I hope all critters, fuzzy or not, have moms like this. I did!

So I'm attending my cousin's wedding in NYC, and we get to the hotel early today--early enough that we got lunch in the city as opposed to along the way. We ended up at a national chain restaurant because it was near the hotel, and I sat down and opened my menu, and...

I totally forgot that calorie counts on menus were mandatory within New York City. Totally forgot. At first, I shook my head a little and tried to clear my vision, hoping that it was some mistake or maybe the little numbers just accompanied some of the dishes.

Oh no. Every appetizer, every entree, every sandwich, every dessert, every beverage had a calorie count next to it.

My head started spinning and hasn't stopped, nearly twelve hours later. Numbers swam in front of my face. I didn't look at what the food was- all I could see was calories, calories, everywhere the calories. I don't remember anything on the menu, except what I ordered. Thankfully, I have a meal plan from my dietitian that helped me focus a bit, and I did pick something reasonable.

I struggled the rest of today. All I could think when I ate was "How many calories would be listed on the menu for this? How many calories are in this bite? How about this one?" It's bad enough for the numbers to be buzzing in my head all the time, but to see them in front of my eyes, in black and white, when eating at restaurants is hard to begin with, was a little too much. If my obsession with calories and numbers is supposedly a Bad Thing--and given the effects this obsession has had on my health and my life, I can see how my treatment team might think that--why are there calories on the menu? If calories could turn into a life-threatening obsession for me, couldn't it turn into an obsession for others?

I understand, to some extent, that the purpose of printing calories on menus is intended to be positive, a way to empower people to make better choices. I get that. But all of that empowerment! and knowledge! and health! might not be what goes through people's minds when they order. Even before the ED, I would be self-conscious about ordering something too "high calorie." I would feel guilty. I wouldn't want to call attention to myself. What would the other people think?

Here's the less-than-pretty corollary to the above: I would compare myself to what others ordered. If I ate something "healthy" and they had the cheeseburger and fries, I might very well have felt virtuous that I was "better" than them. I mean if eating a salad is a so-called "good" choice, and eating lots of fries is a "bad" choice, then it would make me "better" because I had the salad. Right?

For the record, I had a sandwich, not a salad. My mom offered to read me the menu choices and/or decide for me, which would have been a good thing had I not already seen the calorie counts by the time my mom figured out that I was silent not out of awe for the spectacular menu choices but that my brain was spinning from all of the calories. By then, the damage was done, and I simply found the first thing where the number didn't totally freak me out, that wasn't on the diet menu, and also fulfilled most of my meal plan requirements. And then I snapped the menu shut and stared off into space.

As I was staring off into space, calorie counts clicking through my head on a frenetic abacus, all I wanted to do was to find the person who first had this bright idea and introduce them to the madness in my head. I want them to understand what it is like to be me. I want them to understand that good intentions can have very bad effects. I want to explain to them that people making "healthier" choices because they feel guilty eating what they want isn't really any better.

Wouldn't someone take about 30 seconds out of their day and think about the "downsides" to this obesity hysteria?

I think this pill will take care of all of my worries...don't you?

I am heading out of town for about a week and a half- the first part of my "vacation" will be spent at my cousin's wedding in NYC. Then, I am heading back to DC to move all of my stuff out of my apartment as my lease is up and trying to keep up with rent when you don't have a job is kinda hard.

On some days, I may be without reliable internet connection and/or without time to post. So I'm guessing my writing will be a little lighter than usual, though I will pop in and make sure the ED blogosphere hasn't exploded.

Have a good one!

There's a new eating disorder blog on the scene, this one by a real, live trained professional (Barnum and Bailey probably would have charged you a quarter for a peek sometime last century- alas how copays have changed). I am thrilled beyond words that Dr. Sarah Ravin is joining the wonderful, wacky world of ED blogs.

I love Dr. Ravin's bio:

A major component of my professional identity is staying informed about recent developments in the field so that I may provide my clients with scientifically sound information and evidence-based treatment. There is a plethora of information on the internet about eating disorders, depression, anxiety, and psychotherapy. Unfortunately, much of this information is unsubstantiated and some of it is patently false. It is my hope that by sharing my thoughts and opinions on psychological issues, with scientific research and clinical experience sprinkled in for good measure, I can help to bridge the gap between research and treatment.

Her first post, Top 10 Mistakes in Eating Disorder Treatment, is so spectacular I had to link to it here, and it's going in my permalink section to the right. It is a must read for anyone who even attempts to treat an eating disorder and is filled with wisdom and truth.

I can't wait to see what else she has to say!

(An extra gold star for those who caught the Flannery O'Connor allusion in the post title. Dr. Ravin is in Florida, so I thought the Southern reference would be marginally appropriate.)

Sometimes I think this series on "In the name of health" could go on ad infinitum (you can read the first episode here). For my own mental well-being, I won't write an endless series of posts about it, but an article I found on Facebook (h/t Libby and Amy) made me realize that I certainly needed to do more than just the two original planned posts.

The name of the article? Throwing out the wheat: are we becoming too tolerant of gluten intolerance?

Writer Daniel Engber takes a long, hard look at the sudden proliferation of gluten-free foods, sales of which have risen an estimated 28 percent each year to make an industry worth nearly $2 billion. Take a look at some of the boxes of Chex cereal these days- many are now prominently labeled "gluten free."Although avoiding gluten, a protein found in wheat and certain other grains, is necessary for those with celiac disease, this autoimmune condition affects no more than 1% of the population (or at least, less than 1% of the population has received an actual diagnosis of celiac disease). And though this proliferation may be beneficial for them, it doesn't seem that such a small segment of the population would drive such a large segment of the food industry.

Engber's hypothesis is that most people who cut out gluten don't actually have full-blown celiac disease. Rather, it's a way to avoid foods in the name of "health" and maybe lose some weight in the process. In other ways, the association is blunt and in your face, as Elizabeth Hasselbeck's latest book The G-Free Diet: A Gluten-Free Survival Guide contains a chapter titled "G-Free and Slim as Can Be!"

Writes Engber:

The fact that "going G-free" means eating fewer cupcakes and less pasta suggests another source of relief. It is, after all, an elaborate diet—and so delivers all the psychological benefits of controlled eating and self-denial. "Once G-free, you are no longer simply robot-eating bag after bag of pretzels," writes Hasselbeck...Gluten intolerance may be a medical condition, but according to Hasselbeck, it's also an approach to eating—like South Beach or Skinny Bitch—that's supposed to make you lose weight and feel good about your body.

One of the most fascinating parts of the article is the graphs that compare the rise in newspaper mentions of "gluten intolerance" with the rise in popularity of the Atkins diet.




Coincidence? Perhaps. But it strikes me as kind of unlikely, especially when you compare the rise in "lactose intolerance" that happened alongside the popularity of the Mediterranean diet.


Engber makes his key point here:

I'm not suggesting that anyone who avoids gluten is secretly trying to lose weight. The purpose of a gluten-free diet is, naturally, to feel better. But there's a complicated relationship between feeling good and eating less. When a restrictive diet becomes an end in itself, we call it an eating disorder; when it's motivated by health concerns, we call it a lifestyle. That's why Hasselbeck says going G-free will make you slim (a sign of wellness) rather than skinny (a symptom of anorexia). It might also explain the relationship between food sensitivities and fad diets: People who are intolerant of gluten or lactose get a free pass for self-denial.

