Medical Complications of Anorexia

Most people with eating disorders feel that they are superhuman and impervious to the various medical complications that inevitably arise during the course of the illness. Books and articles present lengthy lists of the ways the body deteriorates from an eating disorder. I find the medical details numbing and completely disconnected from the reality of the disorder itself. I end up drifting when I try to absorb the information and I really want to remember it! If I cannot maintain focus, imagine how much a patient--deeply ambivalent about recovery--will actually remember. It makes much more sense to organize the information into a series of necessary steps the body takes in order to survive chronic starvation and vomiting rather than a laundry list of impersonal problems.
Let's start in this post with the effects of starvation. In the short run, eating less means the body uses more energy than it takes in. The body initially burns fat--the energy storage unit--to make up the extra needed calories. This line of reasoning is familiar as the natural result of a diet. Once the fat stores are depleted--a few months at best--the body adapts to survive the apparent famine in three interconnected ways: the use of protein as the new energy source, harboring limited resources for the most basic functions and a gradual slowing of metabolism.
Once the body begins to break down protein as an alternate energy source, survival becomes a zero sum game. Fat storage exists largely as a reserve to protect against lean times. Any use of protein as energy means using up this valuable and necessary resource. The body initially burns up skeletal muscle protein leading to atrophy and decreased strength. In time, however, any protein will do including cardiac muscle which leads to a weakening heart--one of the myriad ways eating disorders kill. Essentially, the body slowly eats away at itself to create as much energy as possible to survive, no matter the cost. However, the body was not created to survive through self-cannabalism. There are many deleterious effects, and one of the most severe is that protein metabolism leads to different waste products that need to be cleaned out of the bloodstream. The kidneys are damaged by the prolonged exposure to protein waste products, and even recovery will not always fully repair renal function. If this were the only adaptation to starvation, anorexia would kill people much more quickly so let's shift to what happens to metabolism.
During this prolonged famine, the body has to decide how to use its limited resources. For people with eating disorders, this concept is not evident because food feels like an unnecessary indulgence rather than a critical resource. Sometimes an analogy can emphasize why these circumstances are so dire and circumvent the denial of a patient. Consider a community experiencing severe drought. At first, people may decide to stop watering their lawns, a minor inconvenience. As the drought worsens, desperation sets in and the residents may agree to flush toilets less frequently or may limit each household to a maximum quantity of water per day. Finally, plumbing may be shut off completely so that individuals need to go to pick up their daily ration of water at a local well. Similarly, the body takes increasingly drastic steps for survival. For example, two common initial sacrifices the body makes during starvation are decreased peripheral circulation and trouble focusing--two functions not needed during a famine. The next step might be prolonged fatigue and dizziness, from not using energy to pump blood up to the head. More severe famine necessitates drastic changes: slowed heart rate and very limited mental function. The body may gradually eliminate all needs outside of the heart and lungs: the basic needs for minimal survival. Although the body will do anything to continue to live, the sacrifices are enormous.
The third way someone survives famine is a gradual, steady decrease in metabolism. The body, almost miraculously, adapts to become an extremely efficient machine. Each and every calorie of energy extracted from food is used as wisely and judiciously as possible. The gastrointestinal system slows down until it is almost paralyzed. In part this is atrophy from lack of use but also is to ensure extraction of every bit of energy from the limited food intake. Then the body slows down all of its functions in order to maximize the use of the energy taken in and minimize self-cannabilizing. There are countless examples. Liver function slows down leading to excess waste products in the bloodstream. Immunity is weakened and leads to increased susceptibility to infection. Heart rate slows down to levels commensurate with limited survival. The menstrual cycle stops because it isn't possible to be pregnant with limited resources and the menses itself wastes valuable resources.  Maintenance of healthy bones ceases. These adaptations severely limit what people with anorexia can do and often lead to irreversible damage.
This intuitive approach to the medical problems of anorexia is much harder for patients to dismiss. Humans have learned to adapt to famine in order to survive. Anorexia only exploits these genetic adaptations. It is unclear to me how effectively medical knowledge leads someone towards recovery, but I find that patients are more likely to process and remember the information presented in this way. The next post will describe the medical effects of binging, purging, and laxative and diuretic abuse.


