Metabolism in Eating Disorder Recovery

Our genetic makeup plays a large role in how eating disorders develop and an equally large role in recovery.

The most important risk factor for an eating disorder is an extended period of food restriction. Surviving a dearth of food has been necessary for human survival, so genetic encoding and inheritance of these metabolic adaptations enabled humans to still be here.

People can survive famine by both slowing metabolism to function on little food or binging when food is plenty to live on the energy stores for as long as possible. Many people have both genetic predispositions and some have neither.

People trigger these tendencies with dieting. Once engaged, the metabolic changes don’t always turn off so easily. Even when food is aplenty, once adaptive metabolic behaviors start, they won’t necessarily stop which leads to anorexia or binge eating behaviors. In these cases, the behaviors are an adaptive response to food restriction that persists for our survival.

In recovery, people switch from disordered eating to eating regularly, hopefully on a consistent basis. At some point, our metabolism recognizes that food is now available and can adapt to the new energy available and abandon strategies to cope with food deprivation.

For some people, metabolism adjusts quickly and returns to baseline function that would have existed without an eating disorder.

For many people in recovery, metabolism won’t adjust so fast. Once triggered, metabolism sometimes is primed to expect another famine on the horizon. It does make sense that if one prolonged period of food restriction happens, our bodies will protect against the next period that may very well arrive. This is a clear and evident survival adaptation.

However, for people recovering from an eating disorder, it’s a challenge because the adaptation in metabolism leads to a period of weight gain not commensurate with food intake. Body image is hard enough to tolerate in recovery and even harder when weight gain does not match the meal plan.

Metabolism usually does respond over time by gradually resuming pre-eating disorder function or a lot closer to that function. Some people benefit from medication that communicates to your body that food is now plentiful and will continue to be available.

These metabolic changes through an eating disorder and recovery and the differences people experience in their bodies all reinforce how eating disorders are genetic adaptations triggered by food restriction. A significant part of recovery is recognizing that healing means listening to your body and what it needs. Without trusting your body to heal, recovery isn’t possible.

Stop Blaming People with Eating Disorders

The ultimate paradox of eating disorders in our society is the disdain we have for people suffering with them. We live in a culture obsessed with thinness, dieting and “healthy” eating, yet the most common response we have to people with eating disorders is “why can’t you just eat the food?”

As I have written extensively in this blog, the most important risk factor for developing an eating disorder is dieting. We are all genetically programmed to respond to prolonged restricted eating differently, and many of us respond by developing eating disorder behaviors.

Despite the fact that our society focuses so much on weight and food restriction, people who have eating disorders are almost always blamed for their illness. It’s difficult for people to have the kindness and compassion people with eating disorders need and deserve to get better. Instead these patients are faced with an endless barrage of anger and blame which only intensified the already harsh, critical thoughts central to an eating disorder, as I wrote about in the last post.

So many treatment approaches to eating disorders use blame and anger as a supposed therapeutic technique. Treatment teams often use ultimatums to attempt to force people to get well or else terminate treatment. Hospitals tie patients down or lock them alone in rooms to force them to comply. Clinicians harp on patients to “want to get well,” as if getting better is simply a matter of will. Medical care doesn’t usually punish people for being sick but that’s incredibly common for people with eating disorders.

The key to moving forward in eating disorder treatment is simple: understanding, care and kindness.

People with eating disorders need to be heard and understood. Rather than telling people what to do, clinicians, doctors, family members and friends need to be quiet and listen. Given time, people will find their voice and learn ways to express themselves.

Eating disorder thoughts are very harsh and cruel. People struggle to ignore the loud thoughts in their head and try to take steps towards wellness all day. Kindness and compassion serve as bulwarks to keep going forward.

The shift from blame to kindness can enable people to feel supported in recovery. Rather than reinforce the hypocrisy in our society of blaming those with eating disorders, let’s try to be kind and chart a new path to being well.

The Negative Thoughts of an Eating Disorder

One almost universal part of an eating disorder is the internal monologue both around food and negative thoughts about oneself. The intrusive thoughts about how to eat and how to look are relentless and exhausting. Even more insidious and destructive are the negative thoughts about oneself.

These thoughts typically are categorical negative statements about who the person is. They can vary from you’re fat to you’re ugly or stupid or useless or a terrible person. The list goes on, but these thoughts loudly reiterate that, in one way or another, they are a bad person.

