The Biology of Starvation

Most patients remember one specific event as the initial trigger for their eating disorder. For people who get well in the first few months, the story of the illness stops there. But after even just six months of taking over someone's life, the eating disorder often takes a different course. What started the disease is very different from what lets it continue and worsen over time. In the end the factors that perpetuate the eating disorder easily overshadow the initial event. And one central but easily ignored factor is chronic starvation itself.

Most treatment for eating disorders focuses on both the need to maintain a meal plan and the psychological/emotional issues. However, treatment teams typically separate the duties. The therapist ignores food to focus on the underlying concerns. The nutritionist handles the meal plan. And the primary doctor monitors medical stability. This approach may be thorough, but no one considers all aspects of the illness and thus can't see the entire picture. Without piecing together the psychological and physical, no clinician has a birds eye view of the treatment. No one considers the biological results of starvation.

The doctor would be the team member most likely to recognize this problem, but it's no surprise doctors can't see it either. The Western medical community knows little about chronic starvation. Although many people in this country go hungry, few truly starve. Chronic malnutrition isn't a regular occurrence in the first world. It only occurs in severe, terminal medical illness such as cancer or dementia, at the end stage of these illnesses when palliative care is paramount, and in eating disorders.

Although treatment has come far in the psychological and nutritional approach to eating disorders, few practitioners, academic texts or new therapies focus on the biology of starvation. The development of new treatment follows trendy therapy modalities and new pharmaceutical options, but the medical community remains uninterested in the biology of eating disorders.

The body's adaptation to severe, prolonged malnutrition is profound and powerful. Organ systems will go to great length to survive, and energy conservation is so elemental and complicated that many doctors are stumped by test results in the severely malnourished. Moreover, these adaptations have a psychological component too. Although cognitive function declines in the malnourished, all remaining brainpower focuses on food: obtaining it, savoring it, hoarding it, and of course devouring it.

It's no coincidence that these obsessions are all fundamental symptoms of eating disorders. Ironically, the adaptations which enable the ill to survive may also be the foremost reason people with eating disorders stay trapped in their illness. In other words, many symptoms of eating disorders are the result of starvation, not, as most assume, the other way around.

A look at the basic science of malnutrition helps clear up this confusion. The body suffers three losses without food. First, the sheer lack of calories leaves insufficient energy for the body to function. Second, the body repairs all tissue and organs daily in order to remain healthy, and the lack of variety of nutrients means there are no building blocks to use for repair. Third, the body is constantly dehydrated not because of limited water intake but because of the metabolic changes in starvation. In order to create more energy, the body metabolizes muscle. The chemical pathway to metabolize protein uses water, thereby depleting supply and causing chronic dehydration.

In essence, starvation triggers destructive changes in body function to increase the chance of survival. The three aspects of being malnourished cause widespread damage in all organ systems. The inability to do needed daily repair and the metabolism of tissue for energy leaves the body depleted, only to function at a suboptimal level on backup generators. Forced to survive on very little sustenance, the body hijacks the brain to focus on only what's necessary: food.

The biology of starvation complicates current treatment for eating disorders. When treatment is divided between clinicians, the role of starvation isn't obvious. Therapy working towards the underlying cause for the eating disorder won't address that chronic malnutrition drives the eating disorder thoughts and behaviors. The brain and behaviors have programmed responses to starvation which closely resemble eating disorder symptoms. So for someone chronically starved, these obsessions with food ensure they find and eat any food available. They no longer represent a wish to avoid circumstances or emotions in life; they are a biological response to mortal danger.

The typical result of incorporating the biology of starvation into treatment is twofold. First, it absolves the patient of a large portion of blame. Recognizing that many eating disorder symptoms result from starvation helps the person realize that significant improvement will come from eating, and the goal is to find the environment where that's possible. Second, it eases the pressure to focus on the intensive therapy until starvation is no longer the driving force of the illness.

Furthermore, basic knowledge of the medical factors in these illnesses would help educate families, clinicians and doctors in the true tenacious, destructive nature of eating disorders.


Weight and Eating Disorder Recovery

In a successful recovery, weight plays a very complicated role. On the one hand, the obsession with weight is a core symptom of the disease, a preoccupation the mind of the ill person. For clinicians, restoring and monitoring weight remain one of the best indicators for continued health and progress.

These distant poles of illness and recovery can play a demoralizing game of tug-of-war between encouraging the eating disorder and maintaining recovery, especially if the therapist isn't careful. Striking the right balance between monitoring weight and staving off obsession is challenging. In the end, treatment needs to gradually relegate weight to a less important status in recovery and identity, a tight rope walk that's critical to free someone from the prison of the eating disorder. 

Weight is not only the focus of people with eating disorders but a national obsession. The public health obesity crisis, the media focus on thinness and the universal reach of the diet industry all point to the endless public appetite for weight obsession. The universality of the focus on weight applies to clinicians too: no one is immune.

So when a patient expertly couches their pathological weight obsession as if it were within the norm of society, it's too easy for the clinician to fall into the trap. The conversation can become familiar, casual, without sensing the danger. The result is the patient feeling validated: yes their own weight obsession is normal. They aren't really that sick.

Similarly, living with an eating disorder in today's world encourages and rewards successful weight obsession. Weight loss invariably leads to an endless string of compliments. Weight gain by someone who was underweight triggers the rounds of "You look so much better," as if weight gain were synonymous with full recovery.