Adult Binge Eating

Within the obese population, there is a subset of patients who first exhibit binge eating symptoms in their late twenties and thirties and who are increasingly recognized and treated by eating disorder professionals. However, these patients too often fall below the radar of the eating disorder community and remain unseen and untreated for long stretches of time. There are several components of this eating disorder that make both diagnosis and treatment more challenging and different.
Because people who binge eat are overweight, this disorder is often overlooked and lumped in with the general rise in obesity. The misdiagnosis leads to an ineffective and potentially dangerous course of treatment. A weight loss program is disastrous for someone who binges: the hunger triggered by calorie restriction only increases the urge to binge and the shame of binging. Even more damaging, these patients are considered candidates for Bariatric weight loss surgery. The screening process for these procedures should exclude people who binge eat, because even a physical restraint--gastric bypass or banding--will not curb their emotional and psychological need to binge. However, many find a doctor to perform the surgery anyway. The failure of this drastic surgery leads to even more hopelessness. The same treatment for binge eating disorders outlined in previous posts is equally effective for these patients, but the primary problem is accurate diagnosis.
The key difference for people who start binge eating later in life is that they have spent years as an adult at a normal weight. Typically, these patients have a long history of abnormal eating but were able to maintain normal weight and keep the disordered symptoms from fully disrupting their lives. As the binging escalates, they believe this is a short-lived phase and that they can regain control of their eating. In our culture of thinness, weight is seen as the central problem, and doctors often readily agree. This single-minded approach allows the eating disorder to stay hidden. As I have written several times, eating disorders are most powerful when they remain secret.
Typically, people who begin to binge at a later age have difficulty with the pressures and expectations in life that develop as they get older. In high school or college, students struggle with the early stages of independence and personal identity. In their twenties and thirties, people shift their focus to relationships, family and career development. Unfortunately, binge eating and gaining weight have a significant impact. People who are overweight report feeling invisible both personally and professionally. For someone terrified of intimacy and professional challenges, gaining weight reinforces feelings of inadequacy and worthlessness. The constant pressure to lose weight becomes life's central focus and supplants any other goals or dreams. If only they could lose weight, these patients say, their lives would be so different. After rounds of inaccurate diagnosis and ineffective treatment, patients retreat to the solace of food, lowered expectations and the veil of obesity. Often they seek psychiatric help as a last resort.
The key to diagnosis lies in the patient's own assessment of her problem with food and weight. Someone who overeats but does not binge will understand that food and weight are problems to be handled alongside her concerns in daily life. Patients with an eating disorder see food and weight as their only problems. They say their life is on hold until they lose weight. This obsession with weight loss is the most debilitating symptom because it takes over the patient's life. The result is a sense of paralysis and hopelessness simultaneously hated by the patient and coveted--because it helps her avoid the fear and anxiety daily life would otherwise trigger. The longer the disorder continues undiagnosed and untreated, the farther the patient is from fully addressing the issues at this stage of life.
Once the diagnosis is clear, the treatment is straightforward but challenging. First, the nutritional goal is normal eating with regular meals and snacks, with adequate--but not restricted--caloric intake. Patients will lose weight slowly because they aren't binging and will adjust to a sustainable meal plan. Once the binging has subsided, the treatment goal is to avoid restricting. Tempted to lose weight quickly, the patient will start cutting calories, get too hungry and then start binging again. That cycle allows the patient to remain focused on food and weight. When a patient can follow the meal plan, she will not have the distraction of the eating disorder. Then the patient will start to become aware of the initial triggers that started the binging and begin to tackle the fear of moving forward in life. This is the core treatment of the therapy, and what differentiates it from other obesity treatments: shifting the focus away from weight and towards helping the person feel grounded and content in her life.
The next post will shift the focus to address some of the medical consequences of eating disorders. It is easy to find a list of specific medical issues but little that explains what is happening to the body and metabolism in general. Stay tuned.


Building Our Food Community

I heard a very disturbing story the other day. A woman --not a patient--spoke about a group of young mothers all of whom see a doctor for weight loss. These are all thin women who want help to look even thinner. The doctor employs two main tactics: he prescribes diet pills and he screams at them to eat less and lose weight. Apparently, some people go to doctors to induce anorexia! Is that really how we share food in our community?
This story finally brought me back to reality: food no longer brings us together. For some, it is an enemy to avoid at all costs, even by seeking out dangerous pills and abusive doctors. Food may still help drive a sense of community but not in traditional ways. We share diets or weight loss stories. We swap stimulants or juice fasts. Or we all trek down to the local McDonald's for processed food that has replaced real meals. We have all had to put down our political stake in the world of food. Many people opt out of the entire food debate. They just eat. For those who do enter the fray, there are many decisions to make: Organic? Vegetarian? Meat-lover? Fast food? Farmer's markets? Pro-industry? Striving for thinness? Food network? This is our current community: find a political (or apolitical) stance and connect with like-minded people. Is there room for another way to share food? Can anyone shift the way our society thinks about food?
I don't believe this society can go back to seeing food as culture. Each home can refocus the conversation around food as I wrote in the last post; however, global food commerce, powerful multinational food corporations, compliant federal regulatory agencies and omnipresent nutritionism are all too influential for the world to turn back now. Obesity, dieting and eating disorders are persistent public health problems. The new community of food resides in this current reality. 
What does it mean for a society to define food through abstinence or gluttony? How does community persist when The Biggest Loser and pro-Ana websites represent such strong cultural voices? Food has become the vehicle for capitalism, for entertainment and for the post-feminist woman. I see food as one of the loudest and most powerful forms of communication. Our approach to food quickly reveals, to anyone paying attention, our approach to life. As disturbing as it is, the group of women seeing the weight loss doctor knows what is most important to them. In their community, these women find a sense of belonging. We all can find people who speak the same language of food, who share the same meaning of food. Whether food represents health, culture, control or safety determines which community of food fits one's lifestyle. By no means are we then bound to that one point of view: as we change what food means to us, so can we change where we belong. 
These dramatic changes in food and culture place a large burden on individuals and parents to find a new balance. Taking responsibility doesn't have to mean taking the blame: the core food industry message. Although government--and to some extent industry--has a duty to protect society from undo harm and public health hazards, everyone must decide what they will eat. We all need to make that decision every day. Change on an individual level--by making informed decisions about food--is necessary for our world of food to change. Our own active role and decisions matter for us, for our families and for our community. 
The next post will bring the blog back to eating disorders, more specifically binging and overeating later in life.