Surviving The Pressure to Diet, Part I

For adults and children, the concept of dieting or restricting eating for health reasons is commonplace and even considered healthy. A part of modern day living is to constantly monitor and reconsider which foods should be eaten and which avoided. Our general appetite for more nutrition news is seemingly insatiable. 

Unfortunately, when these studies are fully evaluated, it's clear that they do not represent trustworthy science. There is no regulation of this information, and anyone is allowed to impart their own personal wisdom as fact in a new book, diet or food fad. 

The result is a world where it is virtuous to follow any diet without considering the validity of the recommendations or the health of the suggestions. Even the medical field tends to be unclear as to how to change eating behaviors since doctors themselves have minimal training in nutrition. 

Diets rarely consider some basic facts about our bodies, nutrition or metabolism. We focus mostly on calories and ignore other critical pieces of information such as essential items of nutrition necessary for healthy body function. We don't take into account the variety of foods necessary for general health. We also do not consider that changes in metabolism almost always, in countless studies, lead to a reversal in weight loss from every diet. How can a society supposedly grounded in science be so willing to forgo reason and diet incessantly when all evidence points to failure?

Therein lies the confusion. We all diet when reliable data points to its failure. We even encourage or turn a blind eye to dieting children until a real problem, such as an eating disorder, presents itself. 

A final issue is that all this dieting has increased the incidence of eating disorders significantly in the last forty years, yet no one seems to acknowledge this change. 

Three pieces of information can help explain why an entire society continues to make the irrational decision to diet without even considering the consequences: the desire for thinness at all costs and as a panacea for our daily woes; the collective panic over endless supplies of processed, irresistible food; and the total lack of protection by industry or regulatory agencies from the massive change in available foods in recent decades. 

I have written about these concerns in this blog before, and nothing has changed in recent years. This post serves as a bridge between the risks of starvation and the ways to combat the societal pressure to diet. The next post will focus on ways to rethink and revise our thoughts about dieting. 


The Risks of Dieting and Starvation

The model in the last post described a three step process to explain the cause of an eating disorder: genetic predisposition, environmental trigger and emotional/psychological stimuli. Although the first and third part of the model increase the likelihood greatly of illness, there is no chance an eating disorder will occur without the trigger of starvation. 

It remains somewhat controversial to view dieting and undereating as a necessary part of the evolution of an eating disorder. Dieting and losing weight are seen as a beneficial and even health-promoting parts of modern life. The increased concern over obesity and the incessant focus on thinness make dieting a cornerstone of our daily life. Dieting has become the de facto answer to many medical ills. 

Yet no one speaks of the medical risks of dieting and chronic starvation. Various diets of 1200 calories per day, half of which often comes from a shake made of processed protein powder, are commonplace. Starving all day in order to wait and eat at night is considered virtuous. The diet industry is a booming business. 

This message seeps down to children and adolescents who easily fall into the trap of dieting and soak up the praise that comes with weight loss while nobody seems to worry about the risks associated with a malnourished child. 

The immediate risks, including lack of energy, slowed thinking or weakened organ function, do not come to mind when we think about a diet. Instead weight loss is blindly equated with health.

But dieting also triggers ingrained biological adaptations to starvation, the body's protection against times of famine. The adaptations include obsessive thoughts about food and weight, slowed metabolism to conserve energy and the preservation of essential body functions at the expense of less necessary ones. The basic functions include cardiovascular function, maintenance of core temperature and basic organ function but sacrifices muscle mass, higher level brain function and reproductive capability. It's like the body running on a backup generator. 

This metabolic shift is the key to the illness model. It is the trigger. If someone rests in starvation metabolism for too long, they run the risk of triggering a longterm, adaptive shift into starvation metabolism, essentially a semi-permanent state to survive famine. In modern life, this mental and physical shift isn't based on actual famine. The food is still all around us. But starving for long enough can trigger the thoughts of an eating disorder if someone is so predisposed. That is the central risk. 

When dieting was not pervasive in our culture, this risk was minimal, but recent decades have made dieting almost a rite of passage. All of a sudden, we all are exposed to this risk, we all try to diet and starve at some point, we all test to see if we have a genetic predisposition to an eating disorder. And we all do this without any understanding of the risk we are taking.

Instead when a child or adolescent turns out to have an eating disorder, the general consensus is to throw up our hands in confusion, but the number one risk for developing an eating disorder is that first step to start a diet.

The implications of what this knowledge means for adults and children will be the focus of the next post.


