The Dangers of Thinness and Dieting

It isn't hard to find article after article expounding upon the scourge of obesity in our society today.  The most popular magazines know a little teaser on the front page about weight loss will always sell more.  Slower moving academic medicine has cottoned on to the trend with scholarly writing on various, unsuccessful weight loss measures.  Bands of young women cannot help but jealously ogle the newest pop star or actress singled out for her recent weight loss or demonize one who has recently ballooned.  Not to ignore the supposed even-handed media like the New York Times, any number of weight loss tips (written by an exercise-fanatic who herself does not look well) can be found regularly in the Science Times section.

The fetish of "fatism" and the concomitant obsession with thinness is so pervasive as to have surpassed the current mode and become an accepted fact of life today.  Everyone wants to be thin: it is considered healthy, attractive and necessary for survival and success.  No one wants to be fat, which equals lack of willpower, sloth and undesirability.  It has become much too easy to forget of course that this is a cultural preference.  There are many, usually poorer, countries for which the opposite is true.  In fact, the flip-flop of thin-fat preference is all but new, a few decades old.  How has it not only become the norm but unassailable?  Now even the most sober, rational parts of society cling fiercely to this notion, as if it were handed down from on high.

The most insidious means that leads skinny to prevail over fat is the medical establishment.  Although it is clear that the mass media preference follows the current mode, that is to be expected.  Fashion and trends are meant to be fickle. As much as the general population blindly follows the movements of the famous, what is fresh and new is meant to be upended regularly, and the masses will follow.  However, the medical establishment, and often confusing medical journalism, moves much more slowly.  The growing medical treatment for obesity now dominates many of the brightest minds of medicine and comprises a vast array of new preventative, medical and surgical treatments.  It has become impossible to ignore how mainstream the public health problem of obesity has become and how no one can question its veracity.

What goes unnoticed is that acceptance of a general issue by the establishment reinforces a prejudice by the masses.  When government and law supported slavery, the general public felt vindicated in the belief in such an abhorrent practice. When psychiatry included homosexuality as a mental illness, the hatred of gays was accepted.  That doesn't mean that being overweight can be compared with bias against innate parts of who we are.  However, it does highlight the power of the establishment to sanction accepted bias.  The rational justification of the dangers of obesity shouldn't condone blatant prejudice.

The way people sneer at an overweight person walking down the street, avoid him on the subway or scoff at him on a TV show now feels accepted, a part of daily life.  The irony is that although a fuller figure could become a la mode in a moment, the medical prejudice against obesity will take much longer to overcome.  Although the rationale of the medical risks of obesity are clear-cut, the overarching risks of promoting thin over fat are great.  Where are the articles on the scourge of thinness?  The underfed, underweight population risks osteoporosis, various vitamin deficiencies and anemia. The chronically underweight also are always at a cognitive loss, struggling to think clearly and to maintain a normal memory.  Moreover, it isn't just the underweight who suffer.  The number of overweight and even normal weight people who diet comprises a larger and larger percentage of our population.  One effect of "fatism" is a general sense that everyone could stand to lose some weight.  The pervasive and unchallenged diet industry has the freedom to tout one crash diet after another and guilt people, fat and thin, into severely restricting their food intake.  These normal weight people starving on the newest diet are not able to function at a normal level.  Even more troubling is the assumption based on the set point theory of weight explained in a recent post.  The long-term effect of chronic diet restriction is overeating to compensate for recurrent starvation.  The overeating and body's instinctive fear of famine triggers the body to slow metabolism, store fat and paradoxically gain weight.  In fact, the drive for thinness in the general population may actually be worsening the obesity problem.  We all need food to survive, yet this basic fact is summarily ignored for the supposed common good of facing obesity or perhaps facing our own misguided prejudice.

