An Adult's Guide to the Overweight Child

Many parents or adults find it challenging to adjust to the transformation of a child's body into an adult's. We all have certain psychological and emotional associations with a child's body that shift markedly as that child grows up. There's a dissonance people experience between the feelings towards a child juxtaposed with the child physically looking like an adult. Too difficult to manage emotionally, adults hope that ignoring the change will make it go away. 

Similarly, the way a parent reacts to the idea of an overweight child is much different than reacting to a child one knows or a child of one's own. Adults, in a hypothetical situation, would easily brush off the idea of a child on a diet. We can all quickly realize the detriment of teaching a child about restricting food, and my recent posts to this blog highlight the dangers of dieting. But what happens when this is a child you know? Or if it is your child?

There is so much media attention to child and adolescent obesity that a child one knows on a diet might feel appropriate, the risks outweighed by the fear of obesity. For some parents, having an overweight child may even signify a sign of failed parenting. Then, in a much more personal situation, a diet might not be so absurd after all but a needed step to right a wrong. 

Rather than reflexively jump to a diet, an adult needs to survey the entire situation. Not only does a diet run the risk of triggering a starvation response and perhaps even an eating disorder (as explained more fully in the last two posts), the diet also sends a message to the child that he or she is doing something wrong: their weight is a personal fault that needs to be fixed.

Body weight and shape are largely fundamental aspects of body both genetic and based on developmental stage. Fully assessing the child's situation is already a way to put weight and shape in its place and not give them too much importance. 

The first step is to assess the child's general food intake and exercise. If the child eats normally for that age and within the norm of most children, then it is a fair assumption that the child's diet is not an issue. Similarly, if the child's physical activity falls within the norm then that is also not relevant. It can be surprising for adults to realize that children all of whom eat about the same amount and types of foods and engage in moderate activity can end up in a wide range of body weights and shapes. Many factors affect what anyone's body looks like. The goal is health, not some preferred body shape. 

The second concern is the child's developmental stage. For boys and girls, the few years before puberty can be a time of weight gain. Often this seems to be preparation for the vast changes the body is about to undergo. If a child gains weight around that time without any lifestyle changes, it is likely a response to development. 

The third critical piece of information is family history. If the parents or other close relatives have a larger shape, then it is likely the child will as well. If the parents gained weight at certain times of childhood, then it's not surprising if the child does too. In other words, the child has the parents' genes so his or her body will likely grow in ways that are similar. Punishing a child for having a similar body to his or her parents is paradoxical. The goal is acceptance of who we are, not pressure to be something different. 

An adult can approach a child's change in body weight and shape with reasoned, thoughtful questions. The reflexive jump to a diet sets the child up for self-doubt, if not worse, over time. Acceptance and self-worth are necessary goals for any child that clearly overshadow any goal of ideal weight and shape, which only seem to derail development and risk disordered eating and worse.


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.


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.


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.


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.


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.


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.


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.


Raising a Child in a World of Dieting Part II

It rails against everything parents know to say less is more in raising children.

The time and energy spent managing the success and future of a child leaves little room for the child's personal growth and exploration. Forget any concept of small successes and failures: these kids are praised moment to moment as if they invent electricity every other day.

No measure of success truly matters because it is the norm. In fact, many communities just create endless rounds of success for kids these days--trophies for everyone--and not a whit of criticism or room for improvement.

Perfectionism has become the expected way of life. Difficulty translates into difference. No one, parents included, can tolerate failure. Ever. 

For readers of this blog and, for that matter, any literature about eating disorders, this mindset will be very familiar. It describes to a tee one central personality trait for people with eating disorders. Motivation gone awry turns into overwhelmingly impossible standards.  Internal drive without reason or purpose makes people need a way to opt out of completely unrealistic goals. Life is too hard when the expectations are so unreasonable.

Instead kids find perfection another way, namely through manipulating food and weight. 

Parents also struggle to accept imperfections in their children. Just because each kid gets a trophy doesn't mean they're all equally good at the sport. Adults, even those taken by fantasies of wildly successful prodigy, see the writing on the wall sooner or later. Accepting that reality and realizing their child is just another imperfect person are not easy pills to swallow. 

When faced with this reality, parents can turn to food and weight just as much as children. The illusion of creating a perfect child because of correct eating and weight maintenance becomes very alluring. Part of that can be positive reinforcement by adults who approve of a child's body type, but an overweight child can cause concern in adults and lead parents to use weight loss as a goal with their child, as a way to perfect their offspring. 

