Practical Steps to Fight Obesity, Part III

Even if parents understand the message about food and weight that can help their kids, it's not clear how to reinforce it. One way parents date themselves is how they discuss the role of television in their family. It's especially quaint when the smug ones boast about not having a TV in the house at all, as if they've risen above the riffraff to aspire to new cultural heights.

But the statement "I'll never let my kids watch television," once considered a critical element in defining ones family, is meaningless today. Sure, television still matters but only as one of many forms of entertainment. At least for now, the internet age has turned us all into consumers of content, however it gets into our home. And that's a fact for no one more than today's kids.

Children no longer need to wait for their favorite show each week, now it's instant gratification. Content in all its forms is available on every electronic gadget in the house and in every possible form to rope in a child. Perhaps even more troubling to adults who aspire to TV-free households would be the definition of content today. Scripted shows, reality videos, YouTube and movies all clearly fall into the content category. What about novels and news outlets? What about research, which, to kids today, constitutes creative googling or emailing questions to an expert they find online? When the only successful internet business model is based on clicks, a website will do whatever it takes to lure readers or viewers. As the line between knowledge and content blurs, there's no easy way to eliminate entertainment from the house. Every bit of information comes with an ulterior motive. It's all content now.

Advertising clued into this new opportunity long ago and capitalized on the easy access to children's minds with, not surprisingly, problematic results. The business goal was to rally children to ask parents to buy products, but the actual effect was to inculcate the suggestible with misguided information. The repercussions of the advertising onslaught were profound, note the toy fads and growing tween culture considers critical to the economy, and not challenged by alternative messages until decades later.

Public health spots and non-profit campaigns, the first alternatives were no competition for advertising. The ideals of consumerism and a free market even for children persisted. However, more recently, the creative freedom allowed by exponentially growing content outlets led some forward-thinking creative types to make shows intended to teach children ethical and moral lessons. These shows are so powerful that kids use and apply the information in school and at home.

That I know of, these lessons, easily tolerated by parents, are from the bottom of the creators' hearts. Among the messages are kindness towards others, tolerance of difference and self-respect. Sometimes the messages are more concrete like do your homework and clean your room. On that list a common theme is eat healthy food, but the message to eat more carrots, as I have written many times, has no real impact on how children learn to live in the world of plenty. 

The last post explained the new paradigm adults can use to teach children about food, weight and identity. The content children consume must reflect the same values to compete with the extant pressures from advertising and the drive to be thin. Older shows like Sesame Street and Mr. Roger's Neighborhood were primarily educational and aimed at younger children. A new genre for older kids provides ready-to-absorb values to take into their world. Coming from coveted content, children accept this information much more readily than anything parents might say. Ironically, content provides an opportunity to challenge what kids learn in the world of plenty.

The momentum needed to start a shift in children's content about food and weight already exists. I began this blog almost three years ago in response to desperate emails from confused parents unsure where to turn for help with their kids' eating. Those emails keep rolling in. As many have told me, it's a full-time job just to get some worthwhile advice. The faulty paradigm of eat less and move more reinforces the problem. As the internet economy attracts the bright, creative minds today, content could quickly spread a new thought process about food and weight to kids, which if accompanied by adults and peers who feel the same way, might start to undo the toxic climate in the world of plenty.

The new approach to food and weight has three simple points. What you eat and how you look do not determine the person you are. In other words, it takes years of growing up to figure yourself out and there's no magic fix, including food and weight. Eating is about pleasure and sustenance. The body needs a variety of foods to survive, and human culture has long connected food with enjoyment and connectedness. Last, kids need to dissociate eating from good and bad behavior. Eating is only about eating, and praise and punishment must be separate from food.

The message is clear and simple. More importantly, rather than attempting to refute the years of successful advertising, this paradigm creates a new way to incorporate food and weight into kids' lives and minds and perhaps a new way to spread the word.