Medicine itself needs to own up to the risks of chronic starvation and an underweight population.  This goes beyond those with eating disorders and instead highlights the general population risking their health by following the unsubstantiated advice of the powerful diet industry.  Education is not just about a new government-sponsored food plate but a goal of weight normalcy.  The population needs to be aware of the risks of chronic food restriction, and the diet industry needs clear guidelines as to what is medically acceptable.  A strong voice against thinness and dieting might at least open the door to a backlash against this dangerous fashion and simultaneously ease the bias against the overweight.

The next post will apply these thoughts about diet and the drive to thinness to children and the risk not just of developing an eating disorder but of a culture of youth that prizes thinness over everything else.

"Pathological" Obesity

A New York Times blog post this week started a discussion about "fatism."  It is widely accepted that obese people endure professional and social bias in America.  The data point to slower advancement in the workplace, decreased appeal as a mate and social isolation.  The shame of being fat in this day and age feels like a scarlet "F" emblazoned on your forehead.  Obese people frequently describe feeling invisible in their daily life, any attention quickly turning into scorn.

Although this is a sad commentary on the current trend to emphasize thinness above all else, the blog post aligns the bias against obesity with the gay rights, civil rights and women's rights movements.  Being born a homosexual, African American or woman is an inescapable fact.  Prejudice against people based on basic elements of their personhood is a strike against human rights.  Not to minimize the impact of the bias against overweight people, obesity is a not a similar genetic trait.  Although people may be born with a genetic predisposition to being overweight, that is a very different story.  Unfortunately, jumping on the political process that has been highly effective recently in the gay rights movement oversimplifies the growing bias against the obese and obscures the real, underlying problem for this population.

It is critical to remember that obesity has been rising precipitously for the last 40 years.  The significant advances in the food industry has created a land of plenty with more than enough food to feed our entire population, a remarkable feat of production and engineering.  The drive behind providing the country with adequate nutrition is the profit-seeking, under-regulated food production business.  Accordingly, the food widely available is what will appeal most to our sensibility and thus sell best: highly processed food laden with fat, sugar and salt and, based on increasing amount of hard data, deleterious to human health.  There is no reason a profit-driven company should factor public health into its business plan unless a regulatory agency insists on it to protect the population's health.  Although the exact medical reasons behind the rise in obesity remain unclear, the increasing availability of highly caloric, unhealthy foods is one obvious cause.

The clash between government just starting to recognize its collusion in this vast public health problem and industry hellbent on profit above all else has just begun.  In the meanwhile, the social problem of millions of citizens lugging around dozens of extra pounds continues to grow.  The empty promises of the diet and weight loss industries just cement the overall frustration.  The medical establishment tries vainly to keep up with the increasing medical problems associated with a vastly overweight population.  But, as the Times blog post suggests, individuals need to learn how to live with the reality of being overweight.

The eating disorder community has coined the term pathological obesity to describe this phenomenon.  In addition to the practical component of both weight loss and weight maintenance meal plans, the most important psychological step in obesity therapy is to separate the physical and psychological effects of being overweight.  The physical symptoms range from metabolic illness to orthopedic problems to long-term cardiac effects.  Psychologically, the overwhelming shame of obesity combined with the prevalent social bias creates a mental state of absolute obsession with food restriction and weight loss.  Repeated severe dieting triggers an overwhelming sense of starvation, as explained in the last post, which only exacerbates the ruminative state of pathological obesity.  The result is that a functional, driven and psychologically healthy person puts life on hold until the weight comes off.  Years can elapse while someone spends more and more energy focusing on the latest diet or exercise plan, holding off all goals for the future, only to be devastated when one magic cure after another fails to deliver.  The wasted years and energy of this process is so demoralizing as to render life truly hopeless.

