12/12/14

More about the Main Risk Factor: Dieting

After more thought and discussion, I realize that pronouncing dieting as the most important risk factor for a child to develop an eating disorder is both confusing and terrifying. To imagine that something so ubiquitous and considered fairly harmless could trigger an eating disorder can be quite alarming for parents. I thought it was worth writing more on the topic. 

Dieting is basically a self-imposed type of starvation. Originally, starvation started from a person's inability to find food, likely famine. Now starvation is often a choice; however, the body can't distinguish between dieting and famine so the lack of food triggers an innate biological reaction to survive lean times.

The initial reaction is universal and includes slowed metabolism, conscious focus on finding food and energy conservation. However, the long term effect of starvation is dependent on one's genetic predetermined response.

A small percentage of people are programmed to respond to starvation in a way that can precipitate an eating disorder. They can thrive on restricted food intake for long stretches, a boon for the species in the distant past but a clear hindrance in today's world. The eating disorder symptoms begin as an adaptation to a harsh environment, but, over time, the survival instinct goes awry and hijacks a person's life. Eventually, the obsessive thoughts about food combined with constant starvation become a way of life. 

The idea that such a basic mechanism of our body, namely hunger and fullness, can go so wrong is terrifying. Parents spend years feeding their children, assuring them their basic needs to live in the world. It doesn't seem possible that all that work can disappear suddenly and turn into a horrible illness. 

What's more confusing is that a diet, something so banal and innocuous, can be the catalyst. Most people take for granted that dieting or cutting back certain foods on and off throughout the year is a staple of modern life, a natural response to our world of plenty. For better or for worse, focusing on weight has become a right of passage into adulthood. No one expects dieting to last but instead comes and goes over the years. Having a scale in the bathroom is like having your toothbrush there. This is just part of normal adulthood, right?

The juxtaposition between the universality of dieting and the rise in eating disorders makes it clear that we are all ignoring an enormous risk. Adolescents are ripe for new experiences and change. The draw of a diet to transform their lives and help them create a new identity is very strong. The positive feedback from weight loss is addictive to vulnerable children. But if this step is so easy to make without any supervision, then all children seem to be exposed to the risk of an eating disorder. 


Food restriction triggers a body's adaptation to lean times. There is no way to know how a child will react to the change. A teenager's first diet can be the start of a long and harrowing illness. The answer to this problem is education: parents, adults and schools can counter the power of dieting by making clear the risks.  I'll elaborate in the next post.

11/26/14

Four Risk Factors for Eating Disorders in Children

The process of helping people recover from an eating disorder at some point returns to the inception of the illness. Many stages in personal and emotional maturing stop when an eating disorder takes over, and recovering means restarting that maturing process where it left off. 

There are many reasons why the trajectory of growing up goes off course into an eating disorder. Among parents aware of these illnesses and concerned about their children becoming ill, the fear of contributing to this transition is a common yet somewhat mystifying concern. Worried but misguided parents often focus on the wrong things while inadvertently contributing to the risk.  

Many important elements of raising children are in large part determined by the zeitgeist of the time. The trends of parenting that lead to what is considered properly raised children change from generation to generation. However, recent decades have shown that something in the culture is a part of the increased incidence in eating disorders. 

The rise of helicopter parents, intense competition between children for success and perfection at all costs has brought pressure on children at younger and younger ages and appear to contribute to the increase in eating disorders. These changes have largely wrought a childhood devoid of freedom and independence. Children follow strictly determined guidelines and struggle to find the space or time to figure out who they are while spending every waking hour trying to reach unattainable goals. 

A common thread for people with eating disorders is that the illness itself becomes the core of identity. The successes of manipulating food and weight followed by the increased attention, positive or negative, transform a child's self-image.

People often relate that the start of the eating disorder was a liberating and formative moment in their lives. The rules and structure of the eating disorder begin to feel like not just a triumph but a sign of true superiority. The guidelines of the eating disorder align with the expectations of the world around them. 

It was the first moment they felt as if they mattered in the world. Sadly, they had no idea where that moment would go.

On the other side of the timeline of the illness, the emotional struggle with recovery later in life reveals what kind of support and guidance may have been missing when the eating disorder first took hold, a treasure trove of advice for worried parents of younger children.

My implication is not that eating disorders are caused by parents. That is the exception rather than the rule. However, parents don't know the fairly common risk factors for an eating disorder and when it's important to step in.

The four central risk factors reflect four components of personal growth and self-determination in these formative years.

The first is the freedom of self-determination. The process of learning about oneself and feeling able to search for an identity without the undue pressure to prematurely be what other people want you to be. 

The second is a level of compassion towards oneself. The presence of a harsh, critical thought process in one's head can drown out any kindness towards oneself and serves as fuel for the start of an eating disorder. 