And it's the last one that concerns me. When people say they are doing something for "health reasons," we become automatically less likely to question it. Dietary changes for health reasons can be totally legitimate, and suffering caused by undiagnosed food allergies and intolerances is very real. But I think the new surge in "cutting out..." gluten, corn syrup, dairy, meat, food in general has less to do with an increase in food allergy diagnosis and a lot more to do as a way to avoid food and not get called out on it.

I was reading a very interesting book called "The Borderlands of Science" by Michael Shermer in which the author was discussing a phenomenon called hindsight bias. The general concept is we unknowingly change the causation or predictors for an outcome after it has happened. That is, in our minds, it was obvious that it would rain this afternoon because it was cloudy this morning, which essentially disregards all the other times it was cloudy in the morning and it didn't rain in the afternoon.

So what did I think of? That's right. I thought of eating disorders.*

More specifically, I thought of therapy for eating disorders.

For the first several years after my diagnosis, my therapy (when it wasn't involved in crisis management) focused on what could have happened in my past that caused my eating disorder. Most of this examined my relationship with my parents and what went wrong. Besides being the result of a false assumption--that I had an eating disorder, therefore my parents screwed me up--this examination effectively caused hindsight bias.

My therapists never tasked me with finding ways my parents had supported me through the years, they tasked me with looking for the negatives. To be fair, my therapists didn't deny that my parents were supportive, but that was brushed aside in the search for How My Parents Screwed Me Up. It was classic hindsight bias. The outcome was that I had anorexia. So I began to discuss my childhood in a much different context. Suddenly, sitting on my therapist's overstuffed armchair, I found event after event in which my parents were too controlling. They kept popping up! I couldn't believe it! No wonder I had an eating disorder.

In the meantime, I kept starving, purging, and over-exercising.

And the more time I focused on issues of control and unexpressed emotions and self-determination and other existential topics, the more I came to believe that these things lay at the "root" of my eating disorder. It was, essentially, a self-fulfilling prophecy. Of course I wasn't recovered yet- my mom was still too controlling. My mom gave me suggestions on what apartments to rent, what clothes might be the most useful, on time management. I didn't have control of my life! I needed to be Empowered, to Make My Own Choices, to Be My Own Person. That meant no one could dare tell me I wasn't eating or drinking enough, that I was tethered to the treadmill, that maybe taking Ex-Lax everyday was a really bad idea. In the meantime, I kept starving, purging, and over-exercising.

I won't ever accuse my parents of being under-controlling. The norm in my family was established mainly by the sheer disbelief that either my brother and I would ever do anything wrong. Though my brother certainly got in trouble far more than I did, he still wasn't a little hellion. Was it the best way to raise kids? I don't know. I have issues with expressing dissent that no doubt relates to this; I also have social anxiety that makes me not want to stick out. None of this means that my so-called "controlling" parents were at the root of my eating disorder.

But the more I kept thinking about it, the more I kept reinforcing my therapist's and my own hindsight bias, the more instances of hyper-controlling parents I found. Weekly perservation on how I never felt I could freely express my emotions made me think of more and more experiences where I felt weird expressing my emotions. Did my mom try to get me to stop crying because she didn't like sadness, or was she pained to see an unhappy child?

All of this looking and searching frankly made me pissed off at my parents. Look at what they did to me! LOOK! They made me anorexic! How dare they try to take that away from me?!? How could people who tried to ruin my life possibly help me recover from an eating disorder?

My parents were not perfect. People with EDs come from dysfunctional families. Most families are a little dysfunctional if you look hard enough (though some stories from my extended family can make most families seem pretty damn normal!). Some parents of ED children have major issues. Do I think my parents should have done things differently? Yep. But that doesn't mean they caused my eating disorder.

The point is this: the more time I spent looking for ways my parents caused my eating disorder, the more ways I found. If I had anorexia, it was obvious my parents were over-controlling. So every instance of control became prominent in my mind. And the issue of control and emotions was blown out of proportion and Ed loved every minute of it.

*If it made me think of cats or something, I probably wouldn't blog about it.

Last night I did something that I hadn't done in a really, really long time: I got lost in a book.

I know what you're saying. But Carrie, you say, I thought reading was your favorite hobby. I thought you read at least 2-3 books per week. And indeed, my dearest readers, this is all very true. I do read copious amounts, mostly geeky stuff with the occasional smutty novel thrown in for good measure. I enjoy my reading, and always have. I won every reading contest ever offered in my elementary school without hardly trying because I naturally read that much. My first job was at the local public library. I now go to the one that's a little farther away because I've already worked my way through most of their books.

You get the picture.

Most of the time, my reading is entertaining, interesting, and informative. I enjoy this part. But every once in a while, I stumble across a really good book that causes me to lose track of all time and place and almost literally fall into the pages. I re-read one of those books last night.

I didn't actually intend to stay up until 5am reading- it just happened. I only meant to leaf through a few pages until my eyes and brain tired out and I could fall asleep. After I flipped the first page, however, it stopped mattering how tired I became. At some point, I would have Scotch-taped my eyeballs open if it meant I could keep reading. I remember glancing at the clock at about 1 am. Then it was 3:30 am. Then? 4:57 am and my eyes were burning and my brain hurt and (this was what finally convinced me to close the book) I really had to pee.

It has been many months since I've done this. After about January or February of this year, this depression began to worsen and my reading stopped having that kind of deep, primal joy that could enable me to lose track of 4+ hours. Reading was a pleasant something to do, a way to distract myself while compulsively exercising, a means of passing the time on my subway ride to and from work. But I stopped looking up from my book with a start, realizing that oh crap, this is my stop, let's hustle it, baby! Instead, I stared at the blur of DC scenery rushing by me, at the rapid flicker of the lights in the tunnels.

As I slid back into the anorexia, the little concentration that hadn't been totally sapped by the depression was simply starved away. I couldn't lose myself in a book because the slightest mention of food would leave me drooling like an idiot. My stomach would grumble and knot itself up as coffee became the base of my "food pyramid," and these rumblings would rudely pull me out of my book and back to reality and the breathless anticipation of my next "meal."

Don't get me wrong- I read some mighty fine literature during this time. Reading was still one of the highlights of my day. But I wasn't with the book, I wasn't in it. The words were something outside of me and I was aware that I was reading.

Last night, it stopped becoming reading and started becoming experiencing.

One of the things I work on with my therapist is mindfulness, being fully in the present moment and not mentally running through a laundry list of Things I Need To Do or Things I Should Have Done. I'm not very skilled at this. To be honest, I kind of suck at it. Last night, though, I felt it.

True, I'm paying the price a bit today. I'm dead tired. My eyes hurt. But I'd say it was pretty well worth it.

Now this is a headline I would like to see more often (take note, New York Times):

Cause Of Anorexia Linked To Brain Circuitry

No psychobabble. No blaming of sufferers, parents, and society. No improper usage of the word "control."

Includes the latest science. Includes quotes from researchers. Includes optimism.

Sure, it's just a press release, but it's a big step in the right direction. Now we just need to persuade more journalists to cover these types of stories.

(And a not-so-subtle hint: the abstract of the paper is here. If anyone can find a full text version and wouldn't mind passing it along, I would be forever grateful. Thanks!)

Part of my current recovery plan involves drinking an Ensure Plus every day. I hated this idea. I felt guilty that they were so expensive. I felt guilty for drinking them. And I didn't particularly like the taste. The vanilla flavor was cloyingly sweet, my lips puckering with distaste as I drank. However much those animated commercials have tried to normalize the idea of drinking Ensure, every bottle I opened made me feel like a medical patient, that I was freakish and abnormal.