The treatment of pathological obesity is twofold.  First, establishing realistic goals of weight loss and, more importantly, weight maintenance creates an environment of success and a promising direction for the future.  The hopelessness is replaced by an advocate clearly able to put the obesity and powerlessness around food and weight into perspective.  Second, the weight maintenance phase focuses not on change but on stability, a state of mind and body never experienced by an obese person obsessed with weight loss.  The relative calm of just eating to maintain weight enables the therapy to re-establish life goals, separate from food and weight and remind obese people of their true passions and goals.  The therapy can reconnect the person with true self-worth and label the weight issue as a solely medical issue.  Although this process cannot eliminate the fatism rampant in today's society, treating pathological obesity gives an overweight person the personal freedom and power to overcome this bias day by day.  Freeing the patient's mind from food and weight obsession opens up the possibility of seeing options in life and goals for the present and future once again.

The perceived powerlessness of the obese reinforces society to continue to overvalue thinness, but the resurgent voice of the obese population can allow those struggling with weight to feel empowered again.  While obesity therapy helps an individual separate self-image from weight and then re-engage fully in life, the steps towards generalizing the experience are less clear. The next post will address how to broaden the message about pathological obesity and help society share the responsibility for the clash between thinness and obesity in our culture today.

Weight Maintenance: the Crux of Obesity Therapy

Psychotherapy to treat obesity cannot be another weight loss program. The most popular medical treatments for obesity focus only on weight loss and are no better than the latest fad diet. The clearest message from any unbiased data assessing the weight loss industry is that diets just don't work.  Calorie restriction, in whatever proportion of nutrients deemed successful by the latest guru, inevitably leads to a powerful feeling of starvation. Surprisingly, the psychological effects of starvation--obsession with food, strong urges to overeat and slowed metabolism--are a universal reaction from the anorexic to the obese.  Although an anorexic patient may have the genetic predisposition to withstand starvation without eating, everyone else will be compelled to eat when ravenous, an evolutionary response clearly geared towards the survival of our species.  So the obese person starved for months on a diet can only resist eating for so long and inevitably will eat enough to compensate for the long-term starvation and gain back the lost weight.

A universal reaction to starvation, even in the obese, makes little sense.  Shouldn't the body be aware that extra weight has medical consequences?  The medical explanation for this conundrum is called the set point theory which postulates that everyone's body has a relatively fluid weight range of about 15% of body weight but will strongly resist moving outside that range. Any pressure to go above or below this range triggers a powerful metabolic response aimed at maintaining the set range.  At higher weight, the metabolism increases to burn off extra calories and hunger eases. The opposite occurs at lower weights.  The human body has a powerful, innate drive to maintain the status quo.

Based on this theory, the eating disorder treatment community has focused on weight maintenance rather than weight loss.  Most anyone who is overweight can lose weight but, once the protective mechanism of set point theory kicks in, no one can keep it off.  Built into obesity therapy from the start is a focus on slow, gradual weight loss for a period of a few months followed by a similar period of weight maintenance.  In fact, weight maintenance is not only meant to be a critical component of treatment but is necessary for consistent, long-term weight loss.  At the end of a weight loss phase, the person will be at or near the bottom of the current set point range. Weight maintenance will allow the set point range to slowly decrease and enable another weight loss phase in the future. It is usually a shock to an adult devoted to the study of dieting to realize that weight loss is only half the battle.  All diets promise short-term, rapid weight loss with long-term effects, but all the promises are false.  The lure of a diet is rooted in the hope for salvation, for the perfect fix to a lifelong problem.  The therapy for obesity immediately grounds the relationship in much slower but realistic prospects of success.

