...for dieting, that is.

Most of us learned about the four seasons when we were younger, about spring, summer, autumn, and winter. Considering I grew up in Michigan, there were really two seasons: winter and three months of bad sledding. Now that I'm an adult, and living south of the Mason-Dixon line, there are many more seasons than I experienced as a kid in Michigan. To everything, there is a season, and to every season, there is a reason to diet.

Winter: It's your New Year's Resolution to have a Totally New You by developing those Buns of Steel. (I'd settle for buns of cinnamon, but then, that's me.)

Spring: It's going to be Bathing Suit Season soon, and you had better fit in that Itsy Bitsy Teeny Weeny Yellow Polka Dot Bikini you wore when you were three. So it looks like a thong. So what. I hear they're popular these days!

Summer: It's Bathing Suit Season and EVERYONE IS GOING TO SEE YOUR FAT ASS IN THAT BATHING SUIT SO YOU BETTER STOP EATING, YOU FAT PIG.

Autumn: Do NOT gain weight over the holidays, and here's how (you can start by not celebrating the holidays at all).

Ta-da! The year in dieting. Winter season is the worst, and right now about all I seem to hear commercials for are end-of-the-year car sales, cigarette cessation aids, and diet products. It makes me almost pity the poor guy who's trying to hawk replacement windows so that people can get their tax credit.

Almost.

Jeopardy!, the game show for grandmas and geeks like me, Jeopardy! for crap's sake, is now sponsored in part by a colon cleanser (aka, an overpriced laxative that just really dehydrates you and then you take a drink of water and bloat from here to Timbuktu. Trust me, kids, don't try this at home).

The Diet Survivor's Group blog has a list of alternate dieting headlines for magazines to use. Start with these examples and then you might just have a fun game to play in the checkout aisle at the grocery store.

Self Magazine:
The Food Lover's Diet - 31 Tiny Tricks That Peel Off Major Pounds
My Edit:
The Food Lover's Diet - Eat What You Love and Savor Every Bite

Allure:
The Easiest Diet Ever: Drop 600 Calories A Day Without Feeling Hungry
My Edit:
The Easiest Diet Ever: Eat When You Are Hungry And You'll Never Feel Hungry (duh!)

Shape:
How We Lost 477 Pounds Together: 6 Women Share The Diet Secrets That Worked For Them
My Edit:
How We Raised Our Consciousness Together : 6 Women Share Their Wisdom And Empower Each Other

Fitness:
Your Best Body Ever
My Edit:
Your Body Is The Best Body Ever

O Magazine:
How To Get What You Really Want This Year: Weight Loss That Sticks - Dr. Oz's Simple Secrets For Keeping The Pounds Off
My Edit:
Keep Working Toward Getting What You Really Want This Year: Body Satisfaction That Sticks - Dr. Oz's Simple Secret Is That There Is No Secret For Keeping The Pounds Off.

Seventeen
Total Body Confidence - Great Abs, Butt & Legs By New Year's
My Edit: (I got kind of hopeful with the first part...)
Total Body Confidence - Enjoy Your Body In Its Fullness All Year Long

Us:
The Biggest Loser - How I Did It!
My Edit:
The Biggest Winner - How I Did It! Tips To Love, Respect, And Honor Yourself
Woman's World:Break Through Ohio State University BELLY FAT CURE! Discovery - Two Spoonfuls Of This Oil Will Block Fat Storage! Melt 5" Of Belly Fat - No Diet Required!
My Edit:
Woman's World Announces Bankruptcy As Readers Boycott Magazine Due To Outrageous Claims!
I guess this game beats hibernating...

My remaining grandmother (my mom's mom) is pretty kooky. She's actually barmy as hell, which sounds really mean but if you ever meet her, you'll know exactly what I mean. My grandmother isn't the family black sheep--we have several others who are doing rather well at playing that role--but she is kind of the polka dot one. For instance, one of my favorite recent Grandma stories:

"When I die," she told me, "I'm leaving all of my jewelry to you. And it's really good quality." {Pause} "I got most of it on QVC!"

Thanks, Grandma!