Establishing food restriction and weight loss as central to a child's identity severely limits their personal growth and development as well. At a time when a child is learning about their place in the world, focusing on something so limiting and narrow as weight can quickly derail their maturing selves. 

In this realm, the goal of parents is to reinforce the personal qualities of that child, psychological, emotional and physical, while protecting the child from the collective forces trying to focus family energy on food and weight. A consistent message from parents can balance those outside pressures and ensure the child knows the alternatives that exist in understanding oneself. 

It can be very difficult for parents to brush off outside comments about their child's physical appearance, especially when critical. Aggressively defending one's child against those adults who make comments only gives their thoughts more credence. The key is to discredit their thoughts while always presenting another way to see the world. 

Consistency, clarity and balance can, over time, allow the child to learn different ways to balance food and weight in a different world philosophy. The idea is not to eliminate those messages that reflect body and weight obsession since parents don't have that kind of power. It's rather to provide an alternative that so that the child  knows there are more important things to life.


Raising a Child in a World of Dieting Part I

In the next two posts, I will switch gears to talk about parenting children about food and weight. Adult attitudes towards these topics are central to a child's understanding of self-perception and of her place in the world. It is one thing for adults to struggle with the role of weight in determining self-worth, but it's something entirely different to saddle a child with those thoughts from the get-go. 

It has become fully accepted that weight is one of the primary means to judge others and oneself. The bias against those who are overweight--and the similar overestimation of those who are underweight--runs rampant in our society. The less discussed caveat to the prejudice is that being overweight or underweight always reflects overeating or dieting, respectively.

Laden with judgment, this reflection represents the implied battle between gluttony vs. restraint and the basis for judgment on our moral character. 

The sad truth of our culture today is that changing this prejudice doesn't seem to be on our radar. Much of the writing about the general increase in obesity and eating disorders reflects changes in accessible food, the plague of dieting, acceptable body type and the drive for thinness, but these cultural changes don't stop us from fully believing the overarching bias. 

This attitude has now seeped its way into judging a parent's ability to raise a child. The increased interest in parenting techniques and the concept that children are a reflection of parents' success make weight an easy target for judgment. Parents of thin children gloat while hose of overweight children shrink away in shame. These tendencies all seem to ignore the general well being of the child. 

Parents heed the fear of an overweight child by focusing on the child's eating right away. Starting with parents' obsession with a baby's feeding patterns, they monitor food intake throughout childhood, first for health and wellness but gradually, with the communal bias in mind, for weight maintenance. The end result is that parents know they will be held responsible for any change in their child's weight. 

It's easy to see how the collective judgment can let a child's psychological development go awry. Childrens' bodies change constantly. As expert pediatricians explain, growth comes in fits and spurts, ups and downs. The message for a parent is to be ready for anything without expectations and certainly without judgment.

Varying growth will undoubtedly include changes in weight. At several stages of development, it is common for children to gain more weight: babies until they start walking and pre-puberty, for example.

Interestingly, some children can be underweight at those ages as well; however, others are likely to praise an underweight child rather than worry about adequate nutrition. Educating ourselves about a child's development--information easily at our fingertips--seems more valuable than judging a child and her parents based on a number on a scale. 

Falling into the trap of judgment sends a message to that child: there is something wrong with you. It isn't necessary to praise everything a child does, but it is imperative to allow her to believe she is capable, that she is not battling against an indelible mark against her. 

The clear step for parents is to figure out how to manage food, weight and health in a child's formative years based on the child's wellness, not the arbitrary worries of a community. Although the ill effects of outside judgment may be hard to bear, heeding those warnings is essential so as not to confuse or derail a child's psychological growth. 

The next post will address these concerns and give practical advice about how to monitor a child's well being.


Dieting, Metabolism and the Toll on our Lives

The central, common symptom of most eating disorders is chronic starvation. This is obvious for people with anorexia, but most patients who binge also feel like they must compensate regularly between binges by trying to restrict food as much as possible.

But even broader than eating disorders, it has become all too common for people to consider an inadequate intake of food to be the norm, if not superior to regular eating. And people often find praise in eating less and showing what is considered restraint, no matter how insufficient their meals. 

Extended periods of limited food intake affect how the body works. Without adequate energy to maintain and support healthy organ systems, the body sacrifices necessary function on many levels to compensate for the lack of energy. These sacrifices can span any organ, depending on the person, and can even become irreversible over an extended period of time. 

