The Dangers of “Healthy Eating,” Part V

It's worth spending a little more time on this exclusive club, those who purport to have willpower and self-control in spades. This group has the current ideal relationship with food, one largely innate, that many people will do almost anything to replicate. Examining them more closely yields knowledge about what is considered the goal of the compulsive dieting and weight loss and what is valued by a society with unlimited food.

People capable of a mostly rational approach to food, and devoid of the base urges to eat, also tend to fit a general personality type. In other words, the ability to resist the cornucopia of food in the modern world appears to come with a set of inborn traits, ones for the moment considered enviable, not an iron will. The traits in question include perfectionism, inflexibility, rigidity and, at times, a tendency towards self-punishment. Not only does this kind of person thrive on delayed gratification but often has limited capacity to enjoy the food, once finally allowed, much at all. Typically, food is a repetitive even monotonous daily chore performed with limited pleasure but instead dependent on mundane ritual. This way of eating most resembles the food as a utility model. Even when offered  every possible delight, no food is a treat. Instead, the abstemious eater, completely uninterested in anything the food industry has to offer, exists outside this basic pleasure of human life. At its worst, the rigidity can lead to disordered eating or even anorexia, but the desperate overeater, after years of unsuccessful dieting, often sees this lifestyle very differently. To them, it's impossible to see abstemious eating as the door to a joyless world or an eating disorder as the horrendous and wrenching prison it is. In fact, many lifelong dieters wish all necessary food intake could come in a daily pill and want to totally eliminate meals from our existence. If the endless diet and concomitant weight loss are sacrosanct, then a life devoid of the pleasures of food isn't miserable. It's the newest ideal, perhaps the current American dream.

To learn more about the abstemious eater, it behooves the curious to ask the obvious: what do they eat? The answer isn't so obvious at all because it's a trick question. No one is going to follow a member of the club around and log their daily food intake. In fact, no one even asks what they eat. It turns out that what they eat is irrelevant; the perception of what they eat is what matters. What stops the actual inquiry is fear either of being shamed in comparison or of becoming hopeless after seeing the impossible, depressing meal plan in it's entirety. Left without any real information, the curious happen upon an answer based largely on perception: what would an extremely knowledgeable--from years of reading diet and nutrition books--dieter presume a pleasure-free eater to eat. Thus, there is no need for the idealized group to flaunt its superiority (or even mention anything about how to eat), for it's accepted without question by society as a whole. No one wonders or even cares about how unpleasant and joyless an abstemious eater's food life might be. No one cares what they actually eat. As is typically the case for an idealized group, perception trumps reality.

The fundamental perception of an abstemious eater's daily food isn't hard to figure out. A few years into chronic dieting and nutrition education, even the most optimistic dieter realizes that there is no magic solution. On reading assorted nutrition guides, from the extreme diets to the practical to the solely educational, the same information surfaces again and again: more vegetables, varied diet, fewer processed foods, whole ingredients, home-made food. The sage advice turns out to be obvious; there is nothing complicated about choosing a nutritious diet. The problem lies in the application of basic knowledge. The deeper drive to eat, especially the tasty morsels produced by the food industry, easily supplants the best intentions, thus the birth of the myth of willpower. Because nutrition education is so ineffective, most newfangled ideas simply tweak the facts enough to create a new, sure-fire, and hopefully best-selling diet. The public's insatiable appetite for an easy fix opens a market for meal plans that either subtly alter the specific amounts of the nutrition building blocks--protein, fat, carbohydrates, minerals, vitamins, etc--as the core of success or boldly find a new culprit for failed diets and eliminate it, the dreaded carbs being the current food villain. Even if purely unsubstantiated, any new fad can become popular when nothing works. The only thing the diets have in common is food restriction, necessary for any weight loss. 