Although my grandmothers mental state is loopy and frustrating and only amplified by the fact that she's not exactly the sharpest pencil in the box (she thought the scooter wheelchair we told her to get over the summer was one of the kick scooters that kids used and refused to get one for the longest time), it's not her mental state that frightens me. Frustrates me, yes, but I don't particularly worry about turning out like her. It is, however, her physical state that is most frightening to me.

She's going to be 82 next month, and her spine has essentially crumbled. She has osteoporosis, yes, as it runs in the family, and she also broke her back in a car accident about 25 years ago. Currently, she can't stand up straight. She went in for a surgery evaluation, and the doctor said that there's nothing there to be fixed, as the bones have deteriorated to badly. She's on massive doses of narcotics for the pain (which only adds to the loopy behavior!), and she struggles to do the most basic of tasks.

Her knees gave out a number of years ago after she found herself compulsively walking for several hours each day to deal with the anxiety of my black sheep relatives. It was slightly different than my periods of compulsive exercise in that it wasn't linked to an eating disorder and a fear of gaining weight if she didn't walk, but her fear was that she would be overwhelmed by anxiety if she didn't walk.*

My bones are not in the greatest shape because of the eating disorder. My spine is the worst, and my hip usually walks the line between osteopenia and osteoporosis. I've probably lost about a half inch in height and a full shoe size due to bone deterioration. And I see my grandmother struggle to do the most basic of tasks, be in constant pain, and to be honest, it scares the living daylights out of me. My bones are almost certainly in worse shape than hers were at nearly 30, so I can only imagine what might happen down the road.

And this is one of the fears that helps keep me on the straight and narrow, ED-wise. These fears were never enough to scare me into recovery, nor is fear a particularly good motivator of lasting behavioral change. But fear is helping me stay changed. I still find myself shrugging off bits and pieces of the eating disorder thinking that continue to crop up. For so many years, the thoughts were all I knew that it's hard to feel alarmed when I have them. But seeing my grandmother's deterioration is much more potent than the ED thinking.

*My aunt (my mom's sister and other daughter of my grandmother) also "must" exercise each morning. Although her routine isn't excessive, it probably is compulsive, and I would bet that if she were closer to my age, she would have a full-blown eating disorder.

It's that time of week again- your Sunday Smorgasbord! As there has been actual research published this week, I am going to focus more on research-y ED stuff.

Nutrition knowledge in young women with eating disorders in Australia and Singapore

The results of this study were pretty self-explanatory, so I'll let the abstract do the talking.

Women with EDs had greater knowledge than controls, but the magnitude of the difference was small. Greater acculturation to Western culture was associated with greater knowledge. CONCLUSIONS: The difference in nutrition knowledge between women with and without EDs is unlikely to be of clinical importance. The findings may reflect today's ubiquitous availability of nutrition information.

In ED treatment, nutrition education is considered an important part of treatment. And the dietician that I saw for years was one of the most helpful people on my team. I adore this woman and keep in contact with her even though I'm no longer formally her patient. So I'll be the first to admit that a dietician can be an important part of a treatment team. But my RD didn't so much provide nutrition education (such as here is what 2 oz. of meat looks like, this is a glass of milk, here are how many calories/fat grams/etc you need) as much as she first designed a meal plan to help me gain back to a healthy weight and worked with me on the best ways to split up meals and snacks, and then she helped me work through my fear of food. This study confirms that it's not that people with EDs are less knowledgeable about food--my mom told me I could write the book on nutrition, but I just need to read the darn thing!--but that their fears get in the way of eating properly. And an RD can be helpful in working with specific food-related fears.

One-third of psychiatric inpatients who self-harm also have eating disorders

This study was from the French journal Encephale, and so I once again will have to restrict myself to the abstract. However, the results are interesting. The psychiatrists did a survey of 30 psychiatric inpatients who were hospitalized and had self-harming behaviors, although they didn't mention whether self-harm was the reason they were admitted. Among these 30 inpatients (admittedly, a very small sample), they found that 33% had an eating disorder, and among these 50% had the restrictive subtype of anorexia.

Needless to say, self-harm and EDs seem to co-exist rather strongly, although it still remains unclear why there is an overlap in symptoms, and how related these two illnesses are.