Practical Steps to Fight Obesity, Part II

The conclusions of the last few posts about the obesity epidemic are sobering and perhaps even bleak. The causes of the problem are systemic and deeply embedded in our culture. A drastic change in lifestyle by returning to the era before processed food, agribusiness, the drive for thinness and chronic dieting is highly unlikely. The expectation of an immediate solution to weight loss via surgery, crash diet or miracle pill is pure fantasy. The solution is a hard road through moderation in food intake with reduced expectations for the future. That doesn't mean quick weight loss followed by stabilization but instead slow, steady, sustainable change.

Most epidemics spread horizontally, through a generation, both old and young, and must be contained from sweeping through an entire population. This one grows vertically. A child needs to be taught by adults, peers and advertising how to engage with the world of plenty, how to become obese. The challenge to care for the currently obese isn't enough to stop this epidemic.

The real hope lies with helping future generations avoid the same fate. The current world of plenty may shift slowly over time but not fast enough to save today's youth. Without tools to avoid this fate, children are mere fodder for the societal forces that lead to obesity. Adults and public policy must know what to say and what to do in order to make a difference. The perils of processed food and mass marketing are dire but invisible to kids. They need to be convinced that there's a different way to live around all this food.

Practically, direct education and public health initiatives aimed at children don't do the trick. Certainly, some obedient children will respond to information as law to live by or to fear-based propaganda as horror stories to avoid. However, the innate propensity for children to test adults and rebel against authority will make food rules just another set of parental edicts to disobey. Getting into the minds of children takes somewhat more creativity. Two points are essential to make a difference with kids: educating parents and adults how to talk to kids about food and weight and getting into children's heads through content they'll listen to.

Both parents and public health administrators need to be aware that the teaching points available to educate children are ineffective. Eat less, move more and learn "healthy eating" facts--the trifecta of food education--neither change food behavior nor lessen the risk of obesity. Cooperative, motivated adults are fonts of nutrition knowledge yet find that knowing what to do has no effect on their own behavior and weight. Children, moved more by the innate urge to pick the poison apple, will take on food rules as a challenge to either squeeze extra sweets from exhausted parents or sneak them at any opportunity. The simple education model is a boon to the food industry. Sophisticated marketing and advertising trounces any earnest public health campaign.

Children are all instinct and emotion. The tack of using logic and reason to change clearly preprogrammed urges is hard enough for adults and unrealistic for kids. But there's one thing business already knows: the malleable minds of children are open to suggestion. And much of what draws children in to focusing on food and weight is the promise of a secure identity.

The basis of a child's personality is largely genetic, but the birth of identity forms around relationships. In other words, we are born with many character traits that define how we react to the world, but only by engaging with the world do we learn how to perceive ourselves. Personality doesn't come with a guidebook. Other people provide the feedback to form identity. Self-awareness is a gradual dawning over years that reveals our mental perception of who we are.

In childhood, the powerful desire for an identity comes with the urgency to feel instantly fully formed. Food and weight, the overarching obsession of this generation, is an easy barometer of identity. That can be the kid who eats anything, the kid who doesn't eat, the kid who is thin or who is fat. But food and weight can provide instant identity.

Accordingly, the practical first step is to teach kids to let food be food. Children can't learn food choice is related to good and bad behavior or be praised for eating in any particular way. They can't believe they are special because of how they eat or how they look. They can't learn to associate guilt with dessert or that eating is always a shameful act. They must learn food is necessary for life and a regular part of every day, that meals can be enjoyed and not scary and that weight is not a barometer of success and failure. They have to hear a new philosophy of food and weight every day and allow their internal search for identity bypass food and weight to look for different ways to see themselves. And they need to hear over and over again that it takes time to figure out who you are. Focusing on a quick fix like food and weight won't speed anything up. In fact, it doesn't work for anyone.

If this is the message adults need to teach kids, the second key point is how to get them to listen. That will be in the next post.

Practical Steps to Fight Obesity, Part I

Issues of public health, no matter how dire, can be a hard sell. Unless there's a dramatic angle to the story, few will get fired up by a nation's well being. It's not uncommon for an individual to find the altruistic impulse to help a person in need--there's a bit of a thrill, for example, in the guilty gesture of giving to the homeless--but the overall public health doesn't stir up the same generosity of spirit. With individuals focused on their own extra pounds, the people charged with drumming up support for the obesity epidemic, which shortens lifespans and is very costly to the government, have a tough time building any interest.

