The Halo Top Curse

In light of the upcoming Thanksgiving holiday, I felt the urge to rant about the most recent egregious exploitation by the food industry: Halo Top ice cream.

From a marketing standpoint, the new, low calorie ice cream is an absolute success. The brand is easy to find everywhere and is the most talked about new ice cream in a long time.

The unfortunate news is that the brand has taken an incredibly cynical approach to our food culture. It markets itself as the easy way to eat an entire pint of ice cream guilt free. It encourages people, especially women, to feel free to eat an excessively large amount of ice cream either as dessert or, better yet, as a meal replacement. It feeds the guilt of a generation of women constantly torn between endless dieting and liberation from our culture of thinness.

Rather than enable a feminist escape from the exploitative pressures of modern culture, this brand attempts to box women into the shame of eating ice cream indulgently while preserving the desire for thinness.

As a last insult, the brand doesn’t divulge the possible side effects of overeating the artificial sweeteners in Halo Top: gastrointestinal distress and diarrhea.

In the eating disorder treatment world, the brand encourages binging, discourages eating meals and real food and condones eating behaviors that reinforce these illnesses.

That we live in a culture which allows marketing of explicitly damaging brands is abhorrent. It is one thing to market cheap food alternatives and another to exploit the psychological and emotional vulnerabilities of our society for a profit.


Does an Eating Disorder Make You Special?

One reason for the rise in eating disorders in recent decades is the fundamental need to be special in modern life. As longterm health improves, lifespan lengthens and basic life essentials are taken for granted, first world populations have much more time and energy to expend elsewhere.

Striving to be exceptional appears to be one of the most common ways people have found a life purpose. Not infrequently, this common desire to be special is diverted to particularly unimportant goals. One such goal is thinness.

For many people with eating disorders, the goal of thinness feels paramount in life. Achieving it often leads to overwhelming praise, increased opportunity and the promise of a greater life. Whether or not this goal promotes obsessive thinking about food, eating disorder symptoms or extended misery is besides the point.

The idea of giving up on thinness as a primary goal feels like failing on many levels. Not only does surrender mean disavowing the collective fallacy that thinness has true meaning in life, but it also allows for the difficult concept that we are all average.

Ultimately, being human implies being one member of the large dominant species on earth. We can find special parts of any person, especially anyone we are close to, but with eight billion people on the planet, not one of us is truly unique. Using weight and thinness as markers of being special looks absurd in light of the larger scope of humanity.

Past the immediate horror of admitting mediocrity is the relief of just being a person. The incredible pressure to be something more than yourself makes each day so much harder. The unnecessary goal of manipulating food in order to weigh a certain amount only limits how fully a person can live.

If living means developing relationships and trying to develop meaningful activities or work, then expending energy on food and weight has no true purpose. None of us are remembered for how we eat or what we weigh.

The drive for thinness is linked to the drive to be special. Rearranging our priorities, even in a world where so much is given to us easily, is a critical step in limiting truly unimportant goals from dominating our experiences.


The Reality of Medications and Eating Disorder Recovery

A conversation I recently had with the editor of an eating disorder content website highlighted a fallacy about medications and treatment. The editor spoke about how hard it is to find an in-depth, definitive article regarding all different types of psychiatric medications and eating disorder treatment. His concern reflected a deep misunderstanding of the role psychopharmacology in recovery.

The research into medications and eating disorders is extremely limited. The only illness researched with any depth is anorexia but with very disappointing results. No medications have shown to be effective for this disorder.

As I wrote in the last post, a few medications have shown some benefit for binge eating disorder, but even those articles have very few subjects and are of limited utility.

Medications are primarily of value when treating other psychiatric illnesses that are primary, in other words independent of the eating disorder, usually depression or anxiety. 

There are individuals who benefit from medications for various eating symptoms, but the overall psychiatric literature does not point to medications as a central part of treatment.

The problem with a supposed definitive article about this aspect of treatment is that it would be inherently misleading. The underlying message would be that medications can have a significant impact on recovery when reality and research prove otherwise.