Symptoms of psychosis in anorexia and bulimia nervosa

Many of the symptoms of an eating disorder can seem to be almost psychotic in nature. I for once was convinced the entire universe was conspiring to make me fat, and right when I was first diagnosed I refused to take any medication because I thought it was some grand scheme cooked up by my treatment team to get me fat. There were others: at one point, I thought water would make me gain weight, or that I could see my stomach getting larger before my eyes. Clearly, these were not based on reality, and starvation psychosis has been reported over the years in both prisoners of war and in obese patients put on starvation diets. From a study, titled "Follow-Up of Patients Starved for Obesity":

"[Patient No. 15] developed a paranoid psychosis during starvation, left the hospital against advice and since discharge his only communication has been an indignant, accusatory letter to the chief metabolic investigator."

(Can't say I blame Patient No. 15!)

I couldn't find much data on the overlap between schizophrenia and EDs, but it appears that most psychosis seen in people with acute eating disorders is due to malnutrition rather than a separate illness. From the study's abstract:

Compared with controls, the patients with anorexia nervosa were more likely to endorse the item "Never feeling close to another person"; the patients with bulimia nervosa were more likely to endorse the item "Feeling others are to blame for your troubles". Both groups of patients were more likely than controls to endorse the item "Idea that something is wrong with your mind". The students who were identified by the EAT and the BITE as being "at risk" for eating disorders were more likely to assign their body a causative role in their problems. Symptoms of psychosis can be observed in patients with eating disorders, but these could be better explained within the psychopathology of the disorders rather than by assuming a link with schizophrenia.

Prevalence and Factors Related to Substance Use among Adolescents with Eating Disorders

This study wasn't particularly fascinating or earth-shattering, but it did make the recommendation that all people with eating disorders should be formally screened for substance abuse problems.

And thus ends your smorgasbord for this week. I'll be back next week with more delightful little morsels for you to sample!

Despite being the end of December, today was unusually balmy (near 60F!). As such, I spotted an unusual number of runners out today. Many of these runners were just using one of the many trails available, or the bike lanes, or whatever. And as I drove past, I realised with a jolt that I was jealous of them. After all, they were burning calories while I was sitting in my car like a Lazy Fat American™. Even more than that, they were getting the wonderful endorphin high that I so often find myself craving. The runners and other "exercisers" seemed somehow so much more virtuous than me, that if the Candid Camera crew snuck up on them, they would get a high-five and a pat on the back, while health officials would only shake their heads at me.

(Have I ever mentioned that those Ambush Makeover deals on talk shows scare the living crap out of me? I am terrified that I am going to be stopped and someone is going to play Tim Gunn or "What Not to Wear" and tell me how horrible I dress. I am also abnormally paranoid when I'm in a public eating setting that some journalist is going to pop up like a jack-in-the-box and ask me if I know how many calories I'm currently eating, and then I will be seen on national TV with my dinner plate. Scenario B says that I will be seen on national TV kicking the guy's ass, followed by a Central Booking mug shot.)

I am currently allowed moderate exercise by my treatment team. Usually, I ride my bike several times per week and just enjoy myself. This is good. But I still feel incredibly guilty when I compare my psycho exercise regimen when I was living in DC to what I do now. I'm aware, on a cognitive level, anyway, that I was exercising way the hell too much, and it led to my relapse and all sorts of other bad things. Yet the guilt remains. I have tremendous anxiety about the wide variety of "exercise recommendations" given out by almost every health agency and advocacy group around the world, and how almost none of them agree. The numbers that seem to stick in my head are the highest number of minutes people are "supposed to" exercise each week. I do less than that, and so I worry what people must think of me when they hear I only exercise X times each week.

This is where The Therapist will usually stop you in your long, rambling monologue about how disgusting you are for not following the guidelines and ask you to come up with a powerful! positive! and affirming! statement about exercise and your eating disorder, such as "Today, I am Choosing Health," or "Every step I run is one step further from recovery." Which may very well be true, but I've always wanted to grab The Therapist by the shoulders and scream, "Who the f*ck are you kidding? I want to be out exercising right now!" And so it goes.

With all of your help (and I really couldn't have done it without you all!) I managed to get 9th place!!! in the 2nd annual People's Health Blogger Awards. Your votes also meant that I've been named the top Eating Disorders blogger for the second year in a row! My prizes include the nifty badges below:

Carrie Arnold

Eating Disorders Community

This week's Science Times in the NY Times featured a profile of psychologist Russel Hurlburt, who studies the inner experiences of people with mental illness. For many mental illnesses, the DSM spells out the symptoms that people have, but it doesn't really describe what it's like to have a particular illness. For that matter, knowing what cancer is and how to treat it isn't the same as knowing what it's like to have cancer and undergo treatment.