Practically, the treatment involves establishing the calorie and meal goals likely to maintain the patient's weight. For the first 6-12 weeks, the initial weight loss phase, eating 10-15% below the maintenance level should lead to gradual weight loss of 10-15% of body weight. As the patient's weight nears the low end of the range, weight loss slows and then stops, hunger escalates rapidly and metabolism begins to slow and conserve energy.  Further dieting invariably triggers excessive hunger, overeating and a profound sense of food deprivation quickly followed by overeating and weight gain. These physiological responses, in a society that idealizes restraint and thinness, become signs of psychological weakness, not the body's adaptation to extreme hunger.  Instead, the therapist can identify any sign of increased hunger or deprivation as a sign that the therapy needs to enter the maintenance phase.  The addition of the extra food will curtail the excessive hunger quickly and help the body adjust to a new phase of adequate nutrition.  After a period of months, the therapy will be ready for a new weight loss phase.  At the start of treatment, most patients, after a recent period of overeating, are usually at the top of the set point range, but after a period of weight maintenance, the weight is more towards the middle of the range.  Thus, subsequent weight loss phases lead to 5-7% weight loss.  Perhaps the hardest aspect of obesity therapy to accept is the length of treatment.  The behavior modifications are meant to be lifelong, but the weight loss associated with true weight maintenance takes years, something unheard of in a dieting culture.  It typically takes years of overeating to lead to excessive weight gain and it similarly takes time for the body to adjust to weight loss.

From a medical standpoint, this therapy often has long-term success.  Several practical issues can disrupt slow and steady progress such as a sedentary lifestyle, diabetes and a chronically slow metabolism from years of excessive dieting.  These issues can be addressed with education about the process of obesity treatment and the help of a knowledgeable primary care doctor.  However, psychological obstacles also impede the treatment and serve as the most powerful reasons an obese patient gives up.  The next few posts will address the pitfalls in obesity therapy and how to overcome them.

The Treatment of Obesity: Overview

Obesity is the most pressing public health problem of the moment. The average weight of Americans, adults and children, has skyrocketed over the past few decades. The medical complications secondary to obesity have risen precipitously as well. With infectious disease and food-borne contamination largely in the past, the medical establishment has hoped that longstanding health followed age-related illness would predominate routine care. Instead, diabetes, high cholesterol and hypertension are the bread and butter of the primary doctor bent on helping an obese population survive. Meanwhile, the current efforts of government and industry, the parties primarily accountable for this crisis, may reluctantly raise awareness but accomplish little else to find a solution.

The reasons for the obesity epidemic are clear although their relative importance is hotly debated. The transformation of the food industry and available choices in the local market has changed the way we eat. Fast food, sugary drinks and junk food comprise a significant percentage of our diets and explain why literally twice as many calories are produced in our country than what we need to survive. On top of that, the average American leads a much more sedentary life than a few decades ago. And our attitude towards food and weight has changed drastically. The most salient theory of the cause of the obesity crisis combines all three social forces--food options, sedentary lifestyle and preoccupation with food and weight. However, without a fully accepted theory, industry can blame lack of exercise, food pundits can blame industry and government can avoid needed regulations. The overall effect is to dilute the message and splinter the drive for a solution.

The government has finally signed on at least to acknowledge this issue. Despite the lobbying power of the food industry, Michelle Obama has devoted much of her energy to food choice and exercise, especially in children. There is no doubt that placing her powerful spotlight on an issue the corporate food world can easily evade was necessary to have any impact. In addition, government-sponsored nutrition education has taken a big step forward. The new food plate replaced the confusing food pyramid to make much clearer the basics of meals and nutrition. None of this changes the reality that fast food and junk food remain a much tastier and affordable way to feed yourself and your family. Although new initiatives can spearhead debate and, subsequently, awareness, more regulation of the food industry along with incentives to provide healthful food at reasonable costs will be necessary to stem the tide of obesity.

Faced with the deterioration of the health of the population, the medical profession has to tackle the myriad consequences of an obese population and, more to the point, try to devise strategies to fix the problem. Preventive medicine has a history of success with vaccines and vitamin fortification, but those were public health initiatives to combat preventable diseases, the wheelhouse of medical success. The conflicting forces at play in the rise of obesity, both within and outside health care, largely overshadow the good will of the medical community. While many physicians toil away to ensure the health of obese patients, our profit-driven cohorts endorse new, exploitative measures that purport to offer a quick fix for an intractable problem, such as medical weight loss programs and surgical intervention. But these band aids only mask the problem.