The successful public health campaigns in recent decades have gotten creative to generate enough buzz to try to make a difference. The dramatic attempts to shock kids out of drug use (this is your brain; this is your brain on drugs) or to horrify smokers with the medical effects of cigarettes (the public display of emphysematous lungs) elicit most often derision or outright mockery, certainly not the intended effect. Meanwhile, business advertising counterparts, trained in the coercive arts, something not taught in an MPH program, are much more effective in targeting their audience.

Appealing to the national zeitgeist of health at any moment is a challenge. The most effective strategy looks for a dramatic edge, most often the age-old battle of good vs. evil. With a natural enemy or corporate entity to blame, it's a lot easier to frame the solution and rally supporters. It's not hard to understand when the goal is to eliminate the root of the problem.

A systemic change in the way we as a society choose to live, willingly or not, poses a much harder dilemma for the public health rabble rouser. Changes to our food supply, the relentless pressure to be thin and the growing ranks of sedentary media consumers have created a tectonic shift in the public perception and reality of food and weight. A systemic change doesn't present a simple, black-and-white, good vs. evil message to hang the proverbial public health hat on, not when food and weight is on everyone's mind, from industry to the individual. There hasn't been a way to find consensus to galvanize the movement against obesity, not when the solution remains either elusive or incomplete.

Responsibility for the obesity epidemic ranges from business to government to medicine. But pinpointing causes does little more than instigate outrage and blame. Moreover, only information and action can disempower the entities that thrive on the aimless attempts to fight obesity. For future generations to be protected from the endless supply of food and concomitant weight gain, the public health outreach needs to inform the adults responsible to teach children and to connect to kids in novel, memorable ways.

For adults to listen, the campaign needs to present the stark contrast between the assumptions of the food and diet industry and the facts about food and weight. It's patently clear that diets don't work, yet, shockingly, dieting is still the only advice given by professionals and industry alike. That advice tends to come with either disdain for the obese person or with the faulty promise of a swift, magical cure. In other words, a public health advocate needs to debunk the myth of a quick solution to both the common and individual obesity epidemic and present the facts about food and obesity to adults. The caveat, and only reasonable fact the experts agree upon, is that moderation of food intake will lead to weight stabilization and moderate loss, with moderate health improvement. The public won't be eager to hear about lowered expectations, but accepting that reality can be a relief when presented as a true alternative to the diet and weight-obsessed lives that plague most people with obesity. Accepting slow change is worth the liberation from cyclic failure.

Winning over kids to the campaign is a much harder challenge but is essential to avoid passing the crisis down generation after generation. The power children wield in first world culture spurred the formidable advertising and marketing minds to win over the impulsive id of youth. Kids may not plunk down the money for said product but instead must generate enough of a fuss for parents to grudgingly buy the item--be it food, content, toy or electronic gadget--for a moment of peace. Clearly, business has spent significantly more creative energy to attract children than any anti-obesity program thus far. We can ply them with carrots galore, but it's the wont of childhood in this day and age to fight full bore until that candy bar is safely in hand. Add to this scenario the limitless supply of child-friendly content, including television, video games or apps, and a typical child's fate becomes clear: a calorie-dense diet and sedentary lifestyle has become the norm.

Parents may very well want to shape their children's lives into healthy ones, but the information available to do so is confusing and often contradictory. Parents pull blindly from the nutrition cache and try unsuccessfully to replace white bread with veggies and dessert with fruit. They sign their voracious reader up for every sport. The specter of obesity haunts them enough to embrace any half-baked idea about a child's health. The decades of knowledge about child development and the wide and normal variability of a child's body type through childhood and adolescence remain ignored.

Parents need useful information to read and clear guidelines to follow. The basic dietary advice about healthy eating that has little effect on adults is even less effective for children. Given a child's limited, or more likely non-existent, desire to follow any food rules, the endeavor quickly feels hopeless. Just hand over a supersize bag of chips, turn on the TV and give up already. The next post will outline some of the key points to make the public education of children effective and and the important facts for parents to hold onto in order to save their kids from the obesity epidemic.