Except that I am a medical patient. I'm at home, but I'm still recovering from an actual illness.

I've learned that the Ensure Plus isn't all that bad. It's not all that good, but it's not bad. I tried different flavors- the strawberry and butter pecan taste much better than the vanilla (which is still gross to me). I worked with my dietitian to shift around my meal plan so that I could have an extra fruit along with my afternoon Ensure Plus, which my mom blends into a smoothie that almost lets me forget I'm having a supplement.

Logically, I know I need the extra calories. I'm having hot flashes from hell (hats off to all you menopausal women out there- you have my sympathy) because my metabolism has started to remember that my body will be fed regularly. I also know that with the amount I need to eat, having a supplement is much easier than eating the equivalent amount of food. It's also more convenient, considering life has been chaotic around here, to put it mildly.

I doubt I'll continue drinking the supplements even after I'm finished with weight restoration, largely because there are far tastier things I can think of to eat. But they're not that bad. And I know they're necessary. I can deal with that. It won't last forever and soon I will move on to bigger and better (tasting) things.

Some time in the future, I will be able to say this:

Out of the night that covers me,
Black as the pit from pole to pole,
I thank whatever gods may be
For my unconquerable soul.
It matters not how straight the gate,
How charged with punishments the scroll,
I am the master of my fate:
I am the captain of my soul.

--William Ernest Henley
"Invictus"

I stumbled across this poem while I was reading this afternoon, and it made me think more about the ever-thorny issues of nature and nurture, biology and environment, and chemistry and culture. At first, the idea that eating disorders are fundamentally rooted in biology can seem depressing. You're stuck with your genes for life. Your fate was written in the stars before you were even born. So you're stuck and you're screwed because basically you have no control.

I don't have any control about the fact that I was born with a genetic predisposition to AN. I can't control that. Even I, control-freak Carrie, am well aware of this. I also don't have any control over when (late 20th century) and where (United States suburbia) I was born. I can't change the fact that I developed depression and OCD and anorexia.

What I can control is my future. Despite my current ED illness, I can start to take control of my future. I can engineer accountability so that I don't start restricting and over-exercising again. I can learn better ways to deal with anxiety and depression. I can make sure I'm not in a situation where I would have to skip a meal. I can ensure that I eat enough to keep up with my metabolism. I can stay in therapy and I can go back to therapy if I start struggling again.

I don't believe I'm omnipotent and can totally prevent the possibility of another relapse. It will always be within the realm of the possible, and that will help keep me on my toes. But I can start to take steps to make that possibility as small as possible.

The Obama Administration, it seems, has finally gotten around to picking itself a Surgeon General in the name of Dr. Regina Benjamin. A good chunk of the coverage about her nomination, after Pretty Boy Sanjay Gupta turned the job down, is not about her credentials, or how she runs a non-profit rural family health clinic that was destroyed twice (twice!) by hurricanes. Some mention was made of her as-yet-unclear views on abortion, but a lot of the articles focused on Dr. Benjamin's weight. Dr. Benjamin ain't thin, and people wonder if this "Big Lady" can handle the "Big Job" of scaring people about obesity.

The Surgeon General is the head of the US Public Health Service, and besides putting warning labels on cigarettes and liquor bottles, the Surgeon General plays more of a symbolic role than anything with teeth, and is generally thought to be a spokesperson to advise America on health issues. And you can't mention "health" without mentioning obesity. The general consensus is that Dr. Benjamin had better concern herself with the size of our thighs, and fast, lest our lard take over the world.

Some have responded that President Obama was irresponsible to pick a fat woman to be Surgeon General, that Dr. Benjamin can't give advice on losing weight if she so clearly can't take it herself. One commenter opined that s/he "refuses to let fat become socially acceptable," and believes that Dr. Benjamin's appointment is doing just that.

I wonder if this commenter ever thought about the parallels between refusing to accept Dr. Benjamin's weight and accepting her skin color. Many people would be (rightly) appalled if someone said they were going to refuse to let black become socially acceptable, but they feel absolutely just fine to say it about weight. But they're not prejudiced, you see. Oh no. They're concerned about "health." Well-meaning? Maybe. Prejudiced anyway? You betcha.

One blogger from MSNBC tried to take a swing in support of Dr. Benjamin, but kind of clubbed himself over the head instead. Maybe, he writes, Dr. Benjamin would be really good to get us to Shape Up and Lose Weight because she's fat just like us! Wouldn't more people take her seriously that way? Her size, however, is no excuse for us to declare a truce in the War on Obesity. He writes:

I am not saying we give an inch on the war on blubber. Obesity is an epidemic in the U.S. and growing quickly around the globe.

But people need to relate to the surgeon general, and if she can battle her weight on the job, she will do more to curb obesity then all the salads added to the menus of burger joints everywhere.

Why the need to "battle her weight"? I mean, if you're fighting yourself, you're pretty much bound to lose one way or another. Maybe she will bring some insights to issues such as size prejudice- I hope so. Our culture sure could use it.

To be fair, the MSNBC blogger ends wonderfully:

I don’t know about you, but a doctor who chooses to care selflessly for the poor and who has the respect of her peers as a good clinician is a doctor whom I am willing to listen to — even if she wears a plus-size lab coat.

The NY Times addressed this in a story this week called "When Weight Is the Issue, Doctors Struggle Too," in which a pediatrician muses over how to discuss obesity with children when she isn't exactly svelte herself and finds it hard to take her own advice. I'm not saying that encouraging moderate exercise and fruits and veggies is bad, but maybe the problem is with the advice and not the taking of it. When a diet fails, we blame ourselves. The problem, however, is the diet itself.

I'm fairly certain that Dr. Benjamin will have seen failed diets, and will have seen the connection between socioeconomic class and obesity. Will her own personal experiences give her a unique insight on this? Probably. But this woman is so much more than her size. Positive or negative, it's time to take size out of the picture.

Eating disorders (and related issues) have appeared numerous times in the New York Times this week. Besides informing everyone of what I read while I enjoy my first cup or two of coffee, I am glad to see coverage of EDs beyond what celebrity is now doing Master Cleanse. The stories covered thorny issues such as midlife eating disorders, EDs in men, and when your parent has an eating disorder. That these issues would get such wide exposure in such a well-regarded publication is fantastic.

So that's the good news. The actual substance of some of the coverage (besides the major article on midlife EDs), however, was a little lacking. To be fair, I should be specific, which leaves me a little squeamish but deep breath, here it goes. I was really disappointed in the "Consults" blog extras relating to the midlife EDs story. Not that Dr. Zerbe isn't qualified to be a correspondent for such an article, but I felt that she focused almost exclusively on psychotherapy and environmental factors related to EDs to the detriment of what the latest science indicates.

In her responses in the blog post titled "Seeking Help for Anorexia, Bulimia, and Binge Eating Disorder," Zerbe addressed issues of biology and bulimia (it's roughly in the middle of the page). Although she definitely said that EDs have a genetic influence, she was quick to tell the person to look at issues of culture and try to figure out the reasons "behind" their eating disorder. To help with that, she recommends sufferers read stories written by ED survivors.

These stories of recovery in the face of life’s inevitable traumas and struggles paint a broader picture of what it takes to get better and why someone may have arrived at struggle with body image in the first place.