As of now, no doctor or specialty has the answer. Primary care doctors, with almost no formal training in weight management or nutrition, advise patients with their own personal and often distorted views of food and weight. Nutritionists recommend modified versions of weight loss diets with short-term benefit but almost guaranteed long-term failure. Studies show that about 95% of people who lose weight dieting gain it back and more within 6-12 months. After years of futility, patients seek a consultation from a Bariatric surgeon. The FDA recently lowered the BMI needed to consider this option, and many more people, some not even considered obese, are now eligible. While surgery has faster and longer-lasting effectiveness, it's already clear this is no panacea. Complications, subsequent health risks and unclear long-term safety and effectiveness are apt to plague the post-surgical population. Plus, how can we as a society abide lives of overeating followed by surgical remediation? This is no real solution.

As in past decades, frustration within the medical community at large leads to the general consensus that the underlying pathology is psychological. Increasingly, the road to obesity treatment goes through the mental health community and, more specifically, eating disorder specialists. Clinicians who treat eating disorders have two things going for them: a non-judgmental stance on food and weight and a willingness to tackle a challenging public health concern. Initial attempts at treatment combine behavior changes around food with a mandate to not let the weight impede on daily living. Losing weight becomes an obstacle to overcome through gradual lifestyle change rather than an actual disease. The crux of the therapy is a collaboration to change one's relationship with food, an approach fundamentally no different from treating an eating disorder, while simultaneously reinforcing the need to be engaged with the world. It's unclear how successful that philosophy will be, but the increasing number of obese patients referred for therapy will test this treatment quickly. The next post will explain obesity therapy in more detail.

Meaning vs. Materialism: How to Make Food Just Food Again

In all earnestness, a friend of mine once said, "Isn't all technology intended to make our lives better?" After my initial shock at such undiluted naïveté, it was hard not to berate myself for being so cynical. I consider myself a technophile. I can lament the loss of personal time and space and still covet the latest streamlined, expertly-hyped, mesmerizing Apple product. What I can't abide is the loss of process and patience in our lives.

We were always forced to wait for answers. Life took its own sweet time to reach a conclusion. Things happened when they happened and our ability to speed them along was fairly limited. Now we can immediately satisfy our urgency with a text message, email or web search. I embrace the change. I know the unbridled pleasure of googling the answer to a heated personal dispute or the quick fix for a household emergency. But it is the process, the debate, the creative thinking, even the aftermath of doubt, that no longer exists. That internal world, such an essential part of being human, feels as if it's being phased out and, like the iPod classic, discarded into the dustbin of expired technology.

However, the loss feels much greater here. The new adage may say that we have gone from creators to aggregators, the transition utilizing the plasticity of our minds in a new reality. And content, the new term for the creative process, although necessary, is beside the point, relegated to the least adaptable minds stuck in the 20th century. But as our inner lives continue to erode from a steady stream of media and entertainment, packaged and repackaged into new products of sameness branded as content, so goes life's meaning. And as I have stated time and again in this blog, the loss of meaning is intricately connected with the rise of disordered eating.

Our collective minds more and more resemble a linked computer network than an amalgam of individuals. What passes for individual thought turns out to be a formulaic gimmick, advice just reworked from old-wives' tales or self-help mumbo-jumbo. The savvy self-promoter can transform into a modern guru able, perhaps, to unlock life's deepest mysteries, or at least powerful enough to leapfrog a new book to the top of the bestseller's list. Our minds gobble up the endless stream of content, and we each pledge our allegiance to the network by parroting back the information to our colleagues and friends, duly doing our part in the mass marketing machine. What used to pass as individual thought now just marks our acceptance of the vetted data, content, meant to fill our brains.