Medications and Eating Disorder Treatment

The central components of eating disorder treatment are meal planning and therapy, both individual and group. Medications play a peripheral role but can be important in certain circumstances.

Medications are most effective for comorbid psychiatric problems, especially when they are separate from the eating disorder. Treating depression and anxiety alleviates symptoms that typically exacerbates the eating symptoms and allows for more direct focus on recovery.

Seeing a psychiatrist knowledgeable enough to tease apart depression and anxiety secondary to the eating disorder, which typically respond less well to pharmacological intervention, and psychiatric symptoms separate from the eating disorder will help streamline overall progress in recovery.

Medications directed at the eating disorder symptoms have more mixed results.. The research into psychopharmacology for eating disorders is limited but gives a few important results dependent on diagnosis.

Despite the most rigorous research, no medication has proven to be effective for anorexia at this point. Many medications used in psychiatry, and some outside the purview of the field, have been studied to no avail. Even antidepressants tend to have no impact on people with anorexia who are depressed. The overall effect on the brain from starvation appears to trump all other interventions. The essential part of recovery is nutrition.

The most successful effect of medications is for bulimia and binge eating disorder. High dose SSRIs such as Prozac or Zoloft can be very effective for the sickest of these patients who binge at least twice daily almost every day of the week. Medications tend to reduce symptoms by about half after six weeks of treatment. Topamax, an anticonvulsant, also has benefit for people binging frequently but with less robust research results.

For the large number of patients with symptoms not easily categorized in one of the limited eating disorder diagnostic options, there is minimal evidence of benefit of medications. Treating underlying psychiatric problems can be beneficial, and attempting to use medications can have a moderate impact on progress, especially for adjunctive symptoms.

One last benefit of antidepressants is actually via a side effect. Most SSRIs can diminish the intensity of emotional reactions, a side effect called emotional flattening which often leads people to stop taking the drugs. For patients early in recovery who feel often unbearable emotional intensity, this side effect can be beneficial. The decreased intensity temporarily helps people stay on course with the food plan and tolerate the intensity of nourishing their mind. It is an often ignored but very useful pharmacological choice.

Psychiatric medications play a peripheral but often important role in recovery. Seeing a doctor versed in less common aspects of psychiatric care for eating disorders can be helpful to see alternative benefits of medications or to separate primary from secondary psychiatric symptoms related to the eating disorder. When the psychiatrist is integrated as part of a treatment team, the patient will always get the best results.


Residential Treatment Programs or Corporations

There are several posts in this blog about how to choose the level of treatment: hospital, residential program, day program or outpatient team. When residential seems to be the best option, choosing the right program has become increasingly difficult in recent years.
The trend in the residential treatment model in the last five years is concerning and creates a dilemma for families and clinicians. Venture capital companies have bought the most successful residential programs and aggressively expanded their reach in recent years. The increasingly corporate approach to eating disorder treatment combined with the shift in philosophy from clinical care to financial gain has greatly changed the landscape.

I don’t want to ignore the benefits though. There are many more programs accessible to patients and families than there were before. These new companies have tried to expand and replicate the successful treatment models created by the parent companies and founders. The resources for clinicians have multiplied greatly. For instance, the number of outpatient programs in the New York City metro area has multiplied several fold in the last decade.

The problem with the corporate takeover in the eating disorder treatment world is that a plethora of programs doesn’t increase the likelihood of recovery. The most successful programs created an environment of clinicians and programming that helped patients see the path of recovery. From the initial intake coordinator to every staff member of a program, each person had the clear motive of enabling recovery.

Now the staff and leadership of eating disorder programs are charged with building a company and, more importantly, a brand. The focus is to make sure clinicians know the outreach team and the name to increase referrals. Rather than hearing from the clinical staff, I am much more likely to be enticed to a free expensive dinner than to be lured by their clinical competence. Where does recovery fit into the business model?