A New Public Health Approach to the Obesity Epidemic

The original public health problems pitted man against nature. Bacteria in unsanitary water causes chronic diarrhea. Iodine-fortified salt fixes goiters. These days first world public health issues are manmade. Without a common, uniting cause, human instinct leads the search for a villain to blame for the crisis and subsequently purge from society. It's the superhero approach to public health.

Sometimes that's easy. The big, bad tobacco industry played the villain well. It took a while to break down the marketing juggernaut, and the powerful nicotine addiction, but the end result was secure. Sometimes finding the villain is much harder. Who's the bad guy in the obesity problem? If you're an activist looking to stir the pot, who exactly are you fighting?

The obvious first culprit is the food industry and agribusiness. Taken broadly, these companies create processed food that's extremely tasty, inexpensive and minimally nutritious. It's been easy to target industry as the cause of the crisis and embrace the newest David vs. Goliath battle. There's no doubt these companies haven't done society a service, but they're only a cog in the machine. Maybe the diet industry, which encourages a generation to await the newest miracle weight loss plan, is the evil villain. Playing on our deepest desire, its promises are patently false and only worsen the problem. Chronic dieting slows down individual and collective metabolism to a crawl and only leads to more weight gain in the end. Perhaps the fashion industry is most at fault by instilling the impossible goal of near-emaciation in generations of girls.

Even the academics themselves may just make things worse by peddling their solutions to the obesity crisis as if weight loss and maintenance couldn't be easier. The experts' insights into the causes of obesity are eye-opening, but every book ends with the same tired rhetoric. Let's all learn how to have "healthy" diets and exercise, and the obesity epidemic will miraculously disappear.

People who've turned to doctors for help know that the medical field can be implicated too. Internists blindly watch patient after patient fall into the same obesity cycle and scornfully shame each one saying, "Well, if you just eat less ... " Pediatricians hide behind BMI thresholds and ply meaningless suggestions to parents about cutting out extra ice cream or white pasta, as if simple food choice is the issue. And Bariatric surgeons reap financial rewards by mangling perfectly healthy gastrointestinal systems without any sense of the long term success or risk of these procedures.

And then government, regulators, journalists and chefs who do want to help don't know where to turn. The bland advice to eat more vegetables and less fast food, to move more and sit less, to cook more and have family meals is all sound but wholly ineffective. The growing number of desperate people fall into the hands of the powerful industries ready to capitalize with false hopes and dreams.

So whom do you fight? Who's the bad guy? What's the obvious target for a budding idealist? When all the facts are clear and the activists gather around the table to develop a plan, there is no real answer. The problem is systemic. The entire society lost its way with eating. There's no villain to be found. It's a new type of public health problem grounded in how we have chosen to live.

As of now, activists focus on the periphery, the tiny nibbles that won't really matter. Transparent food labeling in supermarkets and restaurant chains helps people know what they're eating even if it doesn't affect food choice. Banning large sodas might help some people decrease sugar intake. Increasing availability and affordability of Farmer's markets looks nice on paper. The slow shift to slightly larger fashion models certainly leads many to breathe a sigh of relief. But when a society expects availability of any food at any time, when the farming industry runs on the subsidized price of corn, when everything a population does is sedentary, when competitive dieting has become television fodder and replaced softball as the national office sport, the writing is on the wall. And a few political gimmicks won't do a thing.

The success of activism lies in its target. Effective public health campaigns have to focus on the future. All eyes on the obesity crisis have addressed the current obese. The paltry ideas of the experts are as ineffective as every diet on the market. The only choice with the current generation is to debunk the myths of a magic cure and encourage steady, sustainable diets with reasonable expectations of, at best, moderate weight loss and improved health.

The only real place for activism is for future generations. That means proactive programs to teach children a different way to eat. Kids may need to learn what balanced meals look like and feel like in their stomachs. They also need to know that food means sustenance, health and pleasure. Kids need the basic facts about how eating is critical to body function and to the success of our species. And then they need a crash course to understand the wholesale changes in how we eat and how we want to look in recent decades. They need to be aware of the endless ways our world can hijack their minds and bodies into food obsession and the obesity epidemic. The world of food might change in years to come, but children have to cope now with the delectable treats on every corner, the endless pressure to diet and lose weight and the confused adults around them unable to find their way. Activists can take a stance to create a smart public health program that offers an alternative to this current world of food and supplies real ammunition to fight the daily pressures to succumb to the starve/overeat cycle which inevitably leads to obesity.