Even the most hard working, diligent dieter will forgo the diet fad and failure cycle after a time. The process is so demoralizing that the next step is usually a period of total hopelessness followed by a resurgent desire to truly understand why each diet fails. All signs first point to a lack of willpower, a myth that saves the diet industry from facing its own shortcomings by placing responsibility on the individual. It is much too easy to sidestep the fact that upwards of 95% of diets fail. The next logical step is to return to the perception of an abstemious eater's diet. After a life of education, it's clear that the answer, of course, is "healthy eating."

Ask anyone what healthy eating is and see the looks you'll get. The gist of any response is how can you not know? Isn't it a given for anyone, especially a parent, to know how and what to eat? It's one of the most basic things in life, like sleeping and walking. Like breathing! Hold on, is this a test? Are you asking if I know what healthy eating is? Really you must know what healthy eating means?

Yes, the reactions range from dumbfounded to incredulous to insulted. But what happens if you probe deeper? It turns out that although the most basic, general rules may be close to universal, once you get to specifics, the answers run the gamut. Anyone can list off the basic rules from nutrition guidelines, but they are of little help day-to-day in the real world.  Tackling the real questions is simply overwhelming. Can you eat processed sugar? When and how much? Are snacks ok for adults? For children? What kind of snacks? How much does food really need to be organic? What do you think about all of the "healthy" food labels? Do you look at or tally the nutritional information labels on food? How much carbohydrates or fat or protein is too much, or even too little? Is it necessary to monitor daily salt intake? What to do about dessert? Is having dessert every day ok? What kinds of dessert? Should dessert always lead to guilt? Is dessert always a "bad" food? Are there even good and bad foods? The questions abound and quickly exhaust even the most patient and thoughtful person. If the abstemious eater follows "healthy eating" and the food rules are endless and unanswerable and the so-called experts often support misleading or flat-out erroneous information, then can anyone actually define what healthy eating is? Or is it possible that nobody really knows how to manage the world of plentiful food? Are we all left to fend for ourselves?

Part VI next

The Dangers of "Healthy Eating," Part IV

It wasn't long ago that modern medicine purported that 90% of the brain was unused, a spectacular assertion to conceal our almost complete ignorance of brain function. The rapid rate of research in the past two decades has since shown how much there is to learn but also left us in awe of our own internal computing capacity.

Without a more complex understanding of brain function, computers, ironically, serve as the layperson's most apt and comprehensible analogy for how the brain works. Many people still see computers as more powerful, valuing the brute force of swift computation over the sophistication of the brain's learning, memory and recognition prowess. What is most appealing about a computer is that what you see is what you get. Ask a question and you can easily get an answer. Use an app and the function is clear. By comparison, the vagaries of what actually occurs in our brain remains very hazy.

In truth, incorporating the knowledge of brain function into modern life is a challenge. The unique element of being human is our self-awareness: a topic addressed by philosophers for centuries. It is our blessing and our curse. Forced to face the reality of human limitations, a uniquely human experience, people have endlessly searched for comfort through religion, power or substances, to name a few of the largely ineffective solutions. In our current world, much of the comfort stems from a sense of direction and purpose, or more succinctly self-determination.

It's a modern-day myth that hard work and confidence can lead to success. Underlying this goal is anyone's ability to harness their mind for a single purpose; ultimately, we are in control. The most confusing and perhaps most disconcerting realization is the concept that the majority of our brain functions unconsciously. It is preprogrammed to push onwards and, much like the heart, function completely out of awareness.   That's fine when we are discussing the gastrointestinal system or neurological reflexes, but it's disturbing to many when it concerns problem solving or personal relationships. To think of our brains more like computers means the triumph of self-control and willpower over the unconscious, automatic brain systems that keep us alive and well. Many people feel lost without self-control as the ultimate tool. But that makes the true implication of brain science tough to process. If 90% of our brain power has been in use the whole time, just not within our awareness, then who are we?