From the profile:

After hundreds of introspective interviews, Dr. Hurlburt still hesitates to generalize from his findings. But he has observed that the basic makeup of inner life varies substantially from person to person.

“My research says that there are a lot of people who don’t ever naturally form images, and then there are other people who form very florid, high-fidelity, Technicolor, moving images,” he said. Some people have inner lives dominated by speech, body sensations or emotions, he said, and yet others by “unsymbolized thinking” that can take the form of wordless questions like, “Should I have the ham sandwich or the roast beef?”

In a 2006 book, “Exploring Inner Experience,” Dr. Hurlburt suggests that these differences may be linked to personality and behavior. Inner speakers tend to be more confident, for example, and those who think in pictures tend to have trouble empathizing with others.

Differences in thinking style may also help explain some aspects of mental illness. In studies conducted with Sharon Jones-Forrester and Stephanie Doucette, Dr. Hurlburt found that bulimic women experienced a clutter of simultaneous thoughts that could often be cleared by purging.

Which makes sense to me. If you want to consider exercise a form of purging, I can definitely attest that purging slowed my racing thoughts and really calmed me down. Purging (granted, I have purged in more ways than exercise, but that was my most common and recent form of purging) was almost like dissociating. It's not exactly the same, and I wasn't dissociated while exercising/purging, BUT my brain also felt very separate from my body, almost like it was observing me running or pedaling or whatever.

I tried looking for any publications by Jones-Forrester and Doucette, but it appears that their work on the inner experiences of people with bulimia consisted mainly of doctoral dissertations under Dr. Hulburt. I found the abstract of Jones-Forrester's thesis, which reads:

Inner experience is of crucial importance in bulimia---clearly something experiential leads individuals to binge or purge. We used Descriptive Experience Sampling (DES) to examine the inner experience of bulimia in 5 participants, replicating Doucette (1992). Our participants' inner experiences were largely consistent with Doucette's but were substantially different from what is assumed by the non-DES literature: our bulimic participants had a consistent fragmentation of attention, hypersensitivity to the sensory aspects of experience, affect that is poorly differentiated and often confused with cognition, and a striking lack of cognition overall. These results suggest that DES can be a powerful tool to challenge the assumptions of the extant literature and to expand our understanding of bulimia.

Hurlburt cited the research of Doucette in his 1993 book "Sampling Inner Experience in Disturbed Affect," sections of which are available on Google Books. From this book:

Multiple Inner Experience is the simultaneous occurrence of a few or many separable, identifiable inner happenings, all taking place in inner experience at the moment of the beep. One of the most striking findings in our study of bulimics was that Multiple Inner Experience was a frequent characteristic of the inner experience of all our bulimia subjects. This is in sharp contrast to the findings of other researchers sampling non-bulimic populations, where the phenomenon of Multiple Inner Experience occurs occasionally but is rare (an exception is the example of Borderline Personality described in Chapter 14). In contrast with other subjects, however, Multiple Inner Experience was the rule, rather than the exception, among our bulimics: the frequency ranged from 40% to 100% within our individual bulimic subjects.

It was also the case that, for our bulimic subjects, the presence of Multiple Inner Experience was directly related to the degree of bulimic symptoms: the more actively bulimic the subject, the more multiple the inner experience. This was true both when considering the percentage of a subject's samples containing Multiple Inner Experience (the more actively bulimic, the higher the percentage) and also when considering the multiplicity of experience at any given sample (the more actively bulimic, the higher the number of separate experiences which were reported to be simultaneously occurring at any one beep).

{snip}

A third characteristic experienced by our bulimic subjects was the relatively blurred distinction between thought and feeling. Our bulimics frequently seemed to "think their feelings" or "feel their thoughts." By contrast, most normal subjects in our sampling were very clear about the distinction between thinking and feeling. Even on those occasions where they have difficulty providing the experiential details of a thought...most non-bulimic subjects have no doubt that the thought is a "cognitive" or "mental" experience; the same is true for affective experiences. An exception is our anxious subjects (see Chapter 13), who also at times had difficulty distinguishing between affect and cognition.