The Unspoken Reality of the Obesity Epidemic: What the Experts Won't Say

From the fame of Michael Pollan to the outcry about agribusiness to the first lady's signature Move Your Body! program, it's impossible to ignore the American struggle with weight. The interest in the issue may be apparent, but the proposed fixes remain rudimentary. Anyone curious how and why the rate of obesity has skyrocketed in recent decades can find a growing library of well-researched, thought-provoking books. Looking for an expert speaker to summarize the country's dilemma? They abound.

However, if you're searching for an effective approach to the problem, you're in trouble. Some experts focus on regulation of agribusiness and the food industry, similar to the fight against tobacco, but that's a long-term project complicated by the fact that people can live without tobacco, but not without food. Others emphasize the truisms of the diet industry, eat less and move more, without divulging the fact that 99% of diets fail. So why would anyone believe the collective national diet will have any more success? And the physicians obsessed with "evidence-based" treatment are holding out for the miracle weight-loss drug while chastising their mostly overweight patients. That's no more than a pipe dream at this point.

Food and weight are not particularly complicated. The real issue is that no one wants to reveal the truths this country faces, much better to pretend that a magic solution is just around the corner.

The clear facts about food and weight are as follows. There is much more food available than ever before, and most of the increase is highly processed and inexpensive. The combination of successful marketing and the development of irresistible foods decreases any one person's ability to manage daily intake effectively. The regular person's life is much more sedentary than in years past. Chronic dieting leads to rebound weight gain  and a gradual weight increase over time. Due to these factors, rates of overweight and obesity have skyrocketed. 

Similarly, the facts about ways to fix the obesity problem are clear. None of the current suggestions work. If any one idea had merit, the word would spread like wildfire. As it is, every new crash diet or exercise program has its fifteen minutes of fame, while the well-meaning "healthy eating" programs are the neglected stepchild compared to the advertising and delectable offerings of the omnipotent food industry. Everyone is desperate for a new solution to cling onto, but no one wants to be clear about what really can be done.

The problem needs to be split up into two parts. First, what are the practical approaches for the currently overweight and obese? And the second part of that question no expert wants to address: what are reasonable goals for long-term weight loss? Second, what can the country do to ensure the obesity problem is limited to a few generations and does not become the new norm? Although the two pieces overlap, separating them clears up the difference between realistic expectations and activism.

Only one weight loss approach works. And it's completely obvious and intuitive. In order to change ingrained behavior, one needs a long-term, sustainable, consistent meal plan developed with a professional or a program since an individual who struggles with food inevitably reverts to old patterns without external intervention. That means working with a doctor, nutritionist or a reasonable program such as Weight Watcher's to implement and follow a clear daily approach to food. The plan needs to provide adequate calorie intake to sustain health and to stay within the person's energy needs. After years of excess food, it will take years for a body to adjust hunger cues and adapt its weight range to a lower food intake. All of the evidence makes it clear this is the only effective option.

There's a reason no expert will make this point. The diet industry preys on the collective desperation to lose weight now. Even the smartest, most experienced dieters know that no magic diet will ever work. Yet the masses suffer under the delusion that permanent, speedy weight loss is in their immediate future. No one will hear otherwise and no one is brave enough to face the wrath of saying it like it is.

What is the benefit of blowing the secret? And at this point would anyone really listen? No one wants to believe that the current overweight generation will remain overweight. Yet, with a little perspective, that fact is evident. As I have written before, chronic overeating drives up an individual's set point weight range. Since the body protects itself against weight loss much more than weight gain, as the set range increases, the low point of the range increases as well. The body will move easily within the range but will resist weight loss at the bottom of the range, even if the bottom of the range is still significantly overweight. Moving within the weight range is easy. Shifting the entire set range down is a much harder long-term proposition that involves sustainable, consistent decrease in food intake over years. It's not a big leap to realize how improbable that result is for an entire country.