Each community, class and region has its own information niche, but the self-worth download to our own workstation in the collective server is fully nationalized. Everyone knows the drill: diet, exercise and thinness are the only road to inner peace. Yes, the sidekicks of yoga, self-help and meditation may reflect new paths to nirvana. But come on! Those people are skinny first before they ever set foot in a yoga studio, or at least so goes the completely misguided, but common knowledge. In the download, you see yourself first in the ideal body gliding comfortably and confidently through life. Only that iteration, body 2.0, will incorporate yoga into a daily routine or check off the list of self-help items in the hippest, new advice book. Body 1.15, the reality version, fails the newest diet, glumly re-ups the membership at the gym and impatiently waits for life to finally start.

The personal loss of mental space, process and patience has created a new universal dilemma. We all may be searching for meaning but have settled for materialism instead. Surprisingly, the transition from meaning to materialism, both in physical possessions and in physical appearance, runs the socioeconomic gamut. The occasional existential crisis may feel as antiquated as a record player, aerobics or Levi's jeans but is as prescient as ever, just in a new form. Some part of our society needs to care before the gluttony of materialism reduces us to a national eating disorder.

Yet there is one fundamental fact I have learned from working with people with eating disorders. Only in a world devoid of meaning can so many bright, driven women become focused on something as mundane as food. The fundamental misunderstanding starts with the self-worth download. Take a driven, talented but confused teenage girl and give her basic rules about food and weight to live by, and it's not hard to see how a few simple mantras become an eating disorder. It is one thing to follow the strict guidelines set by family, school and society, but the adolescent drive for autonomy needs an outlet too. What better alternative exists than to be skinny? Before long, skinny becomes the only way to view life's meaning.

A patient in recovery suffers from the reverse of the dilemma. Faced with the search for life's meaning outside of an eating disorder, a patient quickly grasps that few models exist in the modern world. Is a choice between the eating disorder and a new existential crisis placed in a cultural void really a choice? Obviously, I would say yes. The therapy for people with eating disorders is a tutorial in how to apply age-old philosophical questions to modern life. The time in therapy focused on process and patience brings a disoriented soul to a calmer place long enough to find the meaning food and weight will never really provide.

This is really the underlying lesson. The food business, diet industry and self-help marketing machine have become the parallel educational system of our time. Yes we all learn reading, writing and arithmetic, but we also know about junk food, dieting and how to look skinny for the summer. What we don't learn is how to create a life of meaning. When the matter and substance of our existence are topics of discussion, when a life is considered for its value to society, when a parent's priority is to teach a child how to love and live, food can go back to being plain old food. Social contagion can spread quickly. A people bent on tearing down the old foundation can do so in a moment of time. Harnessing the creativity and desire, deftly deleted from the current self-worth download, would steer the debate from the latest fad diet back to the value of a human life.

The next series of posts will shift to the problem of obesity. A growing health problem, obesity has tested various medical specialties from primary care to pediatrics to general surgery. Increasingly, patients are being referred to eating disorder clinicians for treatment. The next posts will summarize the current therapy and treatment for obesity.

The Social Contagion of Eating Disorders

The canon of Western philosophy can be summed up in one sentence: in the end we are all alone. From that first self-aware moment, the first realization we all are going to die, this truism seeps into the zeitgeist of our humanity to become the one balm to ease our panic. But how true is it really now? With the unlimited ways of staying in touch, can anyone feel alone in this day and age? The existential crisis of modern life pits the alone hypothesis against our growing interconnectivity. It all leaves me hopelessly confused. What I do know is that the study of human social systems and group dynamics makes the isolated philosopher a dated creature. The age-old academic stance on the human condition needs an update.

I'm aware that this is clearly a big leap for a psychiatrist. But when it comes to understanding how eating disorders have spread like wildfire, the logic of this post will become clear.

The first point of business is to reconcile the isolated individual with the breadth of humanity. Until recently, any one person's world remained fixed and small. No one could easily travel or keep in touch with the world around them. A life was led in a small geographical area amongst family, friends and neighbors. The larger scope of humankind was a heady concept, an abstraction in need of a theoretical framework. Instead, the nature of pre-industrialized civilization led inward. Living a relatively isolated life, the intellectual focus was on our individual existence and the inherent loneliness of experiencing the world behind the filter of the mind. The juxtaposition between the unique human gift of self-awareness and the universal prison of our own minds occupied the best and brightest minds for centuries. The result is a compendium of philosophical transcendental and religious treatises that solve nothing and ignore a basic, equally important fact of being human.