Even treatment providers can't help but acknowledge and comment on weight as a marker of success or failure. No matter how much it's explained that recovery is not about weight, society says otherwise. In fact, weight appears to be the only way people are able to understand these confusing psychological illnesses. It's much clearer to discuss weight than to understand why someone cannot eat.

The best path for recovery is somewhat counterintuitive. Once weight isn't at a dangerous level, ignore it. Focusing on weight validates one core belief of the eating disorder: the number on the scale is the most important marker for success.

Since the goal of treatment is for life to become meaningful, that powerful number must be devalued right away and regularly. The only value of weight in therapy is as a marker of health, but tracking meals each day and monitoring variety and intake of food, though time consuming, is much more valuable. Health is connected with nourishment, not weight. Following the number more often reflects too simple an approach in treatment and at times too punitive a stance if weight is used to measure progress, a mindset very much akin to the eating disorder.

Unfortunately, the treatment team may find a false clarity in following weight when the best tracking is a lot more ambiguous. If any eating disorder treatment appears that simple, something is wrong. In fact, therapy requires complexity and ambiguity, two qualities most challenging to the ill person, to demystify the simple yet destructive rules of an eating disorder. Any treatment relying on such a simple marker of weight has little chance to succeed and is likely playing into the hands of the illness.

To avoid the pitfalls of weight, it behooves the therapist to explain the role of weight in recovery right away. Weight only matters if it's at a dangerous level and thus a clear sign of severe illness. That's mostly the case if someone is in inpatient or intensive outpatient treatment. Anyone medically stable shouldn't have weight be the primary assessment of health.

It's essential to educate the patient and family that weight stability is only a small part of recovery. Health is a necessary prerequisite for effective treatment because the mind and body need to heal in order to change behaviors and alter one's life course. However, a therapist needs to quickly dispel the myth that normal weight equals recovery.

Putting weight in its proper place in treatment begs the question what does constitute the successful path of treatment. The answer lies in a series of complex tasks: face the challenge and emotion of eating each day, come to terms with the unpredictability of daily life, accept illness and recovery as an obstacle to living more fully and, most importantly, search for people and things that make life much more meaningful than the number on the scale.


Modern Love Redux: Relationships and Eating Disorder Recovery

Well-respected media outlets have a tendency to conflate eating disorders with weight obsession and dieting. Granted, in many circles disordered behaviors around food and weight are now considered within the norm, but that's a troubling reality newspapers and magazines need not take at face value. It's frightening to imagine a world in which severe dieting or purging meals or extreme exercise are barely even something to think twice about, but here we are.

Meanwhile, journalists, striving to find a role, any role, in the internet culture, have latched onto the public craving for dramatic stories about personal struggles with food and weight and have, for better or for worse, received the attention they're looking for. 

A case in point is an article in the New York Times this past weekend. In the Modern Love column, a woman outlines her story from a lonely, eating disordered life to the happiness of marriage and the miraculous ability to eat again. She refers to her years of being emaciated alternately as a source of pride and as the pathological focus of her disease, never quite being sure on which side of the fence she belongs.

The rounds of purging and starving and secrecy are just part of her journey, swinging on a pendulum from disease to a mere stage of development. Can it be that her extremely low weight, one that merits hospitalization by any clinician's standard, is just another badge of honor? Even by the end of the story, the answer is never quite clear. 

Finding love is the next step in her journey, one that allows her to start eating again. She reluctantly admits to a more healthy weight while finally recognizing her eating disorder and starting to get help. Somehow, she thinks that neither her friends nor family had any idea she was sick, and that everyone thought she just looked thin and believed in the same delusion she did.

She writes about gaining weight but neglects to tell her readers whether or how her eating disorder symptoms have improved, furthering the fallacy that normalized weight equals recovery. She is grateful that a relationship awakened her to her illness rather than an ER visit or a family intervention, but the final impression is that she has been cured by a loving man, a dangerous conclusion for her readers suffering with eating disorders.

At first glance, there certainly was something brave about writing this story. I applaud someone willing to confront the secrecy around her eating disorder and let others see that there are paths to improvement and recovery. There is no doubt that this woman has found more peace in this relationship than she had prior. However, writing an article for a platform as widely read and as influential as the New York Times bears a larger responsibility.

The writer and the editor must understand that the readers most interested in this article are those either afflicted with an eating disorder or the family of the loved one who is ill. The unwillingness of the writer and newspaper to directly address the realities of her severe illness and the medical consequences, let alone possible mortality, of the starvation and purging sugarcoats her suffering. Couching her disease in a love story allows other sick people to identify with her and just hope for the right man to come along in order to get better.

To confuse the situation further, her central message is one very much accepted in the eating disorder treatment community. Meaningful relationships in the world are critical to recovery. The reality of these illnesses is an inward preoccupation with food and weight which intrudes upon personal relationships. Finding connection, caring and love helps speed up the process of getting better but isn't a cure. In that vein, she really got it right.

In order to get through to her readers, the writer needed to face her own fear and be more honest. She needed to name her illness and speak more widely and knowledgeably to her audience. Revered outlets like the New York Times provide critical exposure for eating disorders but have a responsibility not to turn severe illnesses into a rite of passage or a modern-day fairy tale.

Even if a story is likely to draw in readers, the editors need to consider their role as educators about these misunderstood and difficult to treat illnesses. The writer's flippant yet self-deprecating comments about her weight both trigger obsessions for people with eating disorders and propagate false beliefs these illnesses. She ought to know better than to throw frighteningly low weights around several times in her article. People in recovery have a responsibility to state the facts about their disease, confront the bias and stigma and help others understand what constitutes effective treatment.