To much surprise, the metabolic effects of food restriction apply to overweight people as well. When people gain weight, their body becomes accustomed to a new normal weight range over time, so severely restricted food intake might lead to initial weight loss but then triggers the same metabolic reaction as it would for anyone. That sacrifice of organ function combined with shunting energy to basic needs are survival mechanisms. Ultimately, survival trumps the number on the scale every day for the human body. 

The combination of an endless supply of treats, all intended to increase food and economic consumption and the falsehoods of a diet industry leave much of he population at a loss as to how to eat. A significant percentage of the population is trying to diet every single day. Our metabolic reaction to these mixed messages render all extended food restriction pointless. The only real effect of dieting is a constant sense of failure. 

There's another insidious way chronic dieting invades our way of life, societal norms and pop culture. The expectation of many social communities is thinness at all costs. Much of the information from celebrities reinforces these same messages, as does any promotional photos that are photoshopped to reveal impossible looking bodies. 

Through my work to help people eat regularly again, I find myself fighting an uphill battle against constant and much more powerful messages outside my office from industry to celebrity to general norms. The ways to normalize food by returning to our roots of culture, meals and pleasure are typically drowned out by the endless ways society approaches food and weight. 

What is even more astonishing is realizing the extent of sacrifice in our lives and world. All the people who are chronically underfed cannot function at their top level. Hunger quickly turns off the most potent and creative parts of our mind and leaves us unproductive and unable to perform at our expected ability. 

It certainly appears that body and weight are more important than healthy bodies and highly functioning minds in our society, but I don't know if that is clear to the general public. 

I wonder if this message would have more impact than the current attempts to change how we eat. It feels like competing with the dieting maxims and convincing people to rest at their body's normal weight are ineffective. People need a clearer reason to see how we are constantly duped by a society bent on pushing us all to limit our lives because of a number on the scale.


Delusions of an Eating Disorder

Some recent posts have focused on the medical issues inherent in eating disorders. Classifying these illnesses as psychiatric belies the reality that disruptions in eating patterns trigger significant medical comorbidities, some obvious like vitamin deficiencies or osteoporosis, others less so like renal dysfunction or endocrine abnormalities. 

The classification system for eating disorders elucidates the more obvious psychological symptoms of these illnesses: feeling fat, the overwhelming need to restrict intake and the urge to lose weight no matter what cost. The sad reality of our current societal norms is that many people who don't have eating disorders espouse these beliefs, at least on the surface. 

The plethora of unrealistic, if not harmful, diets, cleanses, and reality weight loss shows points to the fact that eating disorders are only a step past what's considered perfectly reasonable in this day and age. It appears that the unlucky few who are genetically programmed to respond differently to an extended period of food restriction or overexercise cross the line into a disorder from the more typical disordered eating. The acceptance of disordered eating puts the susceptible ones at risk, but the drive for thinness makes those who get sick necessary casualties to satisfy our collective obsession. 

Despite the communal experience of food and weight, there are some psychological thought processes of eating disorders that step past what is considered reasonable and can even be seen as delusional, a fixed belief that is clearly false but unwavering. These thoughts often reside in the eating disorder of someone who is otherwise very practical, clear-headed and logical about life, someone even whom others seek out for guidance and advice. However, buried deeply under the rational facade is a host of thoughts about food and weight that is nonsensical and clearly untrue but guide that person's daily life. 

In these symptoms, the psychiatric nature of an eating disorder is abundantly clear. 

Common symptoms tend to involve the same basic premise that food is somehow detrimental for one's health and well-being. This thought process extends past a fear of foods, an idea that many diets and ill-advised nutrition research advocate, towards the attribution of an almost evil purpose to food. As that belief becomes more fixed, the natural response to avoid food and to feel that eating will jeopardize one's well-being is a natural, logical step. 

Once food is seen as the enemy and harmful, convincing someone that this thought is patently false becomes very challenging. It is so antithetical to people without eating disorders to view food in this way that someone with this kind of eating disorder seems very foreign and lives life very differently from other people and in fact differently from people with eating disorders who don't have these delusional thoughts. 

The process of realizing these thoughts are false takes time but is very possible in successful treatment. It's clear that other people don't view food in this way and that approaching food, something commensurate with healthy life, as harmful makes one's daily existence very difficult. There is a learning process to change deeply rooted behaviors associated with the delusion, but sustained challenges to old thought patterns can be very effective. 