{snip}

The intensity of the urge to purge seemed more related to the heightened multiplicity of thoughts and feelings than to the content of food or weight.

(Emphasis mine)

I find this work of Hurlburt, Doucette, and Jones-Forrester to be absolutely fascinating, and I really wish there was more peer-reviewed research on the subject. Still, this work may help fill in the gaps between what we know about bulimia and how BN is experienced.

Although a paper from the research journal Nature was typically covered as yet another reason why fat people are fat, it actually has quite a bit of application to eating disorders. The paper, titled "Regulation of adaptive behaviour during fasting by hypothalamic Foxa2," looked at the relationship between hormones released during short periods of fasting and activity levels in mice.

I'll let a press release from Science Daily do some of the explaining for me:

The key switch player in this is a transcription factor called Foxa2. Transcription factors are proteins that make sure other genes are activated and converted into proteins. Foxa2 is found in the liver, where it influences fatburning, but also in two important neuron populations in the hypothalamus -- the region of the brain that controls the daily rhythm, sleep, intake of food and sexual behavior. The control element for Foxa2 activity is insulin, in both the liver and the hypothalamus.

If a person or animal ingests food, the beta cells in the pancreas release insulin, which blocks Foxa2. When fasting, there is a lack of insulin and Foxa2 is active. In the brain, the scientists have discovered, Foxa2 assists the formation of two proteins: MCH and orexin. These two brain messenger substances trigger different behavior patterns: the intake of food and spontaneous movement. If mammals are hungry, they are more alert and physically active. In short, they hunt and look for food. "If you watch a cat or a dog before feeding it, you can see this very clearly," says [lead researcher Markus] Stoffel.

The researchers discovered a disorder in obese mice: in these animals, Foxa2 is permanently active, regardless of whether the animals are fasting or full. This explains a well-known but until now unaccountable phenomenon: the lack of movement in obese people and animals.

To prove this, the researchers used a genetic trick to breed mice, in the brains of which Foxa2 is always active, regardless of whether they have just eaten or are fasting. These mice produce more MCH and orexin and move five times more than normal animals, in which insulin deactivates Foxa2 after eating or which are obese. The genetically modified mice lose fatty tissue and form larger muscles. Their sugar and fat metabolism works flat out and their blood values are considerably improved.

To simplify even further: hungry mice were more active.

Starving people with eating disorders tend to be more active as well. Excessive exercise is very common in people with eating disorders, and is associated with higher levels of anxiety and somatization (that is, physical ailments brought about by psychological stress). Although most people with EDs cite exercise as a way to lose weight or otherwise self-regulate, it may be driven by other biological factors as well.

So why would biology be prodding an organism to get moving when common sense would indicate that they should be resting and conserving every last calorie? One explanation is that a more active animal will move further afield to seek out food. Sitting around won't get you fed; seeking out food just might. Short-term, this is a costly strategy, as there is no guarantee there will be food anywhere else, either. But long-term, you'll definitely starve if you stay in your den where there's no food, so it makes sense.

Of course, for people with eating disorders, the problem isn't the lack of food as much as it is an inability to eat the food that's already there. The body, however, doesn't really care why you're starving. It just knows you are and prods you to go get soemthing to eat, dammit!

Despite the almost complete lack of new ED research published this week, I have assembled a few scrumptuous morsels for this week's Smorgasbord. It even includes video segments, so sit back, make sure your speakers are on, and enjoy.

Fake Sugar May Alter How the Body Handles Real Sugar

A new study in the journal Diabetes Care, titled "Ingestion of Diet Soda Before a Glucose Load Augments Glucagon-Like Peptide-1 Secretion." Translated from medical-ese, Reuters summarized the findings as follows:

Combining artificial sweeteners with the real thing boosts the stomach's secretion of a hormone that makes people feel full and helps control blood sugar, new research shows.

It's unknown whether this means anything for people's health, but "in light of the large number of individuals using artificial sweeteners on a daily basis, it appears essential to carefully investigate the associated effects on metabolism and weight," conclude Dr. Rebecca J. Brown and colleagues from the National Institute of Diabetes and Digestive and Kidney Diseases.