It's important to recognize that even if this generation as a whole remain overweight, many individuals will find the right meal plan, rely on considerable support and gradually bring down the set weight range. As more clinicians and programs provide effective solutions, more people will find an approach to weight loss and maintenance that works. But the likelihood a country will do so is very slim.

In the fight against long-term obesity, the current generation will have a very specific role. The fate of the overweight generation is to attempt to reject chronic dieting in favor of a sustainable change in eating and live with the modest weight loss and health benefit. Adults can teach children how to survive the world of plentiful food and how to avoid the cycle of overeating and dieting and thus not become obese themselves. That's the topic of activism in the fight against obesity, and I'll address it in the next post.

What do the Experts Say about the Obesity Crisis: A Summary of the Current Information

The clamor for practical, effective information about obesity and weight loss is growing rapidly. Although the latest fad diet, magic cleanse or false nutrition claim still attract the most attention, word has spread through the major news outlets that 99% of diets fail. A quick review of the available resources reveals that the recent global transformation of lifestyle and food supply created and now perpetuate the obesity epidemic. More scientists, researchers and clinicians recognize that the issue needs thought, concern and action to counter the disastrous effect of unregulated food and diet industries. So what's the verdict of these newly minted experts thus far?

Even a quick summary of the available data about dieting is unequivocal. It doesn't work. Diets pretty much always fail. Any combination of severe calorie restriction, magic nutrient compositions and newfound supplement concoctions are sheer quackery meant to capitalize on the desperate willing to try anything for success. The underlying motivation of every diet guru is monetary gain. The diet industry is huge business and is sure to quash the obvious conclusion that diets fail at every turn.

Another consensus opinion is that nutritionism is man made myth, not true science or medicine. Nutritionism, as explained in previous posts, is the process of creating meal plans based on food components, protein, carbohydrates, fat, vitamins, minerals, etc., rather than actual food. The concept implies that current knowledge of nutrition is complete and that the best, healthiest meal plan is easy to create based food components and is completely effective for weight loss. Experienced academic nutrition professors and scientists dismiss nutritionism and instead expound on the dangers of spreading such misleading information. Omnivores one and all, humans need to eat a wide range of foods, not food components. We adapted to survive on an extremely wide range of diets, a trait sure to extend our longevity. The sage advice of the experts is that the best meal plan is simple and general: not too much food with ample variety. These are simple words to live by.

Yet the simple advice has been woefully inadequate to make a dent in the problem. At this point, the conversation inevitably turns to metabolism and weight management, basic facts needed to tackle the problem of obesity, which are incompletely understood and surprisingly complex. Metabolism encompasses how the body uses food, our energy source, to function. Weight is generally stable within a range but varies according to overall food intake and energy expenditure. The body stores energy during excess and uses that stored energy during lean times. And that balance has been very effective to maintain weight, until the last few decades. Put simply, the recent introduction of significant excess food with high fat and sugar content apparently overrides the mechanism that maintains weight and has triggered the obesity crisis. Human evolution protects against weight loss effectively but much less so against weight gain, something that has never before been a problem in human history. The experts then conclude with this statement: years of human function and evolution show that moderate food intake and moderate physical activity lead to a stable weight range, and we need to return to that basic concept. Beyond that, the experts, one and all, throw up their hands. As of now, they all seem to agree: that's all we have to counter the issue of obesity. Since everyone is still hooked on a quick fix for the crisis, the experts' message is largely ignored. Although the experts' opinion is undoubtedly accurate, it's the presentation that needs a little work.

The underlying premise of the obesity crisis is that we need a fix now. Our current knowledge about weight and metabolism relies on the largely unchangeable evolutionary adaptations of the human body. Maintaining stable weight and energy stores is essential for life. Human survival depends on a body that can adapt easily to change and is resilient in hard circumstances. In fact, we even have multiple backup systems for any possible failures to essential organs, much like a backup generator for a power failure, all to maintain the status quo, or in medical jargon, homeostasis. Homeostasis means that the body always will work to keep things stable. This can refer to blood levels of various electrolytes and blood cells, heart rate and blood pressure, hormonal balance and pretty much all body function. Of course, metabolism and weight are included. In recent decades, the average weight range has gone up but that hasn't done away with homeostasis. Instead, the body recognizes the new norm is a higher weight range, and the body uses the evolutionary system to protect this new range. So a quick fix tests an age-old system and repeatedly fails. But if we apply the experts' advice, any approach to the obesity problem has to respect that homeostasis is here to stay.