These delusional thoughts are part of an illness. Even though they are not logical and clearly untrue, they render an otherwise thoughtful, kind and caring person seemingly very unwell. However, these illogical thoughts are circumscribed solely to the experience with food and don't take away that person's value as a human being. Even the most confusing parts of an eating disorder cannot take away the humanity and empathy of the person underneath.


"Getting It" Part 2

When people hear about children or young adults developing a serious, potentially chronic and even fatal medical condition, the responses are fairly predictable. Often an adult will feel sadness at the thought of someone early in life struggling, of a life derailed by illness, something most people are fortunate enough to associate with old age. Someone might focus on the unfairness of getting sick young or the loss accompanied with being unwell in the formative years. Many will feel powerful sympathy and even the deep desire to be able to heal a sick child. 

However, these are not the responses to a child or young adult diagnosed with an eating disorder. These reactions are also predictable but much less helpful. An adult often is perplexed at the idea that a child is not eating when food is plentiful. People often get frustrated and angry at the one who is ill. Someone who might sympathize with a sick child instead sees the eating disorder as a personal flaw and consequently only feels sympathy for the parents. 

Unlike other childhood illnesses which elicit support and love, eating disorders lead to confusion and frustration. A child or young adult in pain and suffering with an eating disorder needs care, love and kindness to find a path to recovery. Instead, the child is more often ostracized by the adults most likely to help.

The rise in the incidence of eating disorders was quickly followed by two phenomena that could bind together people with eating disorders against the universal lack of comprehension of these illnesses: the rise of eating disorder treatment programs and the birth and spread of the internet. These two events allowed isolated, scared children and young adults to find others who were sick and understood what they felt and experienced each day. As much as the growth of community has had negative consequences by allowing the birth of the pro-Ana and pro-Mia websites, the connection also created the opportunity to feel understood. 

The concept of "getting it" fundamentally reflects the powerful desire for people with eating disorders to feel understood. From the start, family, friends and clinicians treat them like pariahs, strange, confused and potentially threatening. The power of knowing that someone understands them, their behaviors, emotions and desires, is undeniable. In fact, just the experience of being understood often opens a door to imagining recovery more than any part of treatment. 

When I think back to my first experiences as a therapist in the outpatient program at UCLA, I realize that somehow I really did understand the internal struggle one has with an eating disorder very quickly. There was a level of communication around these illnesses that struck me personally and allowed me to deeply learn and understand. The group caught onto that piece of me and, desperate to feel understood and cared for, capitalized on it during my time in the program. 

In fact, they seemed to indirectly ask me not to abandon them by pursuing other avenues in my career. The message was clear: "Since you get it, we need you to help us. Please understand that not many people can make sense of the struggle and suffering of an eating disorder so use your knowledge to make this your career path. Please don't abandon us."

I got the message loud and clear  and have diligently followed that path. It isn't perhaps until now that I understood the message I received years ago, but I have felt the strong urge to make treating people with eating disorders my calling.

My very late reply to that entreaty from years ago is simple: I will do just that. Thank you.


"Getting It" Part 1

When I first started learning how to treat people with eating disorders, I was a psychiatry resident at UCLA. A colleague and I were the therapists in a weekly group therapy session as part of an intensive outpatient program. The age range of the women in the group was 18 to forties. Calling us the therapists was generous. We learned as much from the patients, if not more, as they did from us. 

I have been thinking about this group lately, more than for some time. In particular, when asked why I treat people with eating disorders, I speak about this group as the initial experience that began a quest to understand and help people with these illnesses. But recently, I have come to wonder whether I actually picked this specialty or, much as people find themselves trapped in an eating disorder, it picked me. 

As an impressionable and nervous resident, participating in this group therapy was a formative professional experience. After a few months, the patients who were more experienced in treatment settings had had sufficient time to vet the new trainees and determine that I, in eating disorder program lingo, "got it."

No stamp of approval was more potent. I had been accepted as a member of the club. I was now deemed worthy as a therapist. I had magically cracked some sort of code of empathy. I understood the complexity and confusion of having an eating disorder. The concept of not eating or of throwing up one's food, in the context of a complex life, made sense. Somehow, I had crossed over and now was one of them. 

I wasn't aware of any of this at the time but instead felt a heady, out-of-body sense that something significant has changed. It felt as if I had something special and had a responsibility to do something with it. 

Interestingly, my new status spread from patients to the clinicians who ran the program. I became one of their chosen residents and, over time, was invited into a small cohort of trainees considered capable of working with people with eating disorders.

