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. 


The Most Important Part of Eating Disorder Treatment

Recent exposure to non-clinical blogs and videos has led me to review my own blog and reflect on the overall message of my writing. I was surprised to see only a limited number of posts specifying treatment differences between anorexia and bulimia. However, there are a lot of posts about obesity and binge eating disorder, two increasingly recognizable eating disorders only now getting attention from the mental health community. 

But the majority of the posts concern the psychological experience of having an eating disorder and the treatment approaches necessary to counteract and heal that suffering. 

The nature of treating people with eating disorders has clearly inspired me to focus primarily on what leads to the difficult changes in the thought processes central to the eating disorder. My experience treating adults with eating disorders led me to realize that finding ways to fight the thoughts is necessary for recovery. 

The eating disorder treatment community has now created treatment centers, both inpatient and outpatient, that help people with eating disorders find immediate stability with food and nutrition. Depending on the severity of malnutrition and behaviors, almost every person can find appropriate care, often even covered by health insurance, to accomplish short-term medical stability. 

These patients leave treatment after a month or two and almost always quickly relapse within a few months. The gains of medical stabilization do nothing to change the eating disorder thought processes which inevitably consume the person's mind and restart the behavioral cycle. 

The path from seeking treatment options, attending a program followed by relapse is exhausting and demoralizing. The process of recovery really starts after discharge and involves help from an experienced team and the daily struggle of identifying the eating disorder mindset, questioning it while adjusting behaviors around food and body. That process, day in day out, is the work of recovery that leads to becoming fully well. It's painstaking work.

I have come to know the intimate details of what true recovery looks like. I have seen people suffer with relapse and struggle to apply everything they know for the purpose of getting well. This experience is both heartwarming and excruciating and has led me to want to share my experience two ways.

First, I want to help people in recovery understand they are not alone: there are crucial parts of recovery that are universal. Second, I want people in recovery to understand the key mental and relational components of what makes treatment more effective.

The urgency to share these two things has inspired the majority of posts to this blog. In my mind, these key points reflect the needed parts of a treatment plan that lead to full recovery and to open the door to personal discovery.


Recovery and Discovery

I was recently referred to a podcast called Finding Our Hunger hosted by Kaila Prins, a woman professionally and personally focused on eating disorder recovery, body positivity and women's wellness in general. Her approach to women's health around body and food is as refreshing as it is profound. Her freedom with herself and the world around her is clear from the opening words of her podcast. 

From the few episodes I listened to, I was struck by the vocabulary and use of terms that were much less clinical and very empowering. One phrase she used to describe the path out of an eating disorder or disordered eating is "recovery and discovery." Although the term is simple and straightforward, the language emphasizes the nature of wellness that steps out of the medical model and into the space of living one's life freely and fully. The pathology of eating disorders, still mostly tied to women's role in our culture, continues the age-old tendency to pigeonhole women's struggles as a sign of illness. The term discovery throws off that mantle for something very different. 

Recovery is a useful term to describe the process of normalizing eating patterns, the experience of hunger and fullness, body image and changing the punitive thoughts of restrictive eating. When applied to the exploratory nature of learning about one's own thoughts and feelings, likes and dislikes and overall identity, the term recovery implies that this search is a journey related to pathology. Instead, the journey of discovery is a path towards living life more fully and rejecting the pressure from society to overvalue body, weight and food over truly meaningful aspects of our humanity. 

I have written extensively about these two parts of treatment but labeled them as different aspects of recovery. A subtle change in terminology can be just enough to differentiate between illness and wellness, between a medial/psychiatric issue and the daily struggle of living life. 

Discovery is truly the end result of effective and successful treatment for an eating disorder or disordered eating. The goal is to find out who you are and to live life. And that is a lifelong process and philosophy. It's the bastion of hope to convince people that full recovery is possible.


A Novel Eating Disorder Revisited: Pathological Obesity

Although most people consider eating disorders to be solely based on eating behaviors and weight, the central problem with these illnesses is psychological. The relentless thoughts about food and weight and the incessant negative, punitive thoughts about oneself are torturous for people with eating disorders. With help to combat those thoughts, changing behaviors and full recovery are both very possible.

The newest and least talked about eating disorder is a result of societal pathologizing of being overweight. Medicine insists that obesity is the cause of endless health problems and in the end an issue with an easy solution: just lose weight. Rather than seeing weight as a complex variable with a plethora of possible causes, doctors approach weight as an easily fixable issue that is at its heart a dire medical concern. 

The public has followed this conclusion and pathologized weight long enough to create a large group of people plagued by constant doubt, shame and self-loathing. Since diets and weight loss plans are almost universally unsuccessful, people attempt to follow prescribed solutions, feel constantly like failures and are obsessed with food and weight instead of trying to live their lives. 

From a psychological perspective, the experience of these constant thoughts are synonymous with an eating disorder. The primary cause of the problem isn't eating or weight. Instead, it is the manifestation of a society excluding, isolating and shaming a population into a submission. In effect, sanctioned prejudice against overweight people has created a psychiatric condition and worsened the growing public health issue of eating disorders. 

The real solution to the problem is to stop pathologizing weight. Overweight people can also be healthy and medically well. The myth that a higher weight is directly linked to poor health is steadily being debunked by research. People deserve to live their lives fully and feel like complete, valued human beings no matter their weight. 

The growing movement of weight acceptance demands that people identify and question the bias towards those who are overweight, a very ignored and tolerated prejudice. Acknowledging the unfair treatment of this population is a big step towards challenging the accepted norms. It is no more acceptable to say one doesn't like fat people as it is to not like people of another race or sexual orientation. 

The best treatment for someone with pathological obesity is to work towards self-acceptance. Rather than believe life isn't worthwhile without weighing a certain number, healing comes with the growing idea that someone has as much inherent value no matter their size. Personal acceptance of that statement needs to accompany a more general belief that bias against someone because of their weight isn't acceptable in any form.