In the most recent blog about "When a Parent Has an Eating Disorder," Zerbe also failed to mention the well-known (in the ED world, anyway) fact that EDs run in families, due not just to shared environment but due in no small part to genetics. Could the man writing in have been helped also by learning that the traits with which he and his parents have struggled are genetic in basis and aren't simply due to bad parenting? Sure, these traits can cause parents to do things that are less-than-helpful, and a good therapist can help deal with the aftereffects. The biological basis hasn't absolved me of all anorexia-related guilt, as I still carry plenty, but it definitely took a weight off my shoulders.

What is wrong with saying that some people got smacked with the shit stick when it comes to EDs and body image? Yes, our culture has a multitude of issues about weight and shape and appearance, but that's not exactly an eating disorder. In fact, it's astounding to think that more people don't have eating disorders when you look at our messed up world.

Am I being nitpicky? Perhaps. But this is also one of those things that never fails to get my panties in a knot. When it comes to eating disorders, I was always told psychotherapy, learn to love your body, figure out what's causing your eating disorder, and my, isn't the idea of size zero pretty effed up? Well, yes, it is, but all those years of looking at those issues did me almost no good. Why are people so hesitant to say "It's the biology, stupid!"* Saying something is based in biology is a far cry from turning us all into DNA code-reading automatons. But it's the way forward in determining better treatments for EDs.

*This is a quote adapted from Dr. Tomas Silber, who I interviewed for my Washington Post article. His direct quote was "It's the nutrition, stupid!" It didn't make it into the actual article, but it's a great quote. Those of you who have heard him speak will know of the hypnotic accent in which he expressed it, too.

Many mental health conditions begin to emerge in adolescence. Some conditions, such as depression and anxiety, are much more common in adolescent females than males. For me, OCD emerged before any full-blown depression, although I did get very depressed during my OCD episodes. As the OCD improved, so would the depression. It wasn't until college that I was walloped with out-and-out depression completely separate from OCD.

But a recent study looking at how adolescents process emotions and social interaction shows how these features change during adolescence and how they can make a person vulnerable to anxiety and depression. The study asked a group of healthy adolescents between the ages of 9 and 17 to view a series of photos and determine both who they would be most interested in speaking with and who would be most interested in speaking with them. While they were evaluating the last question (who would be most interested in speaking with them), the teens' brains were scanned using functional Magnetic Resonance Imaging (fMRI).

During this evaluation, the fMRI scans found that older female adolescents showed greater activation in areas that processed social emotion, such as "the nucleus accumbens (reward and motivation), hypothalamus (hormonal activation), hippocampus (social memory) and insula (visceral/subjective feelings)." Very little shift in activity was found in younger vs. older male adolescents.

Lead researcher Daniel Pine, of the National Institutes of Mental Health, said this:

"In females, absence of activation in areas associated with mood and anxiety disorders, such as the amygdala, suggests that emotional responses to peers may be driven more by a brain network related to approach than to one related to fear and withdrawal," said Pine. "This reflects resilience to psychosocial stress among healthy female adolescents during this vulnerable period."

And it was this last quote that really stuck with me and made me think not just in terms of EDs, but in terms of ED vulnerabilities. Although I don't have social anxiety disorder, I do have social anxiety. Back in February, I had to go to a large science conference for work, and part of my task involved networking. My supervisor also went, and this is a man who loves to schmooze. He thrives on this kind of social interaction. I would just as soon volunteer to have a new dentist fix my messed-up teeth sans Novocain. I made my appearance, did my duty, and then got the hell out of there. I retreated back to my hotel room and read a book. When I have to mingle, I feel very anxious, very fearful, and more than just a little threatened. I'm edgy. I can't relax. I'm constantly evaluating how people respond to me and what they must be thinking and the second I can leave, I usually do.

So when Pine said that emotional responses in people with anxiety and depression are related to "fear and withdrawal," I realized how true this was. I'm guessing that I'm not the only person with an ED to respond this way to social interactions. This isn't true for all social interactions, but for many of them, especially where I might be "evaluated" by my peers. And maybe a transfer of activity from the more functional emotional circuitry (the nucleus accumbens, the insula, etc) to the amygdala is part of what drives not only the emergence of depression and anxiety, but also when these illnesses occur.

How do you think this ad reflects our current attitudes about food? Would you be more likely to buy a Starbucks baked good because of the change?

Full disclosure: I'm probably going to go. I like the lattes at Starbucks, and it's probably good for me to try and work something different into my meal plan. Starbucks, like all of the other businesses out there, is trying to sell their product. I don't eat their baked goods enough to tell if the taste has changed any, so I won't try. It's a sales pitch, pure and simple. And if I get a free muffin out of the deal while being caffeinated, I'm okay with that.

Disregard the sensationalistic title and check out this wonderful essay called "I was a baby bulimic: A food critic comes to terms with his appetite," by Frank Bruni.

What struck me, besides the descriptions of bulimia by a male in the early 1980s, was how early in his life the overeating and purging started, and how it appeared to be an echo of many of his mother's conflicts with food.

What also struck me was his haunting descriptions of his illness and how closely it echoed my own frenzied episodes of binge eating and purging:

To be a successful bulimic, you need to have a firm handle on the bathrooms in your life: their proximity to where you’re eating; the amount of privacy they offer; whether — if they’re public bathrooms with more than one stall — you can hear the door swing open and the footfall of a visitor with enough advance notice to stop what you’re doing and keep from being found out.

You need to be conscious of time. There’s no such thing as bulimia on the fly; a span of at least 10 minutes in the bathroom is optimal, because you may need 5 of them to linger at the sink, splash cold water on your face and let the redness in it die down. You should always carry a toothbrush and toothpaste, integral to eliminating telltale signs of your transgression and to rejoining polite society without any offense to it. Bulimia is a logistical and tactical challenge as much as anything else. It demands planning.

It is interesting, of course, that Bruni wound up as a food critic. This essay was adapted from an upcoming autobiography titled "Born Round: The Secret History of a Full-Time Eater," which has now gone on my reading list.

Were you struck by anything in particular in the article? What could you relate to? What didn't you like? Share away in the comments section!

I first saw them in the refrigerated section of the grocery store today: Pillsbury Simply...Cookies. These were packages of the premade dough that you break apart and pop in the oven for quick homemade cookies. The package told me how "wholesome" they were and how they didn't have anything "artificial." This wasn't the first time I'd seen products recently that prominently advertised the food's simplicity and purity- Haagen-Dazs has a line of ice cream called "Five" because they only contain five ingredients.* Some types of Chex now have "gluten free" on the box. And on and on it goes.

But it wasn't until I saw the refrigerated cookie dough that I suddenly understood what I was seeing: a new trend. Of course, I am more than aware of the changing interests in how food is advertised and displayed, but the facts settled into place with a resounding clunk that this was going to be the Next Big Trend.

Spring 1996: I have to contribute items to a time capsule our social studies class is making, and I am in a group with three other girls. The items were supposed to represent our current culture and what it meant to us. I threw in an old banana clip** and a crusty tube of my mom's used mascara to indicate the emphasis on beauty and advertising. One of the other girls in my group brought in a box from some Snackwell's cookies, a popular brand of fat-free cookies in an emerald green box that were tremendously popular. They also tasted like the cardboard box they came in.

In the mid-90s, when I was in middle school and high school, low fat and fat free were the big buzzwords. Fat was bad and we needed to eliminate as much of it from our diets as possible. "Carbs" were not evil--in fact, no one really called them "carbs" much.

2001-2002: Fat is in and carbs are out. I remember this rather vividly, as the Atkins diet and other low-carb diet plans exploded in popularity just as I began recovery (well, the first round of recovery, anyway) from my eating disorder. I was plenty paranoid about food, and this was clearly not helping. But I eschewed fat far more than carbs, a pattern that has continued with each of my relapses. Fats went first, then proteins, then carbs, until I was living on lettuce, apples, and fat-free yogurt.