Because artificial sweeteners are virtually carbohydrate-free, they have been thought not to have any effect on how the body handles glucose (sugar), the researchers explain.

But there's some evidence that artificial sweeteners may trigger secretion of glucagon-like peptide-1 (GLP-1). GLP-1 is released from the digestive tract when a person eats as a "fullness" signal to the brain, curbing appetite and calorie intake.

Interesting, I think, as I sip my Diet Coke. What effect, if any, that artificial sweeteners have in promoting fullness with minimal calories in people with eating disorders, isn't known. I usually went after any calorie-free fluid that also had caffeine (for energy). This meant I drank a lot of diet soda and black coffee. I've cut way back on my diet soda intake (1-2 cans per day), and I now drink my coffee with milk and sugar. Still, I'd be curious to see if/how this translates to eating disorders.

Engineering Food with Aromas that Make Us Feel Full

From Popular Science:

Usually the enticing smell of food is associated with hunger pangs, but researchers in the Netherlands think that foods can be engineered to release satiating aromas during chewing. This would help combat obesity by stimulating areas of the brain that signal fullness. In a paper published in the Journal of Agricultural and Food Chemistry, the researchers outline how food products could be tailored to release a higher quality -- or a higher quantity -- of aromatic food molecules, thus discouraging overeating.

...The science works like so: When you eat, certain molecules break free from the food as you chew, working their way up to your nasal cavity and to your olfactory sensors. From there, they've been shown to stimulate certain areas of the brain connected with satiety, or the feeling of fullness. The problem is, like many processes in the brain, the feeling is based on perception, and that varies from person to person.

**Full Disclosure: I used to work for the American Chemical Society, which publishes the Journal of Agricultural and Food Chemistry.**

Which is both bizarre and fascinating. I think it just goes to show how complex our senses of taste, hunger, and satiety really are.

Now for the entertainment section of the smorgasbord:

1960s British Educational Film on Childhood Obesity called "Cruel Kindness."

Aside from the accent and listening to the narrator pronounce "vitamins," British-style, what the films really captured was how little obesity propoganda has changed over the years. How all fat kids do is eat too many sweets, watch too much TV, and shame on the fat parents for producing fat children! The video is in three parts from the Wellcome Trust Film Archives:

Part One:


Part Two:


Part Three:


Disordered eating could be affecting ten to fifteen percent of women

Although this study, titled "Eating-disorder symptoms and syndromes in a sample of urban-dwelling Canadian women: Contributions toward a population health perspective," was initially published in 2008, it received some renewed coverage this week. A Canadian research group interviewed 1501 women by phone and asked them about binge eating, purging, and dieting behaviors. The results showed that:

Weighted frequency analysis showed the prevalence of frequent binge-eating to be 4.1%, that of regular purging to be 1.1%, and that of frequent compensation to be 8.7%. Although we found none of the women to meet full criteria for anorexia nervosa, 0.6% met criteria for bulimia nervosa, 3.8% provisional criteria for binge eating disorder, and 0.6% criteria for a newly proposed entity, purging disorder. As many as 14.9% fell into a residual category representing subthreshold, but potentially problematic variants of eating disturbances. Logistic regression analyses showed that clinical-level maladaptive eating attitudes and behaviors predicted self-rated physical- and mental-health problems after sociodemographic factors were controlled.

This population-based survey provides prevalence estimates of BN, BED, and purging disorder that are compatible with those of recent epidemiological studies and shows that maladaptive eating attitudes and behaviors represent a substantial population burden.

Thus concludes this week's smorgasbord. I hope you all enjoyed!

At an initial glance, a new study from the Journal of Consumer Research appears to have absolutely nothing to do with eating disorders. It wasn't about magazines or models or the purchase of diet products. The title of the paper had the rather bland-sounding titled of "Counteractive Construal in Consumer Goal Pursuit." That sounds as exciting as organizing my sock drawer. Rather, what caught my eye was the title of a news brief about the research titled "Resisting temptation is easier for those who exaggerate the threat."

And I thought, "Huh. That sounds a lot like what happens in eating disorders."

It sure does.

The authors of the research did four different studies, which they looked at to draw their conclusions. Two of those studies had to do with dieting and weight loss.