Even if the person with an eating disorder tries to counter these thoughts, the repetitive, forceful nature of the thoughts often triumphs.

The origin of these thoughts often precedes the eating disorder itself whether based on prior traumatic experiences, lack of attention to personal and emotional growth or external negative reinforcement through one’s life events. The eating disorder behaviors both provide momentary relief from the negative thoughts and, afterward, reinforcement for the deep sense of shame of being a bad person.

Being trapped in an eating disorder for years solidifies a binary way of seeing oneself, either good or bad, but mostly bad. The eating disorder thoughts provide a simple, black and white framework to understand and assess one’s identity. Since these thoughts dominate the internal mind of someone with an eating disorder, there isn’t much mental space to learn a more nuanced way of understanding who they are.

Accordingly, eating disorder recovery involves a profound exploration of one’s understanding of identity. As the old negative thoughts are stripped away, people first often experience a void in their mind. Gradually, recovery can focus on how to better understand who they are as a person, what they think and feel and how they want to live.

It is imperative that the therapist have an open, nonjudgmental stance to help explore this growing identity and understand how to nurture a caring, curious way to learn about oneself.

At first, this part of recovery can be overwhelming if not frightening. Over time, the idea of learning about who you are begins to be exciting and revelatory that life can feel so different and new.

The Only Real Nutrition Advice to Follow

The newest battle to stop the continued explosion of eating disorders in our society is against Ozempic, but the endless war has many fronts.

The medical establishment continues to vilify obesity at every turn, now even recommending Bariatric surgery to children. The diet industry capitalizes on our fears by rebranding every few years, currently expounding upon the benefits of “healthy eating” and intermittent fasting. The pharmaceutical industry, like a siren song, promises the newest wonder drug for weight loss, Ozempic. The food industry creates addictive, non-nutritious foods or diet foods to tempt us from every angle. And the fashion industry, despite valiant attempts to promote body positivity, still values the thinnest models first.

Amidst so much noise, one basic question that arises regularly in eating disorder recovery is this: what is normal eating?

Too many industries and too many capitalist pressures make this question difficult to answer, but there are a few clues.

The most savvy professors of nutrition and reporters laid out clear guidelines years ago which remain sacrosanct in eating disorder recovery treatment.

First, eat all variety of foods. We humans are omnivores who are at our best when we eat all different kinds of food. We need the various nutritional elements, vitamins and minerals we get from eating lots of different things. Our digestive systems vary as well, so we all do best with different types of food and will get everything we need from a varied diet.

Second, eat mostly real food. The food industry has created an endless assortment of processed foods and packaged foods. These items are very convenient and heavily marketed. In addition, people with eating disorders are focused on calories and often prefer foods with clear nutrition labels. However, these foods are not real food. They have some nutritional value, but our digestion was designed to eat real food and our bodies are actual healthiest when given actual food not made in a factory.

Third, be sure that a good part of your food includes fruit and vegetables. Intentionally, there is no exact amount that is best, but the overall guideline is perhaps a quarter to a third of your intake can be from fruits or vegetables. Too few limit the nutrients needed, and too many limit the more substantial food our bodies need to survive.

Truly, these are the only guidelines. All further information has limited research and reflects individuals’ preferences or opinions rather than the data from actual clinical studies. If only recommendations could be clear and straightforward and not disguised by the barrage of messaging about health we endure each and every day.

The Holy Grail of Ozempic

The juxtaposition between the medical diagnosis of obesity and the epidemic of eating disorders has become a battlefield in the social and health sectors of our society.

The idealization of thinness at all costs continues to supersede body acceptance and to supplant overall health as a goal. In fact, the diet industry has dangerously co-opted the term “healthy” as synonymous with the term thin. The medical establishment frequently uses social norms instead of medical research to promote thinness as well.

Striving for thinness already is the number one risk factor for developing an eating disorder. As long as sanctioned dieting is culturally acceptable, the incidence of eating disorders will continue to rise.

The pharmaceutical industry is a cog in the machine of dieting, but no drug has been as successful as Ozempic. A weekly injection that suppresses appetite continuously and indefinitely is completely new to the weight loss market. A culture desperate for this wonder drug can’t get enough of it. Ozempic flies off the shelves, was out of stock for weeks and has been glamorized by celebrity culture as the must-have drug.

So we are all entering the grand experiment of an extraordinary number of people trying a new drug that stays in our bodies for weeks at a time with possible cancer risk, let alone other risks we aren’t aware of yet, all in the name of weight loss. Many people taking the drug don’t have any supposed medical reason to try it either. They just want to lose weight.