I was still far too phobic of fat to embrace the low-carb fad. But it is kind of hard to live in an environment saturated in this anti-carb propaganda and not absorb some of it. I began to speak "carb." Low-carb was fine, but it also had to be low-fat to satisfy my eating disorder. I learned about maltitol and sorbitol and how to count carbs should I be so inclined. Carbs were bad and we needed to eliminate as much of them from our diets as possible.

Today: Ah, yes. Simplicity. Purity. Wholesomeness. When I was younger, a "wholesome" food indicated more that this was what mom used to make you. It smacked more of nostalgia than morality. Within the past year, that has changed. Mott's for Tots apple juice has 40% less sugar- not because toddlers need to start counting their carbs, but that "added" sugars are unnatural and unnecessary; therefore, they're unhealthy. Stay away from "processed" foods, we are told. They're bad. We need to eliminate as much of them from our diets as possible. (Does this refrain seem at all familiar?) Over the past 15 years, we've moved from low fat to low carb to low ingredients as the new Key to Health.

The research still keeps coming out and constantly contradicting itself on how to live longer and healthier. In the nine months of my latest job, I've written about numerous compounds, foods, diets, vitamins, and/or minerals that hold the key to longevity and health. It's almost laughable because it's almost impossible to eat the amounts of those foods that produced such impressive results in lab rats.

The more I look around, the more I see EDs being triggered by "healthy eating," and less by a desire to lose weight and look better. My own ED started nearly a decade ago as I simply decided to cut out anything extra, which started as a switch from cream in my coffee to skim milk, and gradually turned into no snacks, then no fat, then no meat, then no meals, then no carbs, then no life and no freedom as I was corralled into the hospital. The more "extras" I cut out, the more extraneous everything seemed. I wonder how this pattern would translate in today's cultural lingo. If I got sick a year later, would I have been carb-o-phobic? If I had gotten sick six months ago, would I have cut out gluten and high fructose corn syrup?

I find these trends fascinating, both from a personal and an intellectual perspective. Is the increased attention being paid to orthorexia a result of an actual increase in the number of cases? Are more people becoming so obsessed with healthy eating that it ultimately becomes unhealthy? I see less and less overt dieting as the so-called gateway drug into eating disorders and more and more emphasis on healthy eating. This seems especially prominent in younger children with eating disorders, children who've been lectured about good foods and bad foods and who take the advice very literally. And then take it to the extreme. Don't get me wrong- a balanced diet is a very good thing, but when it becomes the focus of your life, that's a problem. When you become afraid of food and eating, that's a problem.

Tomorrow, I will look more in-depth at EDs in the name of health. In the name of my health, I'm going to bed because my train of thought is threatening to derail.


*I highly recommend the ginger flavor with grilled peaches or pineapple.
**Shut up. No really, just shut up. At least I didn't have mall bangs, okay?

Midlife eating disorders are being increasingly discussed both in the research literature, amongst clinicians, and in the popular press. Today, the New York Times ran a piece on the subject that raised many of the issues facing both sufferers and clinicians.

Most clinicians are in agreement that they are seeing more and more older women with eating disorders. I don't doubt this, although it should be said that we don't have hard data on whether that means more older women are suffering from eating disorders or that more older women are presenting for treatment. Several treatment centers (including the Cambridge ED Center and Renfrew) have programming specifically geared towards older women and addressing the issues specific to this age group. Which is a really good thing as many of the practical, day-to-day coping needs of adolescents and older women are probably going to be different.

A study comparing female inpatients aged 40+ and those aged 18-25 found that the older women showed

"significantly more diagnoses of anorexia nervosa, both subtypes, and fewer diagnoses of bulimia nervosa; greater ED severity but fewer body image issues and less body image distortion; greater emotional and behavioral overcontrol and symptom denial; more bipolar and major depressive disorders, suicidality, and sexual abuse histories; a trend toward greater misuse of calming/sedating substances; and fewer maturation issues."

The real question is: why the uptick? Why is it that more and more older women are being diagnosed with eating disorders? Could it be improved awareness, that starving, bingeing and purging aren't just "teen things"? That people are talking about it now? Could we be seeing an uptick from several decades ago and they have relapsed or never recovered?

For women in their 40s and over (which the Times article seemed to focus on) who seek treatment for an eating disorder, there are essentially three scenarios: the ED began in midlife, the woman has been chronically ill since adolescence/young adulthood, and the woman had previously recovered from an ED but has since relapsed. Research suggests that the first scenario is pretty uncommon, as one study found no evidence for midlife-onset EDs, though it did survey a small number of women. Other studies, however, have looked at women reporting midlife onset and found that women whose ED began after age 40 were more likely to be anorexic, and showed higher symptoms of denial.

Clinical anecdote, however, does seem to indicate that EDs in most midlife women began in adolescence and young adulthood. This goes along with the NEDA statistic that 86% of ED sufferers report illness onset prior to age 20. No one knows exactly why most EDs are triggered in adolescence, but changes in both hormones and social milieu seem to combine in a very bad way. Another factor is that, in modern, Western culture, almost no woman can pass the age of 20 without having gone on a diet, gotten a stomach bug, or otherwise eating poorly for a period of time. It's pretty darn hard. I had spoken with Harriet Brown during her search for women whose EDs began after 25, and she said she really couldn't find anyone who didn't at least have a sub-clinical disorder in adolescence.

I have much sympathy for the struggle to maintain recovery throughout a lifetime--it's something I'm currently striving for, if occasionally sucking at. Relapse happens. It's a grim reality, and midlife does bring on a host of new stresses that can cause a person to deliberately or inadvertently alter their eating habits.

I have just as much sympathy and empathy for those who have struggled constantly since adolescence. I have a little less sympathy for our long, gloried history of ineffective treatments, but I still wonder. The NYT article said that "the recent surge in older women at eating disorder clinics is not a reflection of failed treatment, experts say, but rather a signal that these disorders may crop up at any age."

It's true that EDs can crop up at any age, but the evidence doesn't support that this is true for the vast majority of midlife eating disorders. Most of them have roots in adolescence. And I can't help but wonder whether we would be seeing these numbers if there were effective treatments around 20 years ago.

It seems odd that I, of all people, would have to remind myself of this. I can (and frequently do) go on hour-long diatribes about the real nature of eating disorders to anyone and everyone in earshot. It makes perfect sense that EDs in other people are mental illnesses because I can see the distortions. I understand how a nibble of a Saltine can seem like "too much food" or how running a marathon can be "too little exercise." I understand it and yet I can see that it's not exactly reality.

My problem is that when I'm thinking these things, they seem perfectly rational. If I had vowed not to eat lunch, and then had a nibble of a cracker, I would have griped about how much I ate. Because a nibble is more than nothing, I clearly ate too much. It doesn't seem distorted in the least. It seems normal and (dare I say it?) sensible.

This is where I have problems. I have a hard time understanding that MY distorted thoughts are symptoms of a mental illness.

I can compare my ED experiences with those I've had with depression and anxiety. I became inured to the mild depression and anxiety that characterized my life, to the point where I kind of stopped noticing it. But when I get really depressed or really anxious, I don't feel like me. I've never been high-energy, but when I don't even want to get out of bed, that doesn't seem like me. It's not pleasant. Taking a shower and going back to bed might be the actual best I can manage, but it's still not pleasant. When I first developed OCD in high school, I thought I was going crazy. I knew that my touch probably wouldn't cause someone to die of AIDS but I was so terrified it might that I washed my hands and tried not to leave the house if I could avoid it. I didn't know that this was , in fact, a mental illness called obsessive-compulsive disorder, but I was able to recognize that something was wrong. More than that, I was aware that other people knew that this was very bizarre behavior.