The rest of the story is less interesting except that I have devoted my career to treating people with eating disorders. The effect of that initial group was to initiate me into the mindset and confusion of an eating disorder and to teach me how to use my own kindness, empathy and compassion to help a cohort of people left with limited treatment options, even in New York City, perhaps the most therapized city in the world. 

I have since learned hat the concept of "getting it" is central to most programs and patients alike. It has many uses like normalizing the confusion of the disorder, helping someone so alone feel a part of something and serving as shorthand for a therapist to trust. But the term can also signify the recalcitrant nature of the illness and the powerlessness the eating disorder thoughts brutally reinforce. 

In the next post, I will address the concept of "getting it" more carefully. Years after understanding its potent effect on me, I am curious to see more clearly the true meaning of this term.


The Challenges of Medical Treatment for People with Eating Disorders

There are pluses and minuses to classifying eating disorders as psychiatric diseases. Although the mental component is clear, managing an eating disorder is primarily a medical issue. The longstanding effects of starvation, binging, purging and other compensatory behaviors like laxative abuse or excessive exercise lead to a host of chronic medical conditions that need regular attention to limit the damage of an eating disorder. The confusion around classification is palpable, and too often the medical consequences of these illnesses remain inadequately treated. 

The central psychological aspect of an eating disorder is an aberration in determining hunger and fullness leading to very erratic eating patterns that follow arbitrary rules instead of the body's needs. The thought processes that underlie the illness can range from the fear of gaining weight and self-loathing to seeing food as terrifying, unnecessary or harmful. These thoughts generally follow the initial change in behaviors around food and become fixed as the behaviors become more fully established. Once these new patterns are set, they become the new norm and exceedingly difficult to change. 

While treatment focuses on the therapeutic attempts to alter the eating disorder patterns, the person endures long stretches of starvation or traumatic events such as binging, purging or laxative use. The emotional and psychological effects of these behaviors biologically reinforce the eating disorder patterns. Starving begets more starving as the eating disorder behaviors are reinforced when the body's metabolism adjusts to the lack of food, binging more binging as compulsive behaviors create a cycle of thoughts and actions.

More importantly, months or years of these behaviors cause significant damage to the body that require medical attention. During the difficult period of recovery, management of these medical issues is critical for long term health and increases the likelihood of full recovery. 

There is a basic fact about medical treatment for people with eating disorders: medical training does not equip physicians with the information needed to treat these illnesses. Teaching the medical management of starvation comes up in only two circumstances: distant poor countries and end-stage cancer.

Chronic starvation in the western world is largely considered impossible while obesity instead catches medical interest. Binging, purging, laxative abuse and other eating disorder behaviors are not at all a part of medical training. In fact, all of these behaviors, rather than being seen as symptoms of an illness, are instead considered personal choices of the patient. The effect is to blame the patient and ignore the medical consequences. Adequate treatment is far from a reality for most people with eating disorders.

Viewing eating disorders as a medical illness would increase the likelihood that doctors learn how to treat the medical consequences of these illnesses. Too often doctors overlook serious medical issues for these patients and instead reinforce two concepts: they are healthy and they just need to choose to eat. These two messages only make patients less likely to continue their path to recovery. The real question is how to educate physicians about diagnosis and treatment of the medical effects of eating disorders. 


Bridging Two Worlds: A Path Between the World of an Eating Disorder and Freedom

Living in the shadow of an eating disorder is a very foreign place. The laws that govern that world, the ways decisions are made and the natural flow of events and relationships are all very different from the world everyone else populates.

But this fact is not clear to people with eating disorders, often for a long time in recovery and for a very specific reason. The combination of self-awareness and our limitations of empathy make humans preternaturally self-absorbed beings. Thus, we humans have a natural tendency to see our own perspective as reflective of everyone's view of life. Although this is clearly false, it's hard to remember that in day-to-day life. 

After living with an eating disorder for some time, it similarly becomes hard to remember that most people don't live by the rules of this illness. Freedom to choose their food is a basic fact of life for everyone else. 

The realization that life without an eating disorder means entering an entirely new world is often shocking for people in recovery. It takes time to understand that entering this new world comes with a host of new rules, most of which do not revolve around food. An eating disorder creates a very rigid system of decision making in life that limits many aspects of what everyone else sees as relatively free: food, friendships, relationships, emotions, self-care and self-determination. Eating disorders restrict not just food but life. 