The world presents children this age with a sense that acquiring the perfect body is the most important life goal. Accordingly, children who become lost in the desire for that body conflate body image with self-determination and can easily find an eating disorder as a viable solution. 

The last and most important risk factor is dieting. The most common story for the inception of an eating disorder is a diet. The combination of dieting as normal behavior and the accolades that come after successfully losing weight is a deadly one. Eating disorder symptoms almost always start with the body and mind's natural response to a diet, and no one can predict how a child is programmed to respond to starvation. Being sure a child does not diet is the most important decision a concerned parent can make. 


Parents who focus on helping their child in these four areas will go a long way towards preventing eating disorders.  These suggestions directly contradict many of the norms of child rearing today. It's time the culture looks at the risks of current behavior and the rise of eating disorders.

11/6/14

Why Most Doctors Don't Help People with Eating Disorders

I had an unusual conversation with a gastroenterologist last week. She explained the situation with a mutual patient including the results of several tests, the likely diagnosis and treatment plan. That was all par for the course. She then asked my opinion, as someone who treats people with eating disorders, both for the best psychological approach to treatment and also for any other thoughts about possible diagnoses. 

This last question, one of collaboration and respect, is very rare in the medical treatment of people with eating disorders. What was just as surprising is that the doctor was not writing in the chart, taking to a staff member in the office or hailing a taxi while on the phone, all common occurrences during doctor to doctor calls. 

It is unusual to find doctors who have the time to talk, listen and collaborate. Patients with eating disorders need that medical approach to get help. Sadly, they tend to give up and ignore the issue rather than face the frustration of seeing doctors who are unable to find any reasonable cause for their symptoms. 

Medical problems associated with eating disorders are complex and out of the norm for a general doctor or specialist to see. One fundamental complication is that malnutrition both in terms of underfeeding and low levels of vitamins and minerals are central to the problem, something doctors learn next to nothing about.

The malnutrition is often different from general starvation due to lack of food. This malnutrition is specific to a world packed with food with no nutritional value. People will often eat some food but will have very inadequate nutrition.

Since doctors in the first world know little about the possible causes, they search for causes of illness as if the person does not have an eating disorder and ignore possibilities likely only to be seen in these patients. 

Any useful medical work-up has to include the expertise of a primary doctor or specialist and a doctor well versed in the medical problems associated with eating disorders to be effective. 

Many diagnoses are common for patients with eating disorders but otherwise would not come up on a doctor's radar: gastroparesis (delayed stomach emptying) that can be treated with food, kidney damage from malnutrition, odd mineral deficiencies such as low blood copper levels, high cholesterol from chronic anorexia and neurological swallowing difficulties from years of purging. 

The truth is that textbooks about eating disorders focus on the medical effects which occur in the first few months of starvation but not those that come after years of eating disorder symptoms. Accurate diagnosis relies on persistent doctors willing to collaborate and think outside the box to find an answer. 

The current state of medicine encourages short visits, minimal time spent on history and physical exam and no attention to detail. This situation leaves the patient with an eating disorder out in the cold. However, doctors like the one I spoke to last week can help create an environment that gives hope for better care.

For the patient with an eating disorder, it's worth looking into finding the right doctors and not settling for the most convenient ones. A doctor with time to think and collaborate will help maintain health through the process of recovery. A doctor who simply sends for a few blood tests will not help at all.

10/23/14

Why People with Eating Disorders are Experts on Nutrition

A common misconception about people with eating disorders is that they don't understand basic nutrition.  This confusion leads not only to misunderstandings but to mistreatment and even condescension to people with these illnesses. 

The crux of an eating disorder is the inability to eat food through the day and to allow one's body to digest food regularly. Feeding oneself is an automatic activity for everyone else, as basic as taking a shower or going to sleep, but that mechanism is broken for someone with an eating disorder. 

When people who eat without difficulty try to understand what has gone awry in an eating disorder, it's very difficult to wrap their mind around the basic concept of the illness. Accordingly, they assume that the problem lies in concerns they themselves struggle with, such as the health benefit of food choices or portion sizes of meals.

It's more apparent to people in general that education about nutrition might solve the problem rather than realize the issue is something much more profound. 

The reality is that people who struggle with eating disorders actually know more than almost everyone else about nutrition. In fact, nutritionists who specialize in treating people with eating disorders know that education is not their primary role in treatment. Their goal is to help someone in recovery relearn how to eat meals and snacks throughout the day while avoiding the pitfalls of eating disorder behavior patterns. 

People with eating disorders, desperate to find a path out of their illness, often obsessively research nutrition. Many of them end up studying nutrition and become excellent clinicians because of their depth of knowledge. Their hope is that a vast amount of knowledge might counteract the eating disorder enough to help speed up recovery. 