The anorexia was very, very different. Basically night and day different. Eating less and exercising more seemed very normal and rational and common. I got compliments about how "good" I was being. No one complimented my freakishly clean hands (thanks, Clorox and Ajax!) even though they were freshly scrubbed. No one complimented my ability to stay in bed all day or scream and cry and throw things at the drop of a hat. I had excuses for all of my odd ED behaviors. I had excuses for all of my other odd behaviors, too, but with the ED, I actually believed my own bullshit.

I seriously began to believe that a sip of water would make me fat, that I just "didn't like eating," that I worked better on an empty stomach, that I simply adored the treadmill. There were definitely OCD moments when I believed I was a death- and disease-spreading machine, but these moments also passed. The AN delusions didn't.

Although I continued to lose weight, I wasn't able to see it in the mirror. The number on the scale was different, my clothes were looser, but I still looked the same. Ergo, I must actually look the same. I could tell when other people had cut their hair or lost weight, so the same must be true for me, right? So if my mom is telling me I'm way too thin, I'm emaciated, I'm dying, and I can't see it, it must not be true. I mean, I know what I look like...don't I? I will eat, I told myself, when I see that I'm too thin. Oddly, this is the same trap I fell into on this latest relapse- I couldn't see a difference in how I looked in the mirror despite my almost hourly trips to the bathroom scale.

When I am really depressed or really OCD/anxious, I can tell a difference between those states and my "normal" state. When I am into the ED, it's much harder. I feel almost more like myself--more intense, more driven, more on top of things, in a sense, I feel like a better version of myself--when I slide back into the AN. I can't point to a difference. My mom can. My boss probably could. But if I feel the same and look the same and am just freaking fine, dammit then how in the HELL could I be sick?

How? Because the illness I have, this pernicious eating disorder of mine, makes it very very hard to understand that I am sick. It's one of the symptoms of the illness, this inability to understand that you are ill. Laura Collins introduced me to the term anosognosia and I love that word. Can't pronounce it, but I love using it. The depression and OCD aren't anosognostic- I knew damn well that something was up even if I didn't have a name for it and didn't know that it was a mental illness that could be treated. Anorexia is very anosognostic and it will probably be my Achilles' heel. Not so much the illness itself, but the difficulties in recognizing it.

However untalented I may be at recognizing my own eating disorder even when the evidence is literally staring me in the face, it doesn't change the fact that EDs are mental illnesses. Including my own.

This is pretty much the $64,000 question in the ED world right now. It sounds kind of silly, but the question remains: what causes eating disorders? And the truth is, we don't know. We know what doesn't cause eating disorders, which includes skinny supermodels, bad parenting, and control issues. Do they contribute? Absolutely. But that's different from cause.

I've contemplated this issue for years and have blathered on and on about it in this blog. Yet these several paragraphs from the Around the Dinner Table forum in response to the question "Are EDs a control issue or a chemical imbalance?" by my dear friend IrishUp says it so succinctly and so right on, that I had to share. I could not improve upon this explanation no matter how hard I tried.

There are two distinct issues being conflated in this statement; A) What is the etiology, or natural history, of ED? and B) What is the internal experience of someone who has ED? The former deals with the brain, our most important organ. While our understanding of the brain is in its infancy, the BRAIN is without a doubt a physical, tangible object and we can describe brain structure and function with the languages of science and medicine. The latter has to do with the MIND, and that is a much more elusive thing. It's not tangible. It's mostly subjective. The nature of the mind is best described in the languages of philosophy and theology. And yet, our MIND is a function of the BRAIN. So we've developed the discipline of Psychology to bridge the gap between the tangible and intangible, the objective and subjective, science and philosophy and theology.

Eating disorders are the behavioral expressions of bio-chemical and neurological disorders of the brain. People who exhibit EDs were born with genetic traits that made them susceptible to developing the disorders if and when certain kinds of experiences occur in their environment. The genetics seem to express themselves as high levels of anxiety/social anxiety, OCD, perfectionism, conflict avoidance, and other related traits long before ED occurs. Common environmental triggers include conscious diets, strep infections, trauma or high stress, and incidental periods of insufficient caloric intake (like the kid undergoing a growth spurt, or the athlete whose training intensifies). It looks like, by and large, you need at least one ingredient from each the "nature" and the "nurture" columns to develop ED, and most people have more than one from each. Additionally, the developmental changes the brain undergoes during adolescence seems to play a key role, as the vast majority of EDs exhibit themselves at this stage. Since our social milieu also changes radically during this time, it is likely that the environmental triggers are stronger and/or more common at this stage.

Given the above, someone who has ED may well experience it as "a control issue". In fact, many ED sufferers report that they have (short lived) positive "control" thoughts when they don't eat, and negative "control" thoughts when they do. They also have a tendency to misinterpret other's actions as negative. And to think thier own bodies as larger and shaped differently from how they actually are. But these thoughts are actually a symptom of the disease. This is similar to how people with the classic symptoms of schizophrenia (hearing voices, believing outside forces are controlling their actions, & etc) are having the symptoms because of the neurological imbalances of that disease. In both cases, the person is having real experiences inside their mind that have little to do with the outside environment.

And different still from the physical causes of a disease, or the mental symptoms the disease may cause in our thinking or our understanding while we are sick, is the MEANING we attach to things we experience. Our experience of "what does this all mean?" is ultimately completely subjective, and completely dependent on our belief systems. If we beleive diseases are caused by voodoo curses, or cold unloving mothers, or imperfect faith, or a kind of test from a higher power, or none of the above, or all of the above, our understanding of the disease experience will be framed in terms of that belief.

So if someone states "I got ED because I needed more independence from my father", he's not "wrong", he's just talking about how ED fits into a larger meaning in his life. It also shows that that person is not being exposed to good clinicians who could tell him "Well, yes, you may have needed more independence. However, if you hadn't had the genetic makeup you do, the stress of the situation would not have triggered the development of ED."

Maybe, then, the answer to this cogent question--are EDs culturally-based or biologically-based--is BOTH.

Eating can be a pain- I know this very well. There's the I'm-writing-and-in-the-groove-and-don't-want-to-stop part that I think most writers know well. Then there's the I-have-an-ED-and-eating-SUCKS part that I think most people with eating disorders know well.

Thankfully, Tylenol has a cure for this.


That's right- who needs food when there's Tylenol? Because eating regular meals is, I dunno, so last year. If white is the new black, then is Tylenol the new food? I just need to ask my dietitian whether Tylenol is a grain or a vegetable...

Thanks (I think) to AS for posting this on Facebook.

Low blood pressure and orthostatic hypotension (a massive drop in your blood pressure when you go from sitting to standing) frequently accompany eating disorders, and I am no exception to this. A recent letter my dad received from our health insurance company provided such a fantastic cure that I had to share it here:

Step One: Get initial blood pressure reading.

Step Two: Read first paragraph.
"As a valued customer of [Health Insurance Company], we want to inform you of an exciting new contest. [Health Insurance Company] is committed to [this state's] health through our unique mission and believe in supporting healthy lifestyles. That's why we're proud to join forces with [local TV station] and The Parade Company for the Biggest Loser: [Big City] Edition.