We have conquered the world through sheer mass and numbers. Our consciousness and self-awareness distinguish us from other animals, but let's not fool ourselves. The sophistication of our individual minds is only as powerful as the community, society or nation we belong to. The lone peacock may spread its plume to attract a mate, but no one cares unless the peacock clan survives. The brain development and capability of humans matter only because the complex social forces--no different from the lion or elephant herds--shaped history as it did. The philosophical truism, enlightening as it is, missed the forest for the trees. To ignore the magnitude of social forces in our own daily lives is akin to the blind spot in anorexia: you can't survive without food.

The social forces behind the eating disorder epidemic are incontrovertible. No one in this country can ignore the mass media pressure for thinness and weight loss. For each eating disorder recovery forum, there is a website schooling the budding anorexic in how to lose weight faster, or the bulimic in purging tips. Even mainstream eating disorder programs, clearly intent on promoting recovery, have to clamp down on underground education for the new generation of anorexics and bulimics. An ambivalent group of patients without clear guidance is as likely to egg each other into illness as into recovery. And the conflicting, powerful forces proceed unabated.

But recognizing the social forces at work in the proliferation of eating disorders only scratches the surface. It is the precious few who still read and follow any guidance from philosophers. We may be trapped in the human condition but are too distracted by the interconnected world to care anymore. In the modern era, it's hard to find a spare minute to reflect on our individual fate. Each moment is steeped in the enormity of the broad scope of humanity and reinforces our small place in that vibrant mass of life. The overarching mantra of the modern era has left behind internal reflection and instead revolves around the philosophy of food and weight. The combination of willpower with the right number on the scale equals salvation. The burden is off the lone philosopher charged with explicating our suffering. Now philosophy 101 is taught in the mass media and celebrated in pop culture. The slow, inevitable reach of distorted food thoughts can feel like our modern-day consumption. Just instead of the image of the philosopher coughing incessantly and wasting away, we all starve, and suffer the consequences.

The obvious examples of the disordered eating contagion abound, but one less obvious choice is the severe calorie restriction movement. I remember vividly the blinding media coverage of the starving rats in the mid-1980's. In a quick summary, rats fed half the normal rodent diet lived significantly longer than their unstarved brethren. In an interesting turn of events, starvation as an elixir of youth and longevity was too tempting an offer for an already deprived society to refuse. No one seemed to feel sorry for the poor, listless creatures. Instead, everyone marveled at the extraordinary discovery. The lure of a guaranteed century of life, no matter how miserable, hungry and food-obsessed it might be, was like a carrot to a bunny. And carrots, along with other vegetables and fruit, are the mainstay of a calorie restrictor's diet. How else to survive on such a paltry sustenance? The steps from lab discovery to philosophical movement to an eating disorder aren't hard to follow. We have all seen it before from Weight Watchers and Atkins to Bariatric surgery.

The real concern is that antibiotics might have eliminated consumption but it's much less obvious what will make us eat again. Stay tuned for the next post.

Let Freedom Ring

Life, liberty and happiness are three fundamental rights borne out of the creation of this country. The meanings of liberty to a society over almost three hundred years fluctuate wildly. Initially as an escape for the oppressed and the pioneers, America stamped its reputation as the land of the free. In later years, immigration and the lure of the American dream bespoke the reality that all classes could aspire to success and wealth. The hypocrisy of a long history of slavery and oppression of women finally amounted to the civil rights and feminist movements and culminated recently in a hotly contested primary between an African American man and a woman. In one sense, freedom clearly still reigns.