That restriction is terribly limiting but also provides security from the overwhelmingly unpredictable and seemingly dangerous world. People typically find that they don't have the personal skills to function in the world without the eating disorder clearly directing the way. After the shock of this discovery, there is a moment of panic followed by a steep learning curve about life. 

Although many people use this sensibility to describe an eating disorder as a lifestyle choice, this seems largely misguided. It appears to be better described as a crutch. The eating disorder may make navigating life a bit easier on the surface, but it severely curtails possibility and opportunity to grow, connect and love, essential qualities that makes life full and whole. 

What sparks the opening of a window into the world without an eating disorder is almost invariably a strong, personal connection. The eating disorder blinds the person from seeing and believing that real connection can provide solace from life's challenges and meaning to daily life. The inherent isolation leads people to present the world a shell of who they are. The jolt of a connection typically allows people to remember past experiences of connection and trigger the universal yearning to be understood and heard. 

But here lies the paradox. It's so hard to be truly heard while living in a foreign land. It feels almost impossible to explain what it's like to live dominated by the eating disorder to someone who's never visited this strange place. Once that person in recovery begins to understand the world without an eating disorder, it becomes easier to explain the hell of the world of the eating disorder. The opportunities to connect with others are revealed, and a path to freedom opens.


A Case of the Bias Against People with Eating Disorders

Public health campaigns and outreach by non-profit organizations such as NEDA and AED have started to educate people about eating disorders in the last two decades. Despite the ongoing confusion and misunderstanding about these illnesses, the work of many dedicated people have led to significant advancements. Eating disorders now receive treatment parity with medical illnesses as biologically-based diseases and are legally mandated to qualify for disability benefits for people on medical leave from work. 

A less tangible benefit from the public outreach is the decrease of bias against people with eating disorders in the academic and professional setting. It has become much more commonplace for people to reveal their illness on school applications, during a semester or to bosses at work without fear of stigma and bias. As a psychiatrist typically coordinating a patient's care, I have become increasingly comfortable suggesting someone be honest and open about their illness with much decreased fear of repercussions based on ignorance and misunderstanding. 

In this environment of growing tolerance and acceptance, I was asked to testify as an expert witness for a patient of mine under review by the New York State Bar committee. In order to provide full disclosure, this patient asked for my support in any way possible after the hearing and offered unqualified support for this blog post as long as her name or personal details were omitted. 

She had passed the Bar exam several years before and had been waiting for review by the committee to assess her fitness to be an attorney because of past symptoms and behaviors directly related to her eating disorder. She has received substantive and ongoing treatment for her illness over the years prior to and since taking the exam with significant benefit and progress. 

Although it is within the reasonable right of the committee to attain professional verification that she has been adequately treated and is stable to be an attorney, the committee proceeded, over several years, to ask for all medical records, obtain many letters from providers repeating the same information and delay the hearing for years for no apparent reason. From all appearances, the committee's ignorance and bias against this person's medical illness contributed to the extensive delay. 

The hearing turned out to be a two day referendum on this woman's character. The committee attacked her and her witnesses as if having an eating disorder were a punishable offense. The members of the committee showed a thorough ignorance of these illnesses and their sequelae and, more concerning, continued to reassert their flawed line of reasoning despite multiple attempts to clarify and educate the committee about the psychological manifestations of eating disorders. Moreover, the committee continued to personally attack this woman based on her illness and placed the onus on her to convince the committee that she can function as an attorney, despite multiple expert witness testimony denying any link between an eating disorder and competent functioning as an attorney. 

As a final insult, one member of the committee commented directly about this person's appearance in the hearing in an attempt to prove she has recovered from her eating disorder. This may be a common misunderstanding for people ignorant of eating disorders, but was personally devastating in this legal context, as anyone with a basic of understanding of eating disorders would know. 

I have written extensively about the difficulty lay people experience trying to understand eating disorders and recovery. It means that public outreach is critical to protect the rights of people with this group of illnesses. However, when the ignorance of a professional committee is combined with arrogance and power, the life and future of someone with an eating disorder is seriously jeopardized solely because of her illness. It's clearly unacceptable for this group of accomplished lawyers to judge the suitability of a potential lawyer with the lack of knowledge about the problem and limited desire to listen to the expert testimony before them. 

This situation is an opportunity for the larger community of those with eating disorders and of professionals to support someone being unfairly punished for her illness. I urge those reading this article to post a comment and gather support for a person who has endured longstanding punishment for her illness. I hope this support can provide more evidence to the committee of their ignorance, bias and judgment and allow this person the career she worked so hard to attain and that has been kept from her for so many years.