Step Three: Repeatedly use four letter words and contemplate ripping letter into small shreds and igniting it on the grill when you make s'mores as part of your new anti-anorexia healthy lifestyle. Your face may turn red- this is a normal side effect of rising blood pressure and should be expected.

Step Four: Read second paragraph.
"The contest is simple. Anyone can enter at [website] by telling us their story and why they want to change their life through healthy weight loss. The deadline to enter is July 24. [Health Insurance Company] and [local TV station] will then select six contestants and track their progress towards a healthier future. One of the six contestants will go on to be named [state's] Biggest Loser, win some great prizes and ride on a float during America's Thanksgiving Parade."

Step Five: Feel face turn from red to crimson. Some veins may emerge, especially on the forehead and neck. Again, this is a normal side effect of increasing blood pressure.

Step Six: Read last paragraph.
"It's about eating well and exercising to lose weight, and [Health Insurance Company] is looking forward to helping people take the first step towards a healthier lifestyle. We encourage you to check out the contest details at [website] and spread the word to your employees."

Step Seven: Get another blood pressure reading. Higher? Congratulations! You've cured your low blood pressure. Now it's time for some matches.

Of course, I would like to send the health insurance company links to educated, informed opinions about the general ineffectiveness of dieting (yes, it's still a diet whether you call it a "lifestyle change" or a "contest") and of the health risks of the Biggest Loser in particular. I would love for them to read in detail about my own former workplace's Big Fat Loser contest and how I wound up quitting to save what little sanity remained after being inundated with posters tallying people's weight loss and signs saying "Nothing tastes as good as thin feels."

I would also really REALLY like this Health Insurance Company to know that there are many different aspects to a healthy lifestyle, such as, I don't know, not having an eating disorder. The jury is still out as to whether obesity significantly raises mortality risk; it's not for eating disorders. A girl with anorexia is ten times more likely to die in the following year than a classmate without anorexia. This is the same douchebag insurance company that refused to cover a DIME of my last residential treatment stay because they said it "wasn't medically necessary" or that the facility I went to wasn't in-network. It depends on which denial letter you read, but the results are still the same. Never mind, of course, that I was in and out of the ER several times a week with hypokalemia, was in ketosis, had irregular EKGs, and was underweight and still dropping rapidly.

Committed to healthy lifestyles, my anorexic ass. They're committed to paying out as little money as they possibly can, and they think that by supporting crash dieting, they will save money in the long run and look good in the short run.

Have I cured your low blood pressure, too? Writing this sure cured mine!

I hesitated a bit to blog on this for a variety of reasons, the major ones being a) the death of Michael Jackson has been a wee bit over-publicized and b) I don't like gossip and accusations. However, the more I thought about it, the more I realized that what I had to say was less about the King of Pop and more about people with eating disorders in general.

To be honest, I don't know whether Michael Jackson had an eating disorder, or body dysmorphia, or addiction problems. Perhaps the final autopsy will have some of those answers, and perhaps we may never fully know what happened. But a recent editorial (working on the assumption that all three were true) said that the medical system had failed Michael Jackson.

Most people with eating disorders don't have the kind of fame and money that MJ had, but perhaps family and friends and medical professionals still fell sway to the same assumptions that MJ's doctors might have. MJ was dancing and rehearsing and performing- he couldn't be that bad. I had straight As and a research position and scholarships- I couldn't be that bad. This is, maybe, fame and fortune of a type. People held my academic and musical accomplishments in awe. Though I would be the first to dispute the accuracy of that, I will also admit that these achievements gave a lot of people plenty of reasons to overlook the oh-so-minor detail that I wasn't eating.

Writes Mark Rubi in his editorial:

Time and again, these pillars of American society reacted to a starving patient with prescription drugs.

I'm not anti-prescription drugs- just look in my medical cabinet and you'll see quite an array. And any toxicologist will tell you that the dose tends to kill you, much less than the drug itself. That being said, maybe what MJ needed was someone to say screw the fame, you need to eat. The medication he may have been most in need of was food. But people may have been afraid to say something because of the fame, afraid of what that might mean. Maybe some of my professors and supervisors were afraid of what my wasted frame might mean. Maybe they just didn't know. Or maybe they thought I could see the problem and would ultimately do something about it.

And that is the biggest failure of the medical system when it comes to eating disorders: that we expect people to want to get better and to do everything possible to recover. But in the acute stages of anorexia especially, the sufferer is almost unable to perceive his/her condition accurately. Either I truly didn't think I had a problem or I didn't think starving myself was problematic, or it wasn't that serious. I wasn't, like, emaciated or anything (except, oops, I was). If a high school valedictorian got cancer, we wouldn't wait for her to will herself well. But most medical professionals were quite content to do that when I developed anorexia.

Did the medical system fail MJ? Perhaps. But sadly, perhaps no worse than many other people with eating disorders have been failed.

In March of this year, I saw a new PCP for the first time in a while. I used the student health clinic while in grad school or have just continued seeing the same specialists (ie, psychiatrists). I told the doctor flat-out that I have epilepsy and osteopenia, that I struggled with anxiety and depression, and was in recovery from anorexia. We then did a standard family health history, in which I was asked about heart disease, cancer, and diabetes in my close relatives.

The PCP didn't ask about mental health issues in any family members, even though these were the main issues I was currently having (the epilepsy and osteopenia being, of course, secondary to anorexia). Even though, more importantly, that all three conditions (anxiety, mood, and eating disorders) have a substantial genetic component, and that a person is probably going to present to their PCP with one of these issues first, especially since I need a referral to see a specialist.

Recent research titled "Predictive Value of Family History on Severity of Illness" from the Archives of General Psychiatry examined how a family history of anxiety, depression, alcohol dependence, and drug dependence was related to age at onset, recurrence, impairment, and use of health services. The researchers found that family history was significantly associated with recurrence, impairment, and service use, though not age of onset, in each of these four disorders.

The authors conclude that "family history is useful for determining patients' clinical prognosis and for selecting cases for genetic studies."

So why have general clinicians shied away from asking directly about family history of brain diseases? They ask about Alzheimer's or brain cancer, but not depression and anxiety. Terrie Moffitt, one of the authors of the paper, gave two reasons in a recent press release. The first was the stigma attached to mental illness: even if doctors asked, would the patients respond honestly? Or would relatives even know about anxiety and depression in a close family member?

The second reason was related to the DSM itself, the Diagnostic and Statistical Manual of Mental Disorders, the so-called "Bible of Psychiatry," makes no mention of family history. At all. Whether this changes or not in the upcoming Fifth Edition has yet to be determined, but I think it's about time we simply started asking about mental health issues. Many risk factors are well-known, even if not well-understood. Even just by identifying those at highest risk, we can more quickly identify or even prevent some illnesses.

I saw this link on Tiptoe's blog and let me just say: I love it, I love it, I love it!

This should be required reading for any health journalist who uses the letters "BMI" in a story--which is basically all of them.

In its entirety (because it's just that good) is the "Top 10 Reasons Why the BMI is Bogus":

1. The person who dreamed up the BMI said explicitly that it could not and should not be used to indicate the level of fatness in an individual.

The BMI was introduced in the early 19th century by a Belgian named Lambert Adolphe Jacques Quetelet. He was a mathematician, not a physician. He produced the formula to give a quick and easy way to measure the degree of obesity of the general population to assist the government in allocating resources. In other words, it is a 200-year-old hack.