The next step is to combine expert opinion and change the time of the conversation. Moderate food intake with variety and moderate exercise will, slowly and steadily, chip away at the obesity problem. Weight loss can only come with a gradual decline in each person's normal weight range as the body slowly reacts to a more moderate daily calorie intake. The key to effective weight loss is sustainable, consistent and small calorie decrease over a long period of time. For this message to work, the focus needs to shift from a quick fix to a reasonable, sustainable solution, one that takes into account how our body functions, not the desire to just fix the problem.

The next post will address how to apply this information practically and how to spread the word.

How Doctors Harm People with Eating Disorders

The prejudice against people with eating disorders extends to clinicians, who are as misinformed as the public. The basic medical and psychiatric understanding of anorexia and bulimia are not part of medical training. Primary doctors have sporadic exposure to patients suffering with these illnesses but no guidance about how to manage them. Even psychiatrists in training can graduate with no more than a cursory knowledge of the diagnostic criteria for eating disorders. If anorexia is the most fatal of all psychiatric diseases, then medical education is missing the boat.

The life of a recovering patient remains isolated, lonely and gravely misunderstood. While family and friends struggle to comprehend how anyone could have trouble eating, something so basic to human existence, the sick are typically silent. But what happens when physicians approach anorexia and bulimia with similar ignorance? The risks are much more consequential.

Too many of my patients have had difficult experiences with doctors. For some, the scars are emotional and that makes seeking medical help in the future a scary proposition. Arrogant doctors typically think one of two things: that they will save the patient or that the patient needs to just buck up and eat. Either erodes a patient's trust in medicine and prompts the person to go it alone. Many others are physically harmed by doctors unaware of the precarious balance the human body reaches to survive an eating disorder. A person with bulimia can adapt to usually lethal blood potassium levels and frightened doctors may dangerously raise the level too fast. Doctors also don't know that overfeeding a very underweight person with anorexia is potentially lethal and will do so anyway. The bold medical interventions aren't just pointless, they can kill.

This leaves treatment in a difficult spot. On any typical day, a doctor relies on the nearest hospital emergency room. I suspect everyone has heard a doctor's voicemail message stating the obvious, "If this is an emergency, please hang up and call 911 or go to your local emergency room." In this message, a doctor is sure to impart a clear directive to a scared and confused patient. In addition, the doctor implies confidence that the ER will address the problem adequately and quickly.

I don't say that in my voicemail message for a reason. It's not because my patients don't often need an emergency room. They do. It's that emergency room doctors do not know how to treat people with severe eating disorders. The sight of a malnourished patient tends to elicit horror and hasty action. The shockingly abnormal lab values in a very sick patient with bulimia leads to the same reaction. An ER doc is supposed to have seen it all. They are supposed to be able to handle any form of crisis and use their knowledge to save a patient. The misinformed, judgmental response of many of these doctors makes an ER one of the least safe places for anybody with an eating disorder. When I do send my patient to a hospital, I am sure to be on standby to protect them as much as anything. These patients often need immediate medical care I can't provide, but when in an ER they practically need an escort to be sure they survive.

Sadly, much of the problem lies in the prejudice. Doctors absorb most of their information about eating disorders from the press and entertainment industry. Convinced of their suspect views about food and weight in general, doctors typically know even less about eating disorders but have no trouble expressing faulty opinions, even when on call. And that precipitates poor, dangerous treatment decisions. Most doctors consult textbooks and supervisors when faced with an unfamiliar situation, but who can help treat anorexia and bulimia? There is ever-growing public attention on food, weight and eating disorders; the problem is ubiquitous and garners significant attention. Just a little time engaging with the main stream media attests to the topic's popularity. It's about time the medical community pays attention and realizes our job isn't to form an opinion but to learn how to keep these patients stable and safe.