The general consensus that individual motivation and conscious decisions should dictate daily life has clear implications in addressing weight and food. In this scenario, willpower is everyone's default excuse for diet failures or eating lapses. In fact, the general credo is that willpower, along with some common-sense knowledge about food, is the only way to manage eating when surrounded by excess. And this commonly held belief is the central building block for all of the marketed schemes to manage eating. Gladly, industry will capitalize on our willingness to accept that diet failures are our own fault! It's too easy to vilify the companies making a profit and not recognize the larger need to believe that the perfect diet or ideal weight management solution is just within our grasp. That's not to say we should blame ourselves, but that the alternative explanation, one that incorporates innate responses to food and the limitations of sheer willpower, remains too much to handle. A more reasonable food plan with moderate results that still demands substantial effort has little appeal. The goal is a quick fix with miraculous results, short-term effort followed by a return to life as we know it. This construct, created by individual desire as much as industry, ensures the repeated failures of any new eating scheme and the continuation of society's obsession with how to eat. We all unwittingly believe in the newest, wholly unproven diet and accept that its failure is always our own fault.

Questioning the willpower hypothesis can infuriate those who have spent their adult life bouncing from diet to diet. After years of obsessing about weight loss and dieting, no one wants to believe that the way we eat and what we weigh is largely predetermined. Who wants to think the endless dieting has all been for nought? These naysayers point to the segment of the population that seems to be able to eat when hungry and stop when full, despite access to plentiful food, and say these people have it all figured out. If they can do it, then anyone can. It's just a matter of self-control.

It's not hard to find a member of this group, especially one who is smug enough to think they have all the answers, that their own relationship with food is the solution to the scourge of obesity. The lack of interest in, at least to most everyone else, typically irresistible foods may very well be a coveted trait today but sure isn't any sign of superior willpower. It's just one of the ways humans are born relating to food. Ask a member of this group what their trick is. Not one person can describe a conscious series of thoughts or actions to explain their formidable restraint. It is apparent that willpower is instead the other end of the spectrum of human reaction to food, a variation of the innate way people eat. The emergence of unlimited foods designed to appeal to our base desires reveals the range of human response, from insatiable appetite to a total lack of interest. There are evolutionary explanations for both: overeating in times of plenty triggers fat storage and protects against famine; and delayed gratification leaves excess food for external food storage for the future. Both biological reactions to times of plenty are beneficial. The fundamental challenge is to recognize how we are all hard-wired to respond to the current food environment. Accepting the fact that we are preprogrammed to eat in a certain way is a very bitter pill to swallow. It's anathema to self-determination, that our brains function independently to dictate how and what we eat; or that the availability and quantity of food sets up many, if not the majority of people, to struggle with food; or that no diet or food elimination is the cure for eating in the modern world. So instead we live in the communal delusion that willpower is the final salvation, self-control is just a state of mind.

Part V soon to follow.

The Dangers of "Healthy Eating," Part III

What is a person faced with an endless supply of food to do? The varied answers to this question have become increasingly important as first world countries buckle under the medical and social problems the world of plenty has produced. It seems so obvious that, with food shortage practically a relic, regular meals and snacks could be such a routine part of our day that food might become taken for granted as a utility, paid and consumed monthly like the electric bill. Some people even dream of a pill taken once in the morning that would provide all the nutrition for an entire day. But our minds and deepest desire to eat just won't comply. No matter the collective belief that overeating has become a public health hazard, for some akin to smoking a few decades ago, even the most clever ad campaign, junk food tax or industry regulation can't override our innate response to all this food. And as obesity, eating disorders and disordered eating wreak havoc with people's lives, society works on an intellectual fix to a deeply embedded, old brain, instinctual problem.

So, in a world overrun by media and overly reliant on the power of our intellect, the average person just can't find a way around the deep desire to eat. In fact, while the messages, whether subtle or overt, around us imply that a solution to eating is always within our grasp, modern life regularly sabotages any real chance of doing so. Alongside the photoshopped magazine covers of impossibly tall, unblemished, emaciated models lie the tantalizing tidbits thrown to all the normal looking people: lose ten pounds in a week!, the best way to avoid those carbs, three tips to the abs of your dreams. But what happens when the reader flooded with the ideal of skinny and easy weight loss looks up from the magazine? The world around them is all food all the time, be it at the office, at home or walking in the mall. Modern life pits the intellectual desire for thinness with the enormous supply of delectable goodies. And it is absolutely clear which drive wins out.

