their life. The urgency leads to a variety of unsuccessful diets that result in higher and higher weights. 

The cure for obesity involves slow and steady changes that require an enormous amount of patience. It also requires psychological help to face life's challenges concurrently to accept the thought that life must continue and progress, even if one is still overweight. 

In honor of this news about the Biggest Loser, I will repost the most read article about obesity from this blog as well. Meanwhile, the next post will address the underlying metabolic problem in treating obesity in words everyone can understand. It will truly explain the role of weight in weight loss.


Threats and Punishment in Eating Disorder Recovery

One of the reasons this blog focuses on compassion as a core value of treatment is that threats and punishment comprise such a large part of the attitude of clinicians and families towards eating disorders. 

Shame is a central part of an eating disorder, and punishment is an underlying manifestation of almost all eating disorder thoughts. These two values are truly the engine that drives most eating disorders. Using those attitudes to approach these illnesses only strengthens their hold on the person who is suffering. 

The general public struggles to understand all psychiatric illnesses, but eating disorders may be the least understood. Still glorified as a successful diet and as a source of envy, most people are hard-pressed to see the torment patients endure. 

When the symptoms finally come out in the open and the medical or social repercussions become clear, family and friend responses are very often punitive. Threats quickly rise to the surface, and the underlying message is that an eating disorder is not an illness but a willful choice of behavior meant to ask for attention or cause trouble. It's extremely rare for the first question about the eating disorder to be, "What is wrong? How can I help you?" Yet this is the only question that might really avert the severe illness that often ensues. 

The public opinion of an eating disorder as a successful diet or an adolescent rite of passage only explains part of this general attitude. The other part is that eating disordered thoughts and behaviors just make no sense to most people. As explained in a recent post, once eating behaviors are ingrained, they become very automatic. Someone with relatively normal eating patterns will find disordered behavior completely confusing and almost unthinkable. Hence the most common initial suggestion of a parent with a newly diagnosed child with anorexia: just have a milkshake! This sentiment only makes the sick person feel more alone and more scared. 

Similarly, it appears to be almost universal to think that anger and threats will somehow snap the person out of an eating disorder even though those reactions only alienate and isolate the person further. Kindness and compassion are the way most people would approach a loved one in pain and suffering. That's no different with someone who has an eating disorder.


The Role of Automatic Eating Patterns in Recovery

A common question when starting recovery is how long does treatment last. That question is hard to answer exactly, but the answer must reflect the reality: it takes quite a long time to recover.

This reality is important for patients, clinicians and loved ones to understand because one underlying tenet of treatment is patience. Slips and struggles cannot turn into a reason for the patient, her family or the therapist to blame her for the illness or the length of time needed for recovery. Everyone needs to understand that this process includes many ups and downs, struggles and successes.

Since people can fully recover from these illnesses, it's perplexing to many why recovery takes so long. Changing eating patterns from disordered eating to normal eating seems like it ought to be very straightforward, yet realistic progress could not be more complex. 

The biological underpinnings of the recovery process are useful to better understand why. 

Some human behaviors, like those of animals, are largely innate and do not require much conscious attention, such as breathing, sleeping, walking or eating. Although we often use our abilities to attend to these actions, our more primitive brain functions will take over and force us to perform these tasks if we choose not to. 

Our brains are hardwired for these specific actions because they are necessary for survival. The gift of conscious awareness and attention can only go so far before our animal instincts force us to continue these tasks. Eating falls into that category. 

Most eating disorder patients who have restricted long-term reach a point where their hunger reaches starvation level and their minds don't let them starve anymore. As upsetting as this is, our bodies are programmed to live. But, as I have written many times in this blog, eating in and of itself doesn't equal recovery. 

Similarly, our brains appear to develop powerful eating behaviors that become ingrained in our daily life. There is a large variety of these behaviors: grazing, substantial meals through the day, constant food obsessions and disordered patterns. However, once those patterns are set, they become deeply entrenched in our daily routine. Since food behaviors appear to be well-protected, primitive behaviors, these patterns become locked into very fixed circuits in the brain. 

Changing those fixed circuits takes a lot of time, practice and attention. Eating like we did when we were children is not akin to riding a bicycle after years of not doing so. Relearning how to eat is a long, arduous process in which every step is not intuitive and demands attention and focus. Over time, the mind can learn a new way of handling food thoughts and behaviors, and the new patterns gradually become unconscious and automatic. Those behaviors do change, but the transformation of any unconscious process takes quite a bit of time.