Previous medications used for weight loss have had similar results for many people: short-term benefit followed by periods of binging as a reaction to prolonged undereating. In addition, so many people are exposing themselves to unknown medical side effects. No magic drug exists yet, and it’s unclear one ever will.

It’s hard not to believe that Ozempic will fall into this category soon enough. When will we, as a culture, stop valuing thinness over everything? When will we realize the powerful industries which benefit mightily from our desire to do anything to lose weight, no matter the personal risk? When will we all stop acting like lemmings seeking the holy grail for weight loss?

As of now, no changes are likely to happen until the Ozempic craze ends.

Imperfect Eating Disorder Recovery

Eating disorder treatment currently focuses so much on meal plans and weight maintenance that one essential aspect of recovery goes by the wayside: life goals.

There is a point about halfway through recovery when people suddenly find they’re not completely focused on food, weight and body. This moment is shocking and often frightening. As all encompassing and miserable as eating disorder obsessions are, these thoughts are grounding and calming; they serve as a foundation to assess every day and every decision.

People in recovery talk at length about a day when these thoughts aren’t so consuming, when there will be room for other parts of life. But when this time comes, they’re often lost and unsure what to think, how to function and where to find comfort and security.

A common reaction to this key moment is to run furiously back to the eating disorder and hide. The current eating disorder treatment world readily interprets the retreat to behaviors as a relapse and ships the person back to residential treatment.

Rather than encourage recovery, the decision to go back to treatment reinforces the identity of having an eating disorder. The message is that the eating disorder is your identity, and the brief glimpse into a world not focused on eating disorder thoughts is too scary to contemplate.

Instead, the initial moment of seeing another way to live needs to be applauded and recognized for the accomplishment it is. The stronger pull of the eating disorder in that moment is to be expected.

The person and treatment team need to embrace this time in recovery, even if it entails an uptick in symptoms, as an important moment to recognize that other parts of life are important and may indeed take precedence over the eating disorder one day.

The creation of other parts of one’s identity outside the eating disorder is necessary for recovery. Just repeating the fantasy that “life will get better” doesn’t help anyone.

Treatment providers need to embrace the moment and realize residential care isn’t always the best option. Sometimes living imperfectly in the world makes recovery much more likely.

Choosing the Right Eating Disorder Treatment

The array of eating disorder treatment has grown significantly in recent years and the new options are even more numerous since the pandemic began.

In years prior, one of the biggest hurdles in outpatient eating disorder treatment was the lack of options. There were few residential treatment programs, ill-equipped hospital programs and a limited number of clinicians who treated people with eating disorders. Outpatient programs had limited insurance coverage and were inaccessible to most people across the country. Just finding any care was the biggest challenge.

Prior to the start of the pandemic, several financial firms bought the most successful eating disorder programs and used the brand to expand rapidly across the country. The programs tried to institute the philosophy of these small programs to the new franchises, but the rapid growth combined with inexperienced staff lowered the quality of care almost immediately.

Virtual care, in its infancy only a few years ago, exploded both due to the pandemic and the continued expectation that remote treatment is an option. Accordingly, many of the new programs offer remote outpatient care, and clinicians do more remote work than ever before. There are even some new programs designed only for virtual care started in the last year.

Another change is the continued growth of eating disorder coaches, people often without formal training but skilled in a variety of supports and able to work around the formal relationships between clinicians and patients/clients.

Questions abound, and even the most diligent patients and families are quickly overwhelmed by the options. It’s necessary yet difficult to individualize treatment now more than ever. There is no one size fits all. Despite the lack of access several years ago, at least the options were much more clear. Now there appear to be unlimited options and no way to make any reasonable decisions.

Here are a few guidelines.

1. Use hospital and residential treatment sparingly and primarily for medical and nutrition stabilization. Few programs have clinicians experienced enough to further the psychological part of recovery.
2. Research outpatient programs thoroughly focusing on two things: the experience of the staff and the clinical focus of the program.
3. Individualize the outpatient team. There are so many more options now so the standard therapist and dietitian may not be the best choice anymore. Creativity may be more beneficial.

Overall people need to think hard about treatment decisions. Programs just recommend more treatment often to bolster the bottom line. Individual clinicians may have more perspective. Treatment is available to most people now, which is a needed change, and finding the right fit can make all the difference for recovery.