The hard truth is that the game is rigged. Yes, the medical community and public health system both know how personal struggle with food is the first health problem shortening average life span in several generations, but several large, powerful industries rely on both over consumption and chronic dieters to thrive, and they continue to dominate the discussion. The end result is that it's hard to find the motivation of society at large to alter how we eat. The diet industry, self-help books, reality TV and fashion magazines all profit from the unfulfilled desire to lose weight. Although the promise of weight loss abounds, scratch under the surface and it's clear no diet has ever shown any meaningful, large-scale success.

Tackling the impossible task of corralling our impulse to eat has preoccupied many of the brightest minds today. The diet industry floods the market with new options regularly. Despite the reputable data that diets fail over 95% of the time, the weight-obsessed, desperate to seize upon the newest hope, jump on the latest weight-loss bandwagon, lose weight and then promptly gain it back, and more. Many diets now include food products or even food delivery options in order to boost profits. The explosion of books which, with no scientific or medical basis, purport to have discovered the solution to managing hunger and weight, either through altering food choices, elimination of certain food groups or an often fabricated understanding of human nutrition or metabolism, has no end in sight. Not only does a successful theory capture the attention of a public starved for an approach to the world of plenty, but even the medical establishment will accept a popular new theory as one of its own. Similarly, a growing branch of medicine, from internal medicine to mental health to surgery, takes on obesity and weight loss. Not only are the masses of overweight people willing to trust their doctor to solve the diet dilemma quickly and easily, but doctors are more than willing to promise the short-term fix, through temporary, potentially harmful medications or surgery with dubious long-term results.

A public health campaign to educate the public about the reality of a weight loss program--challenging lifestyle modification that provides moderate but long-lasting success--is, at the moment, in no one's interest, and in fact could damage several industries whose profits rely on the general public never learning that the advertised weight loss schemes don't work. Some programs are small enough to escape the powerful lobbying organizations in Washington. The worthy government-sponsored programs--such as the Move Your Body campaign by Michelle Obama and the FDA changes in diet recommendations--and growing Farmer's Market movement are just sideshows to each person's futile struggle to monitor food intake and weight.

After years of frustration, people tend to give up on the great hope of a speedy solution and settle for the daily internal struggle. The growing sense of failure and hopelessness becomes a way of life. They seem to be holding out hope for the missing ingredient the diet industry, self-help books and doctors all say will lead to success: willpower.

Nestled comfortably between pop psychology and the latest weight loss guru manifesto, willpower is everyone's default excuse for diet failures or eating lapses. In fact, the general credo is that willpower, along with some common-sense knowledge about food, is the only way to manage eating when surrounded by excess. And this commonly held belief is the central building block of all of the marketed schemes to manage one's eating. Capitalizing on our society's desire to ascribe the regulation of basic human function, like food and weight, to a purely intellectual and cognitive mechanism ensures the repeated failure of any food management suggestion. We all unwittingly follow by accepting the premise that the failure of a wholly unproven method to work is always a lack of willpower.

Part IV will address willpower.

The Danger of “Healthy Eating,” Part II

The flexibility of human metabolism is an evolutionary adaptation, one that conferred longevity to individuals to withstand food shortages and thereby helped ensure the species' continued existence. In a relatively stable environment, survival of the individual depended on a combination of luck and beneficial genetic traits, but survival of a people relied on the traits alone. Only a catastrophic event could throw a species into instant turmoil. Natural disaster, a new, lethal disease or a more global phenomenon like an ice age might upend the order of daily existence. In those moments, a random genetic advantage, rather than a long-tested one, determined an individual's and even a species' fate. These monumental events were, in the past, always acts of nature. Never before have people been able to drastically change the environment enough to create our own cataclysm that directly challenges our built-in survival mechanisms. The unimaginable changes in food production and supply in recent decades has done exactly that. The world of feast and famine, deluge and drought no longer exists in the first world. Now, as if by a miracle of fate, we all live in a perpetual world of plenty. But our current good fortune is no stroke of luck at all; it's simply an advancement of civilization.