Sadly, this information may be useful but does not contribute much to recovery from an eating disorder. 

The rules and behaviors of an eating disorder don't follow logic or reason. It will never be reasonable to starve oneself through the day, eat an enormous amount of food at once, regularly purge one's food or overdose on laxatives to lose weight. The driving force for these behaviors is the illogical but powerful thought pattern of the illness.

Combatting the thoughts of an eating disorder with reason and education will never work. 

I have written many times that compassion, kindness and understanding are the centerpieces of treatment for an eating disorder and for the support one needs from family and friends. This is a far cry from nutrition education, and for good reason. 

People with eating disorders suffer from a punitive, strong internal thought process that makes them feel horrible about themselves. The origin of these thoughts is different for each individual, but once the person is trapped in a cycle of starvation and illness, the thoughts intensify and dominate their lives. 

It's much more logical to combat a punishing thought process with kindness and compassion rather than with nutrition facts. After one understands the facts of these illnesses, the best way to help becomes much more clear.


Recovery is not a matter education about nutrition. It's a combination of learning new ways to manage food in one's life in an environment of kindness and compassion.

10/10/14

The Hard-Line in Eating Disorder Recovery

A common question from families, parents and loved ones about how to support someone in recovery from an eating disorder is about the type of support that is best to offer. After extended periods of illness, many people believe a hard-line approach will be helpful, one that emphasizes eating at all costs. They hope that standing their ground will enable the person to make the harder choices needed to get well. 

But often this kind of support represents frustration more than the compassion the person in recovery desperately needs. 

Given the choice between this type of support and the eating disorder, most people don't feel like they have a choice. The eating disorder is a way of life and has dominated every decision of every day for a long time. It provides comfort as much as it does misery. In the absence of other comfort, it feels like the only option. Just standing firm won't change an illness. It will just alienate the person who is unwell. 

Plus, families typically understand their loved one very well but don't understand the intricacies of the eating disorder thought process quite as well. The emotional bond of a close relationship remains important despite the illness but is not enough to lead to a magic cure. Instead, the person feels worse about the personal relationships but no more empowered to get well. 

The best support remains boundless love and compassion. This is not easy for even the most patient person to maintain through years of illness and recovery, but no one battling an eating disorder ever tires of that kind of support.

It inevitably creates a level of connection that sustains a person struggling to get well. Moreover, love and compassion send a clear message of believing the person can get well. That is invaluable. 

However, standing firm does have its place in the recovery process. The treatment team has a responsibility to assess the person at each step of the way. After a period of learning about recovery and learning how to face the eating disorder thoughts, most people get stuck. They can see the steps of recovery ahead of them but often back down out of fear of many things. 

It can be fear of getting well and the expectations that might come when the illness is no longer a crutch. It can be fear of losing the eating disorder, something that has defined identity for many years. Or it can be fear of gaining weight and looking healthy so that people stop worrying about their well being. Although these fears are the most common, there are many more. 

At this point, the treatment team has a responsibility to stand firm that it is necessary to take those steps forward in recovery. All these fears are present, but they cannot halt the steps towards getting well.

Years of illness have proven that life with an eating disorder is only a shell of a life. That is not enough. 


What the family needs to do is trust the treatment team, their loved one and the process of recovery. Taking recovery into their hands inevitably backfires, but family can provide love and support in ways no one else can. Love and compassion will be sustaining after recovery is finished and present the building blocks to life after recovery. That support plays a crucial role in treatment and allows the team to play its role as well.

9/26/14

Conclusions about Artificial Sweeteners

On the heels of the media coverage of the possible health benefits of a diet low in carbohydrates comes new research into the biological effects of artificial sweeteners. It's hard to resist the urge to magnify a study that supports one's beliefs into gospel, but an eye on any research needs objectivity. Whether or not you agree with the results of a study, all research has utility and limitations. 

Artificial sweeteners are chemicals manufactured and used for two reasons. The first is that they are very sweet, many times sweeter than sugar, meaning they have a much more powerful effect on human sweet taste buds. Second, they are chemicals humans cannot digest and absorb. Thus, they have no calories.

In essence, artificial sweeteners trick the body into perceiving sweet taste without providing any energy or nutrition, an apparent boon for a society bent on losing weight but maintaining pleasure. 

In this study, newborn mice either drank water with various artificial sweeteners or with sugar. Simply put, the results revealed that baby mice exposed to sweeteners showed signs of glucose intolerance while the mice which drank sugar water did not. 

Glucose intolerance is a metabolic precursor to diabetes. The hallmark of Type II diabetes is an inability to maintain normal blood glucose levels. The body has to manage an intricate balance between absorbing food from the stomach while releasing energy to organs all while keeping blood glucose levels within a narrow range. When this system malfunctions, diabetes ensues with the initial sign of elevated blood sugar followed by the many medical repercussions that come with the illness. 