For patients and families, the key to this decision is to learn about the individuals who run and work at each specific program. Even these financially driven companies hire excellent, caring clinicians. If those carers run an effective program, the clinical care will help people start down the road to recovery. Word of mouth can lead people to the best decisions for their care and hopefully drown out the flashy marketing that has unfortunately clouded those seeking help for their eating disorder.


The Importance of Personal Growth during Eating Disorder Recovery

The last post reviewed the often ignored fact that the path from starting treatment to full recovery is long. Patients, family members and friends want treatment to be successful in a few weeks or a few months. A prospective patient’s mother recently asked if a few weeks would be sufficient for recovery, and it was a shock to have to say not just a few months but several years were necessary to really get well. 

The thought patterns underlying an eating disorder are ingrained around food, a very automatic aspect of our daily lives. The more unconscious thoughts and behaviors are, the harder they are to change. Our minds typically focus conscious attention on less quotidian tasks and leave the typical daily necessities on autopilot mode. Shifting attention to change automatic thoughts and behaviors is not a priority for brain function so the steps in recovery, even if they appear simple to the outsider, require an enormous amount of attention and time. 

However, during the process of transforming the automaticity of the eating disorder behaviors, life doesn’t stand still. I am often hesitant to explain the length of treatment necessary for full recovery because people instantly believe life will remain the same during the entire course of treatment. After years of suffering, it is so hard to imagine getting well that it’s expected that one would believe nothing changes at all until there is a miraculous rush to being cured and recovery is complete.

The truth is that life can and often does change drastically during the course of recovery. Full recovery entails not only normalized eating patterns but complete remission of the disordered thoughts as well. During this period of treatment, life continues to grow and change in positive ways.

Normalizing eating will enable patients to be more present in their lives and more able to excel and grow both professionally and personally. There will be opportunity to deepen friendships and start relationships. Returning to school or furthering one’s career become much more feasible. And growing confidence in oneself opens doors to new ideas and directions in life.

Concurrently, life changes make it seem more important to face the deeper, more insidious components of the illness. As the person sees the myriad ways the eating disorder undermines daily life, the determination to face difficult parts of recovery grows.

Recovery is not a switch from sick to well. It is a gradual process. Most importantly, life continues during this time. If it takes years to get well, life grows and changes during that time. Unlike many illnesses, one doesn’t just get cured. Recovery is a process one needs to live through. And doing so makes it clear why this treatment works.


The Long Road of Eating Disorder Recovery

The standard approach to a medical problem is to see a doctor, get a diagnosis, follow through with treatment and get well. This reasonable approach to care for an illness is commonplace but creates miscommunication and confusion around eating disorder treatment and recovery.

If the symptoms of an eating disorder revolve around disordered eating, then recovery should be simple: eat regular meals and snacks and get well. And if the treatment is difficult, then the person just needs to try harder. People erroneously believe that any stumbling blocks must be the fault of the sick person, not a sign of an intractable illness.

This approach to recovery makes sense to someone with limited knowledge about eating disorders. Eating is a staple of every day of life, no less important than sleeping or breathing. But for someone with an eating disorder, meals are fraught with so much stress and anxiety that it feels more like a prison.

Moreover, eating disorder thoughts and behavioral patterns are largely ingrained and unconscious. Even people who are very focused on food but not ill don’t think that much about how or when or what they eat. This may be a controversial concept, but it’s necessary to talk to someone with an eating disorder to understand what it means to think about food and only food all day long. 

The process of changing such ingrained, automatic thoughts and behaviors takes time. Families want people in recovery to get better quickly. There should be a marked change within months, if not weeks, and recovery should be mostly completed within a few months. Sadly, this is not what recovery looks like for almost everyone in treatment.

The process typically takes several years from two to even 7-10 for full recovery. Since the steps are gradual, there is improvement within a few months, but ups and downs are a necessary part of relearning how to think about, approach and eat food in one’s life.

I often hesitate to tell people how long recovery takes, perhaps not to scare them off at the start of a long road. But there is a point where this knowledge is crucial. Committing to the entire process of recovery means embracing this path to living a full and meaningful life, not losing oneself in the minutiae of food, weight and misery forever.