Since the start of the industrial revolution, human capacity and ingenuity have tackled one impossible dream after another: electricity, transportation, even space travel. One less celebrated triumph is in the agriculture and food industry. The impossible challenge was to feed an ever-increasing number of people. The explosion of the human population--recently surpassing seven billion and with no indication of slowing down--especially in the growing urban centers necessitated a grand revision of food production and distribution, at least in the prosperous first world countries. Agribusiness, large food conglomerates and national supermarket chains made feeding the growing population possible, and then some. America produces almost twice the needed per capita amount of food, measured in calories, the country needs. The application of efficient farming techniques, food manufacturing--largely from creative uses of corn--and innovation in food transport is a marvel of the past half-century. These industries, currently vilified for their complete disregard of the public health effects of their products, began with a more progressive motive, to supply affordable food to the masses, and have succeeded beyond anyone's wildest dreams. What is now commonplace in a supermarket--Chilean grapes, choice of any baked good and canned food that could feed a small army--was as unlikely as the fantasy world of 1984 only a few generations ago. Although the national debate over obesity has taken center stage, that's not a reason to ignore another achievement of industrialization.

Depressingly, the people enduring regular starvation--from sub-Saharan Africa to North Korea to those suffering from anorexia nervosa--have evolution on their side, not those who live in the land of plenty. The body has built-in mechanisms to survive long stretches with little food. Much as the electrical conduction system of the heart, the neural "wires" that produce each heartbeat, has several backup systems when the front line breaks down, digestion, metabolism and energy production can run on emergency as well. The eternally well-fed, if not overstuffed, have no such internal regulatory system to rely on. That's how a man-made life-changing event--limitless food supply--has overtaken our adaptive ability to cope. The premise that humans can override our instinctive reaction to food has proven largely to be false, as the sharp increase in childhood obesity and eating disorders can attest. Our internal food and weight regulatory system is thoroughly confused by the interminable excess food intake and availability. The physical effects in just a few decades, to both young and old, act like our own self-inflicted catastrophic event. A system that once ensured human survival now threatens our health and well-being. The easiest way to understand how the system has gone awry is through the adaptive, and maladaptive, ways our body reacts insulin.

Insulin is a hormone that regulates the transfer of energy from the blood supply to the rest of the human body. Food first needs to be digested in the stomach and then absorbed from the stomach and small intestines into the blood supply. After that, it's up to the endocrine system, primarily insulin, to distribute the energy to different parts of the body, to short-term storage--an easily accessible carbohydrate called glycogen--or to long-term storage, fat. In the normal ebb and flow of feast and famine, this regulatory system worked beautifully. The body monitored both energy needs and food intake, and the endocrine system released insulin to maximize the health and longevity of the body through lean and plentiful periods. Weight and metabolism, variables modulated by the endocrine system to maintain health, shifted accordingly. Most importantly, they are not end points but flexible components that fluctuate with the body's needs, not at one's will.

With the advent of limitless food supply, the well-honed system has gone awry, and the rise of childhood diabetes is a case in point. A generation ago, childhood diabetes, caused only by the inability to produce insulin, was to be differentiated from adult-onset diabetes, caused by insulin resistance-- slowed or limited reaction to the release of insulin--an effect of age, or more often weight gain. The public health problem of overweight children has made this nomenclature obsolete. Diabetes is now separated into type I, no insulin production, and type II, insulin resistance, and the unfathomable diagnosis of type II diabetes in children, with the same treatment and long term medical outcomes as in adults, including amputation and kidney failure, is now run of the mill.