The Causes of an Eating Disorder

Patients, parents, family and friends find solace in asking how an eating disorder starts. Often what makes an eating disorder last is more important for treatment than why it started, but figuring out the initial cause does two important things: creates a story that helps someone make sense of their lives and provides underlying clues for therapy. 

I have written at length about the number one cause of an eating disorder: dieting and starvation. Taking in significantly less food than one needs for an extended period of time triggers the innate human response to famine. Metabolism slows, organs function efficiently but less effectively, unnecessary body function is sacrificed. If this time persists, brain changes occur which include decreased cognitive function, obsessive focus on food and increased attention to body shape and weight. The number one reason for the skyrocketing incidence of eating disorders in recent decades is widespread sanctioned dieting, especially in children and adolescents. 

The second cause for an eating disorder is genetic predisposition. Not all kids and people who diet end up with an eating disorder. In fact, the large majority don't, even if many of them stay focused on food and weight into and through adulthood. A certain percentage of people have an innate response to eating disorder symptoms, largely a strong biological and seemingly chemical response to the eating disorder symptoms. Prolonged starvation, binging or purging can all trigger powerful chemical responses in the brain that are very calming and, for those are predisposed, almost addictive. In addition, the rigid rules and routine of an eating disorder create calm and safety not as an immediate response but as a longterm salve to the uncertainty of daily life. People who combine the trigger of starvation with the powerful biological response to the behaviors are at higher risk for an eating disorder. 

The third component of the cause of an eating disorder is emotional. Kids who lack love, warmth and attention feel as if they have found a panacea in an eating disorder. The almost magical trick of having figured out food--whether through prolonged starvation or a method of eating and purging l--and the positive feedback of being thin replace the emotional pain of feeling unloved and worthless. This experience can range from seemingly benign neglect to emotional or physical abuse to traumatic experiences. The severity of the experience tends to correlate to how much the emotional cause contributes to the eating disorder. 

These three components of the cause of an eating disorder do not factor in equally. For some the genetic component is the main instigator of the eating disorder and for some a traumatic childhood is. For most though, the eating disorder started because all three potential reasons came together in such a way that led to the person falling into this illness.

Most people find comfort in having an explanation as to why their eating disorder started. This conversation can be hard but it helps push aside the shame associated with the illness and give the person enough agency to continue taking steps in recovery.


The Food Journal: Five Years Later

I wrote in one of the earliest posts in this blog about the food journal. The reason to revisit this topic is the increasing feedback from the clinical community that the journal is more than a tool and actually a necessity for recovery. Many other clinicians see the journal as a key difference between those in recovery and those who aren't. 

The journal represents a daily external mechanism to see one's daily intake of food and share that with someone focused on helping with recovery. This explanation encompasses the three important aspects of the journal. 

First, the journal is a means to externalize the thoughts of the eating disorder. The act of writing the journal is a daily exercise in separating oneself from the eating disorder thoughts by processing food in a new and different way. Encouraging separation from those thoughts is a critical part of recovery. 

Second, seeing the day's food written out enables each person to see realistically the food intake for that day. Rather than allow the eating disorder thoughts to confuse and cloud that reality, there is no hiding from the words on the page. 

Third, the act of sharing the journal is a daily step of allowing someone else to help. It's a sign each day of committing to recovery and using relationships to move into a place of health and wellness and not become lost in the distorted priorities of the illness. 

The food journal is one of the hardest things for someone in recovery to complete regularly. Writing about food and showing that to someone else is very exposing and activates the shame that is a common stumbling block.

In addition, food is the most intimate of subjects for someone with an eating disorder so sharing that information opens the door to a very intense and close bond, something that feels intimidating when the illness remains so strong. 

It's important to recognize the food journal as a cornerstone of treatment. Writing and sending the journal each day are not just useful steps but instead are clear markers of recovery and need to be a central part of any effective treatment.


Therapy as the Central Focus of Psychiatric Treatment

It is rare that psychiatric research makes the headlines two weeks in a row. The current news discusses the results of a large study on schizophrenia, which, along with anorexia, have the two highest mortality rate of any psychiatric illness. 

The study reports that low dose medications plus regular psychotherapy is more effective than high dose medication alone. 

This is shocking news because psychiatry has hung its hat on medications as the best form of treatment for this illness with hope for more thorough pharmacological cures in the future. The NIMH funded study has clearly proven otherwise. 

Psychiatry has worked hard to find a place in the scientific world by relying on brain science and medications as the best hope for the future. Our limited understanding of the brain may be the reason this supposition is unrealistic. Perhaps it's a matter of time before brain science leads to simple pharmacological cures.