2. It is scientifically nonsensical.

There is no physiological reason to square a person's height (Quetelet had to square the height to get a formula that matched the overall data. If you can't fix the data, rig the formula!). Moreover, it ignores waist size, which is a clear indicator of obesity level.

3. It is physiologically wrong.

It makes no allowance for the relative proportions of bone, muscle and fat in the body. But bone is denser than muscle and twice as dense as fat, so a person with strong bones, good muscle tone and low fat will have a high BMI. Thus, athletes and fit, health-conscious movie stars who work out a lot tend to find themselves classified as overweight or even obese.

4. It gets the logic wrong.

The CDC says on its Web site that "the BMI is a reliable indicator of body fatness for people." This is a fundamental error of logic. For example, if I tell you my birthday present is a bicycle, you can conclude that my present has wheels. That's correct logic. But it does not work the other way round. If I tell you my birthday present has wheels, you cannot conclude I got a bicycle. I could have received a car. Because of how Quetelet came up with it, if a person is fat or obese, he or she will have a high BMI. But as with my birthday present, it doesn't work the other way round. A high BMI does not mean an individual is even overweight, let alone obese. It could mean the person is fit and healthy, with very little fat.

5. It's bad statistics.

Because the majority of people today (and in Quetelet's time) lead fairly sedentary lives and are not particularly active, the formula tacitly assumes low muscle mass and high relative fat content. It applies moderately well when applied to such people because it was formulated by focusing on them. But it gives exactly the wrong answer for a large and significant section of the population, namely the lean, fit and healthy. Quetelet is also the person who came up with the idea of "the average man." That's a useful concept, but if you try to apply it to any one person, you come up with the absurdity of a person with 2.4 children. Averages measure entire populations and often don't apply to individuals.

6. It is lying by scientific authority.

Because the BMI is a single number between 1 and 100 (like a percentage) that comes from a mathematical formula, it carries an air of scientific authority. But it is mathematical snake oil.

7. It suggests there are distinct categories of underweight, ideal, overweight and obese, with sharp boundaries that hinge on a decimal place.

That's total nonsense.

8. It makes the more cynical members of society suspect that the medical insurance industry lobbies for the continued use of the BMI to keep their profits high.

Insurance companies sometimes charge higher premiums for people with a high BMI. Among such people are all those fit individuals with good bone and muscle and little fat, who will live long, healthy lives during which they will have to pay those greater premiums.

9. Continued reliance on the BMI means doctors don't feel the need to use one of the more scientifically sound methods that are available to measure obesity levels.

Those alternatives cost a little bit more, but they give far more reliable results.

10. It embarrasses the U.S.

It is embarrassing for one of the most scientifically, technologically and medicinally advanced nations in the world to base advice on how to prevent one of the leading causes of poor health and premature death (obesity) on a 200-year-old numerical hack developed by a mathematician who was not even an expert in what little was known about the human body back then.

Note: if you click on the story link, you can listen to the NPR segment as well.

I am, yet again, brutally exhausted. I don't know where it's coming from (well, okay, I guess I kinda do), and it's annoying me to the nth degree. My body has taken quite a beating over this past decade, and I think the wear and tear is beginning to show. I'm not bouncing back like I used to. I often feel like I could sleep all day--not in the depressed asleep-is-MUCH-better-than-awake kind of way, but in the my-veins-are-seriously-filled-with-lead kind of way.

Maybe it's a psychosomatic thing, these feelings of heaviness. Could there be a relationship between exhaustion and feeling like I am detectable on radar? Or between tiring out at the slightest exertion and those feelings that I am generating a massive gravitational field? I don't know. I feel like I have gained back all of the weight I lost during this last relapse and then some, despite evidence to the contrary. I know I'm gaining weight, but I have nary a clue how much that is. My "skinny jeans" still fit, although they're a bit tighter. I know I couldn't get them on at my usual weight, so there's that.

But when I look in the mirror, it's all over with. I look in the mirror and I see someone chubby. Overweight. Someone who could use a three-hour-long kickboxing class to get her lazy ass in gear. Someone in the "before" weight loss pictures. It's what I see. It's reality- my reality, anyway. The real reality is that I have no freaking clue what size I am.

Here's a little secret that I'm not proud of: when I pass other women in the store or on the street, I want to try on their pants. Not because I care what size they are, but because I want to know what size I am. Does this make any sense? Some people, I know that I'm probably bigger (i.e., the kindergartner in pigtails) or probably smaller. Many times, I think I'm bigger than the "average" person I see walking down the street. Although I'm probably skewed in guessing other people's sizes, I know I'm a bit more accurate than when I look at my own reflection and just go "Ewwwwww!" If I can figure out what size I am compared to other people, maybe then I can get an idea of what size I actually am. Hence my undying need to try on other people's pants. I really have no idea. None. Whatsoever.

(EDITED: see Laura's great post on body schema and body image here)

This is understandably hard for other people to understand. I do okay with determining my height in relation to other people, though being of average height, that's not too difficult. But the rest of my body image is pretty much this nebulous haze of (what I perceive as) excess adipose tissue. I don't know that I would have understood this phenomenon if I hadn't lived it. I also realize that being afraid of food is something that's hard to understand unless you've been there. My mom joked once, a long time ago, that she could never be anorexic because she likes eating too much. But an anorexic is obsessed with food, in love with it, even. Just so long as she doesn't have to actually eat it.

I still don't like eating and I'm quite frankly tired of it. I'm sick of facing food six times each day, an endless parade of meal, snack, meal, snack, meal, snack. I cringe at the knowledge that I am getting bigger and fatter with every bite I take and that this is the only way out. I then get wondering whether out is better than in and the so-called Point of it All. I hate that the happy little routine I had going for myself has been rudely interrupted while everyone else's life gets to go on as usual.

I get that I have an eating disorder. I get that basically not eating and exercising compulsively for two months (two weeks, two days) is a Very Bad Idea. I knew that at the time, I just didn't care enough to stop. I get that what I see in the mirror and what other people see when they look at me are two completely different things. I understand this and I don't. I want these realities to match up.

Maybe this goes along with my ability to "see things differently"?

To everyone who says that weight loss is the answer to "overweight" and "obesity," I recommend reading this research article:

Comparing the health burden of eating disordered behaviors and overweight in women

The researchers interviewed a community-based sample of Australian women to determine the effects of overweight and ED behaviors on quality of life, psychosocial functioning, and physical well-being. The researchers found that overweight led to increased physical problems but relatively little impairment in normal day-to-day functioning. However, those women with eating disorders showed some increases in physical problems but a large impairment in psychosocial functioning and quality of life.

Conclude the researchers:

Further, impairment in psychosocial functioning associated with eating-disordered behavior was greater than impairment in physical health functioning associated with overweight, and impairment in physical health functioning associated with eating-disordered behavior was greater than impairment in psychosocial functioning associated with overweight. Overweight and eating-disordered behavior were associated with similarly elevated rates of primary care consultations during the past 6 months and of lifetime treatment from a health professional for an eating or weight problem.

Conclusions: In young adult women, the health burden of eating-disordered behavior may be more substantial than previously recognized. Better information concerning the spectrum of disordered eating that exists at the population level needs to be made available. Eating-disordered behavior warrants greater attention when considering the public health burden of obesity and in developing programs to reduce this burden.

Even if overweight and obesity are associated with health problems, we don't know how to reliably get people to lose weight and keep it off. Furthermore, many extreme diet measures can very well be the beginnings of an eating disorder--or at least really unhealthy. And if "obesity prevention" results in higher rates of eating disorders, the "cure" may very well prove to be worse than the "disease."