What has condemned so many children to the early fate of an adult, debilitating disease is the world of plenty. Left to fend for themselves among the fast food chains, ever-present snacks and vending machines at school, children take in much more food than their bodies need. A child's metabolism no longer faces times of famine or drought, so, exposed to the inability of human metabolism to compensate for persistent, increased food intake, the inevitable cycle of weight gain and overeating continues. As in older adults, obesity, in those susceptible, triggers the onset of type II diabetes. Metabolism could rise, fullness could be triggered more quickly, hunger could wane, but the endocrine system doesn't work that way, for coping with a land of plenty never happened before. Nothing stops the overweight, diabetic child from continuing to eat. No such evolutionary adaptation exists. 

The rise of eating disorders--as a general phenomenon, rather than the suffering of one individual--is a different but equally maladaptive response to a world of plenty. Although the ideal female form has, in previous times, been very thin, never before has the entirety of a population encountered this desired body shape and the world of plenty simultaneously. The push-pull of willful food restriction and limitless supply of any food imaginable has tested the human food regulatory mechanism and exposed its weaknesses. The response to starvation, namely slowed metabolism followed by obsessive hunger, is a powerful evolutionary adaptation and almost always wins. The end result, for the majority of dieters and people with eating disorders, is periods of overeating or binging. Repeated attempts to starve only strengthens these internal responses. Surprisingly, years of restricting food intake, even when interrupted by bouts of overrating, affects the body similarly to the overweight who have type II diabetes: their bodies become resistant to insulin. In this case, the body refuses to increase metabolism after years of starvation and instead puts extra food intake into deep storage. Metabolism, and therefore insulin effectiveness, rises only after an extended period of regular food intake. Becoming immune to insulin and storing extra food as fat seems to be the only default reaction to eating patterns outside the norm. In today's world of plenty, it is highly ineffective.

The Dangers of "Healthy Eating," Part I

Just walk through any main street, from the small country town to the big city, and it is evident that we have much, much more food than we could ever consume. The number of fast food outlets, convenience stores and supermarkets seems unlimited. The edible food waste of the First world could feed most, if not all, of the world's starving people.

But the larger realities don't change how each individual, still charged with feeding oneself, thinks about food. The now mundane choice, and for some the burden, of what to have for lunch among the wide options would have been a dream come true for humans through the ages. It is as if we have all become the wealthiest aristocrat with more food than we could ever consume, with every possible treat at our disposal. Yet this purported boondoggle turned out to be much more problematic than anyone could have guessed. Rather than creating a utopia, the world of plentiful food has left millions of people reeling without the ability to handle a seemingly basic fact of life, how to eat.

We are a species designed to live in a land with the natural ebb and flow of feast and famine, not in food heaven. A basic fact of human life for almost our entire existence, the worry of going hungry isn't relevant for an astounding number of people in modern life. The preponderance of food tempting our palate at every turn has completely perplexed our internal ability to regulate hunger and meals. Humans have been engineered to outlast famine and drought but have no clue what to do with an endless surplus. The newfangled coping mechanisms--ranging from arbitrary food rules to diets and, in more extreme cases, from eating disorders to Bariatric surgery--only highlight the futility of trying to outwit our fundamental instinct to eat to survive. But it is the least controversial and most widely accepted solution that confuses us the most. The next series of posts will address the effects of this insidious cultural innovation: the concept of "healthy eating."

In order to understand what's so ineffective about the concept of healthy eating, it helps to start with the current fascination with the human brain. The increasing knowledge about human's higher order functioning, such as consciousness and planning, mental constructs unique to people, has seeped into the mainstream. The unfortunate result is the expectation that people can think and reason their way out of any situation. When it comes to food, it is necessary to remember we have evolved from the same genetic line as apes and other mammals so the basest instincts apply.

Humans, like all animals, value survival of the species above all else. Enduring times of famine and drought was and still remains essential. Just as bears hibernate or squirrels store acorns for the winter months, people developed evolutionary adaptations, mainly an adjustable human metabolism and hunger drive, to weather more challenging circumstances. And that ability to survive, despite the creation of a world of plenty, trumps any intellectual means to manage food. Put simply, when it comes to food, basic drives override rational strategies. It is instructive to take a look at the basic biological reaction to times of need and times of plenty. An often used but misunderstood concept, metabolism, the utilization and dispensation of energy throughout the body, is the central tool to adjust to an ever-changing food supply.