But there is also the possibility that the complexity of our brain doesn't lend itself to quick fixes. So much of our miraculous central nervous system is attuned to interaction with the environment, especially other people. Psychotherapy, a treatment that grew out of, at least in part, the lack of other viable alternatives, may be grounded in something very real and, at its core, scientific.  

In other words, the most potent tool to change brain function may be relationships themselves. 

This new study about schizophrenia and last week's conclusion about eating disorder behaviors as habits have one key similarity. Brain behavioral patterns, once established, are ingrained and difficult to change. Repeatedly research studies have shown that therapy is as effective or more effective than medications for almost all psychiatric illnesses: schizophrenia, eating disorders, depression and anxiety disorders. 

It's a novel idea to approach psychiatric treatment with the expectation that establishing effective, meaningful relationships is at the root of change with medications as an important but secondary tool. Although medication may play a role, relying solely on pharmacology does not have a good track record. 

Heeding the recent news means focusing on the therapy relationship first and foremost as the step into wellness.


Are Eating Disorders Habits?

A new study that received national media coverage uses brain scans to interpret the underlying intention of eating disorder behavior. The researchers' conclusion seems reasonable based on the limited scientific data and on corresponding clinical information: eating disorder symptoms are habit rather than willpower.

The current societal bent towards describing eating patterns as willpower stems from persuasive marketing by the diet and food industry for decades. Rather than understand the complex, innate nature of hunger and fullness, these industries surround us all with irresistible goodies and then perpetually blame us for not resisting them, thereby increasing profit. 

This mistaken understanding bleeds over into the general public's concept of eating disorders with two mistaken ideas: restricting food is about willpower and these people suffering from eating disorder are not sick but have actually mastered the ability to resist hunger.

Nothing is further from the truth. 

Clinicians who treat people with eating disorders will not find anything ground breaking in this study. It is the clever translation of accepted clinical knowledge into a simple research study, namely that the thought and behavior patterns of an eating disorder are habit.

This core knowledge does inform the treatment and recovery from an eating disorder. Simply educating a person about the risks of an eating disorder and explaining the health benefits of normal eating never influence recovery. Neither of these facts can change a habit. 

Two aspects of recovery are necessary to put into place a process that will change ingrained habits. That process is slow and arduous but, with consistent practice, will lead to new habit formation. 

The first step is accountability. Someone else other than the person with the eating disorder needs to be aware of the day-to-day events around food. Habits are by definition largely unconscious behaviors. If there is minimal conscious thought about the habit, the behaviors will not change. Accountability forces the person to pay conscious attention and make an active decision to continue the behaviors or not, thereby addressing the conflict around continuing the habit and recognizing the consequences.  This conscious experience already starts to break the circuit in the brain reinforcing the habitual behavior by inserting debate over whether or not to engage. 

The second component of treatment is behavior replacement. If there is no thought process or new behavior to change the habit, then there is no way anyone can resist doing the same thing every day. In terms of brain science, this means reinforcing a new brain circuit will weaken the old one.

The combination of a conscious decision to choose the habit combined with an alternative behavior that feels within their grasp gives the person with an eating disorder a reasonable chance each day to learn a new habit. 

The media coverage that eating disorders have nothing to do with willpower is important and necessary. This information already informs a large part of successful eating disorder treatment and gives the clinical community an opportunity to educate the public about this growing problem in our society.


Reflection on First Consultations

I wrote in this blog a long time ago about the first step into eating disorder treatment and wanted to review some of the key points.

It typically takes years for people to reach out for help and can often take a few tries before committing to really get well. The result is that first appointments are critical to help someone start the road to health. 

Much has been written about how to engage someone with an eating disorder and for good reason. Experienced clinicians know how difficult it is to transform a consultation into steps towards recovery. 

Unlike most initial consultations, gathering all the facts is not the most critical part of the initial appointment. There will be time to sort through details and understand the facts. This first meeting must emphasize the reason for meeting. After years of illness, what has led to following through with getting help? Namely, what has changed to make this session possible?

It's often a difficult question to answer, but the purpose is to consider what might have begun transforming in that person to want to address a longstanding part of her life.

A marker of success of that first appointment is to help the person have enough perspective on her life to consider herself separate from the eating disorder for a moment and realize that recovery is deeply connected to that separation. 

Looking back at recent posts in this blog, I realize the existential component of recovery begins from the first appointment. Reflection on one's own value and purpose underlies the first session and emphasizes the most difficult part of treatment: finding meaning outside of the eating disorder. 

Stepping into treatment is a courageous act that needs to be matched by direction and courage from the clinician as well.