With no other interfering factors, it appears that the exposure to artificial sweeteners had a part in causing glucose intolerance in these baby mice. This is the first study to convincingly show any possible linkage between diabetes and artificial sweeteners. 

The theory behind this result reinforces the idea that tricking our bodies to eat processed food is replete with dangers. Stimulating our taste buds begins a process of synchronized reactions in the body: preparation in the stomach and intestines for food, secretion of digestive enzymes, shunting of blood to the gastrointestinal system to absorb food and many more.

If this reaction is triggered routinely but then leads to no actual needed digestion, the theory suggests it would have an impact on our biological function. In this case, that means management of blood glucose levels goes awry. 

The study then continues to try to suggest these findings apply to people as well. This part of the study was less conclusive and in many ways secondary to the initial study. 

The most significant limitation of this study is how it applies to people. Mice may be mammals, but a study like this only makes it clear similar research needs to be performed on humans rather than proof we should all stop using artificial sweeteners.

Developing research to show long-term harm from these chemicals in people will be much more challenging. One cannot use human babies as experimental subjects as one can use baby mice. 


As with all research, the conclusions are interesting and thought-provoking but still leaves each of us with personal decisions about how to use artificial sweeteners.

9/12/14

A New Study about Low Carbohydrate Diets: A Study in Irresponsible Journalism

An article in the New York Times recently reported the health benefits of a low carbohydrate diet. The article attempted to explain the importance of such a finding and balance it within the current medical knowledge about nutrition and health.
Instead, this article reinforced that journalists need to better understand the influence of such a piece on the public at large. Many people will use this study to justify disordered eating and strict decision-making around food and health. Influential media need to heed their own power and adjust their reporting accordingly.

The article summarized the findings of a study in a respectable medical journal as follows: a diet comprised of low carbohydrates and high unsaturated fats appears to have improved health outcomes, especially cardiovascular health.

On the surface, a few simple conclusions seem harmless and perhaps even useful for a population eager for guidance on nutrition, but newspapers, desperate for an uptick in unique views and ad revenue, need to understand the way the public will interpret these conclusions.

The article surprisingly suggests that few people will heed this information, but that is clearly untrue. A stamp of approval by this newspaper immediately turns reasoned, balanced conclusions into fact for the public.

For a readership already plagued by confusing nutrition information and a terror of obesity and eating disorders, new, far reaching conclusions from a study the public is not educated to interpret only worsen the fear for the normal eater, who now will believe carbohydrates to be an evil food.

The newspaper needed to expound on the significant limitations of such a study. On first glance, the research has four glaring concerns which limit the utility of the conclusions. I imagine a more indepth analysis of this research would reveal many more.

The first is that the researchers have no way of proving that each subject followed the prescribed diet, and, in fact, research into dietary studies has repeatedly shown that people do not report diets faithfully. They tend to alter food diaries to reflect what they want the researchers to see rather than the truth. This is a common issue with studies about nutrition but must also be acknowledged.

Second, it is almost impossible to factor out all possible reasons for improved health and single out a change in diet as the cause. Making broad medical conclusions from a dietary change is hard to prove in subjects of a study and thus risky to propose, especially for information so desperately sought after, and then followed, by the public.

Third, changing one's diet for one year is nowhere near long enough to make any overall conclusions. The relationship between diet and a lifetime of health is broad and the information available is inconclusive. In order to have real value, a study will need to track health over a much longer period of time and will need to attempt to factor out the many other causes of health problems. However, that is a long and expensive endeavor that this study did not attempt.

Last, over 95% of people who change their diet end the changes within two years, so the likelihood subjects will continue this diet once they are no longer tracked by the researchers is extremely low. Making any reasonable connection between the general public and a dietary change needs to take into account the current, accepted knowledge about how hard it is to maintain changes in one's eating habits over an extended period of time.

The desire for a quick-fix diet and for definitive data to choose a philosophy of eating as healthful is overwhelming. Confusion around endless food choice and unlimited, delectable eating options leaves most people unsure of how to eat each day. Instead, the latest diet craze, research conclusions or evil nutrient lead to the endless string of nutrition fads in recent decades.

With a plethora of knowledgeable, balanced journalists, this reputable paper needed balance the conclusions of one study with the irrefutable evidence that scientific knowledge of nutrition is limited and that a balanced diet is the best alternative. As many of their esteemed reporters have said, we are omnivores who survive best on a varied diet with more real food and less processed food eaten regularly through the day. Any other information presented as fact is, at this point in time, purely conjecture that needs much more extensive research to have medical value.

The media needs to understand its responsibility in presenting new nutritional information and translate the findings into valuable information for the general public.