A withering food supply triggers a cascade of physical changes: slowed non-essential body function, more efficient use of energy, steady breakdown of the body's energy stores and any extra food intake going directly to temporary storage. The swift transition in metabolism when times became lean is a key component to our longevity, otherwise humans would have become extinct many ages ago. The ability to survive famine is a trait deeply embedded in our genetic make-up. In other words, our bodies are built to survive starvation.

The same cannot be said about times of plentiful food. Those periods were, from an evolutionary perspective, mere blips in the calendar. The boom of a large food supply would never threaten humans with extinction so any adaptations are short-lived and limited in scope. In fact, these brief periods of plenty were, if anything, used to protect against the inevitable hungry times in the near future. Consequently, these were times of brief gorges while those more prone to restraint encouraged the tribe to consider external food storage, say for the upcoming winter, rather than rely solely on humans' internal ability to store energy.

After an extended period of overeating, the body will work hard to overcome the excess. Although the metabolic changes are the opposite of the starvation response, sped up metabolism and increased energy usage, the process is much less robust, and the body is willing to give up quickly and just store the energy as fat, fully expecting to need the backup shortly. 

Stay tuned for part II.

Psychiatry and the Pharmaceutical Companies

A patient of mine recently asked if all doctors are as gullible to the pharmaceutical companies’ marketing tricks as it appears. I was immediately transported to my days working in an academic hospital. At the time, the "drug reps," as they are called, used to have much more leeway to befriend and bribe exhausted and overstressed trainees eager for free food and a friendly smile. The companies knew better than we that our future prescribing practices were at stake. Falsely armed with  a lethal combination of arrogance and naïveté, we medical residents assumed that we could toe the line as excellent clinicians while exploiting big pharma largesse. Even our respected mentors encouraged us to at least listen to the pharmaceutical information--advertisements disguised as clinical trials--while eating our free lunch. According to the hospital's motto, we were the "Best of the West" and that meant being fully capable of prescribing all of the newest medications, even if the only supporting data were generated by the drug company itself.

In the ten years that have passed, I have worked primarily in private practice. One of my first decisions was to eliminate all pharmaceutical company influence. I rebuff phone calls from reps every week, occasionally escort the brazen marketer, who appears unsolicited in the waiting room, to the door and regularly ignore invitations to dinners at some of New York's posh restaurants. In the meanwhile, I have also disregarded the bulk of clinical trials studying the newest drugs, even in the prestigious journals, since most of the funding for this research continues to come from the pharmaceutical companies themselves.

During my training, I believed I was simply acting according to my beliefs. Unlike many of my colleagues, I never believed I was immune to these sophisticated marketing techniques, and I wanted to practice apart from from these influences. What has surprised me through this past decade is the transformation of my prescribing practices. First, I have raised my threshold as to whether or not to prescribe medication at all. In an age when medication is supposed to cure all our ills, the default decision of a psychiatrist is to medicate and always medicate. It is liberating to know that prescribing is a clinical decision, not an automatic action. I also take into account variables never mentioned by a pharmaceutical rep: long-term safety data, years of efficacy with substantial independent research, and, finally, price.

Accordingly, I face the challenges of practicing psychiatry in a very different way. I have gravitated to routinely using medications that came on the market over 20 years ago because the safety record is proven and therefore puts patients and me at ease. I avoid new medication combinations and instead choose older, more thoroughly studied options, such as thyroid medication for depression--a treatment which has safety and efficacy data starting from the 1950s. I also weigh price into the equation both for my patient's pocketbook and to measure my small footprint on the explosion of health care costs.