But to the individual, the fundamental American right is much less clear. Class distinction, based largely on socioeconomic and racial differences, is growing. The disparity between the rich and the poor has widened exponentially. Educational opportunities for the lower classes have all but disappeared. Perhaps for the first time, this country is divided into the haves and the have-nots. We all may be grateful for the individual freedom to speak our minds and for our human rights, neither to be taken for granted, but too many people are trapped, their freedom not even an afterthought. Either the fortunate buckle under the pressure to be in the haves or the less fortunate wallow in the despair of never having. One pressure is usually applied by knowing, desperate parents hoping to push their children towards success, the second by hopeless, desperate parents who know of no escape. The freedom of the individual, one pillar of American life, is more a relic of the past. 

Children can sense the futility of a predetermined life. Even the wealthy, a class known to produce children with eating disorders, suffer this fate. A child with means, who knows she will always get what she wants, has nothing to drive her, nothing to prove. The unusual child with preternatural internal motivation might find her way, but the bulk of these children of means live the lives set by their parents and find identity through other means, a scenario that can easily produce an eating disorder. The message is clear. Your life is set by your place in birth and the freedom to move within society largely relegated to distant memory.

There is a glimmer of hope: the philanthropy aimed at improving a broken education system; the technology opening new avenues in staid industries; the growing backlash against the food industry; and a president who represents hope and change. These all foreshadow a piece of society interested in bringing freedom back in future generations but with little sense of how to do so.

What is so often overlooked is that personal freedom doesn't exist in a vacuum. American idealism grew out of a loosely structured but firm Constitution open to interpretation but upheld as the truth. Different legal schools of thought vary widely, some may be controversial, but all point to this document as the American bible. It is a miracle that an entire nation can accept a political compromise as a guide to good living almost 250 years later. And that bible makes clear that freedom is a high priority.

But freedom in and of itself is not what works; freedom within a clear-cut structure is the lesson to be learned. The American dream grew not only in a land of endless opportunity but in a land of endless rules. Granted, those rules largely proclaimed individual freedoms, but a national proclamation of freedom is much more than good intentions. Instead, the message reads like good parenting advice: follow the basic rules, then you can do whatever you like.

Backed by American history, this philosophy works. The freedom of the individual, the wild successes of the high-minded entrepreneur, the social-minded activist and the idealistic politician have in turn molded the innovation, individuality and liberty grounding this country. As the rules break down so goes individual freedom. Class and money now open unlimited opportunity while the growing masses see no way out except the mind-numbing path of materialism and commercialism. The nascent but obdurate class system may just cut off individual freedom at its knees. The new generation is getting the hint. Good grades, extracurricular passions and an entree into elite education don't replace the wide open American life. Individual liberty trumps the class system, even if you're on top. The young deeply feel a sense that they are missing something. The momentary high of an eating disordered identity is like a new generation getting stoned together. It's an adolescent solution to an insoluble problem. But on an individual level, letting freedom ring can open the door back to opportunity. With generations of experience with individual liberty, the land of the free, it isn't like this society needs to remake the world. Going back to basics will suffice, and hopefully make it easier for everyone to eat again.

Just the other day, I was asking a colleague a question about my child, just to surmise what the future might bring. She sensed my trepidation, even anxiety, and quickly interpreted it in her own way: what might happen to my child? Could this snowball into a life of failure? But her way of assuaging my fear was all too telling. She said, "I have known children like your daughter who have gone to Brown, some even to Princeton and Harvard." And then life is set, all worries forgotten? The path is clear? Life's satisfaction as simple as an Ivy league degree? All I could think was that we have surely lost our way. There is nothing sacred to grasp onto when the future is unclear. That philosophy will be the ruin of this country. Contrary to current popular belief, peace of mind comes in a moment when all is not lost, when opportunity lies ahead and when, above all, freedom to aspire, to dream and to live fully remains within our grasp.

The next post will switch to a new topic: the role of social contagion in the spread eating disorders and disordered eating.