The uneasy marriage between academic medicine and big business has had significant costs to medicine as well as to society at large. Physicians, by nature, are not business people. In recent years, several highly-esteemed physicians have been caught lining their pockets with pharmaceutical payouts while using their reputations to successfully sway doctors' prescribing practices. Clearly, no one is immune to such cutthroat and well-practiced marketing schemes. Left to their own devices, insulated from sales pitches cynically disguised as education, doctors might find alternate ways to differentiate between the true goals of a healing profession and the hidden influences of the marketplace. Protecting young doctors from powerful marketing influences early in their careers could have long-term safety benefits and help rescue the medical profession from the aura of skepticism and distrust that has come to surround it.

The Recovered Treating the Ill: Why so many Clinicians had Eating Disorders Themselves

The clinicians who treat people with eating disorders have often themselves suffered from anorexia or bulimia. Little has been written about having the recovered treat the ill, but informal conversations quickly reveal strong reactions from patients and clinicians alike. In fact, many programs and individuals fall in one of two camps: those who think only someone who had an eating disorder can be an effective therapist and those who think that this creates a community of people who never get well.

Although everyone's goal is successful treatment, there is something about eating disorders that generates emotional and even political factions. The confusion only grows deeper as these illnesses burrow further into the modern ethos. The multiple possible causes, limited therapeutic options and endless debate of disease vs. lifestyle choice opens the door for multiple, unsubstantiated and fractious theories.

The movement for the recovered to treat the ill has a clear precedent. Addiction treatment has been notoriously challenging and largely unsuccessful. Alcoholics Anonymous, a peer sponsored, ongoing support network with a clear program and 24 hour system provides what no treatment option can. The components include a group of people like-minded in the desire for recovery with similar experiences and a formula for success. Most important, when an addict feels the craving, there are many people only a phone call away.

Similar to addiction, it remains very difficult for people without eating disorders to understand and have compassion for the incessant mental torture of these diseases. Trying to live in the world while struggling to eat at every meal creates a very isolating existence. The deep sense of loneliness and separateness of the recovery process experience remains a barrier to getting well. The psychological and emotional pain often makes the potential relief of the eating disorder symptoms irresistible.

Understanding why eating disorder recovery is such a lonely experience is very hard. However, everyone can identify with the actual feeling of being alone. One irony of the human condition is that the feeling of being alone in the world is universal. How can we all share together the reality of being so alone? Although feeling part of a group always alleviates this ill, the relief is always fleeting.

In the eating disorder community, the banding together of the recovered and the ill creates just such solidarity. A group of people whose experience runs the gamut from very sick to fully healed can embody the entire scope of the process in one room and generate hope in a way that is at the core of any successful treatment. Seeing a therapist who communicates hope just by being there and saying "I am well" can change the tenor of recovery. In the throes of the daily struggle to eat and get well, a daily reminder of hope is invaluable.

There is one critical, potential pitfall. In any group with people still quite sick with an eating disorder, the internal drive back to starving or binging remains strong. In the face of powerful forces that everyone in this group has experienced, there has to be a constant, overt undercurrent that recovery is the goal. This may seem obvious but many well-intentioned groups have succumbed to the power of relapse. The fundamental notion, borne out of AA, is to respect the disease. As long as even the members with the longest recovery acknowledge the risk of relapse, the group as a whole will remain on track.

What clinicians without an eating disorder provide is perspective. Treatment acts as a bridge from sick to well and from isolation to connectivity. To exist in a therapeutic environment simultaneously without judgment and with the luxury to be fully honest liberates a patient from the prison of an eating disorder. Nestled solely in the arms of the recovered, a patient will remain scared to be in the world. A clinician from the outside can help that person learn how, even with the history of an eating disorder, to be in the wider world.

The community of practitioners--the recovered and the outsiders--need to stay together. The treatment of eating disorders need not be a political battleground between the afflicted and the perpetrators. It need not foster the endless debates of illness or imposed prison. Yes, the social forces behind the steep rise in eating disorders in recent decades are polarizing, but it is the clinician's job to heal. Let's put aside the disparate motives and agree that there are many, many sick people in need of help to get well.