From a press release:

“Four experiments show that when consumers encounter temptations that conflict with their long-term goals, one self-control mechanism is to exaggerate the negativity of the temptation as a way to resist, a process we call counteractive construal,” the researchers write.

For example, in one study, female participants were asked to estimate the calories in a cookie. Half the participants were told that they have the option of receiving the cookie as a complimentary gift for participation and half were not. The results showed that consumers with a strong dieting goal construed the cookie as having more calories and being more damaging to the attainment of their long-term goal of losing weight.

{snip}

In [another] study, female participants entered a room that either had posters depicting fit models or nature scenery. “Participants who were exposed to posters depicting fit models (goal-priming stimuli) were more likely to exaggerate the calories in a tempting drink that they expected to consume later on, and consequently consumed less when offered the drink,” the authors write.

The relevance to eating disorders is obvious, even when you ignore all of the stuff about weight loss. That's not what I find the most interesting. The key words that leaped off the page at me were "resisting temptation" and "exaggerate the threat." For many people, temptation is temptation. Someone who is predisposed to an eating disorder, however, may be much more likely to view temptation as a threat. You can add me to that category. People with AN in particular are prone to asceticism, which Wikipedia defines as "a lifestyle characterized by abstinence from various sorts of worldly pleasures (especially sexual activity and consumption of alcohol) often with the aim of pursuing religious and spiritual goals."

Want something even more ascetic that renouncing sex and booze? Renounce food. If these things weren't considered somehow "tempting"--read any nutrition advice about the holidays and you'll see what I mean--then they wouldn't need to be renounced. Many people with AN struggle with including pleasurable things in their lives. I'm not talking about pleasure from a night with your latest order from Good Vibes and a pair of AA batteries. I'm talking about the pleasure of relaxing in front of a fire, leaving the dishes until morning, going to a party even though you have a paper due the next day. Little things. I don't find them alluring as much as I find them anxiety-provoking, perhaps because they are so alluring to me. The thought of holding up a bank doesn't cause me anxiety because I have no desire to do so.

So there we have the part about "resisting temptation." Now we get to the part about "exaggerating the threat." The all work, no play work ethic of mine gets its oomph largely from my fears of what will happen if I play. How can I relax when there are stories that need researching and writing? How can I leave the dishes until morning when there might be a bug problem? How can I skip working on my paper, which could mean that I do horribly, fail the paper, fail the class, fail out of college, and wind up living in a cardboard box?

Like I said, "exaggerating the threat."

I'm a veteran calorie counter. When I'm wrong about the calories in something (which I occasionally am, although after 10 years, there's not a whole lot that I haven't already looked up), it's because I grossly over-estimated the number of calories in something, not an underestimate. An extra bite becomes 1000 extra calories in my mind. And when you consider that food is anxiety-provoking to people with eating disorders, there's already that tendency to exaggerate how awful, fattening, and massively portioned a food was.

Besides my food issues, I am also terrified of spiders. I've whacked off several roaches, millipedes, centipedes, and other bugs I didn't take that good of a look at. I don't like these bugs, but I can at least get rid of them with some shred of self-respect. Spiders are another matter entirely. Even a daddy long-legs seems huge to me. I see one and I scream like a girl. The other girls in my dorm always asked me to be on spider patrol because I was a "biology person." All I could think was that I use a microscope, not a fly swatter. Spiders seem massive to me- a literal interpretation of exaggerating the threat.

So when food seems far more threatening than it is tempting, it's easy to see how avoiding food would become almost instinctual.

One of the most profound things I learned in treatment for anorexia was how much the symptoms of my eating disorder (obsession with food, increased anxiety and insomnia, agitation, hyperactivity) were as much symptoms of starvation as they were symptoms of anorexia. Not that this made eating any easier--it didn't--but it helped put a context to all of the frightening thoughts and compulsions I was having. Eating seemed to make them worse, but only after a while did eating make them somewhat better.

Undernutrition may actually be at the core of many of the traits and symptoms researchers initially thought were caused by anorexia. Many people with anorexia are probably more obsessive, anxious, and perfectionistic than average; since these traits existed before the eating disorder, they aren't caused by undernutrition, but they sure can be exaggerated. Even just a quick read of Keys' starvation study indicates that many of the behavior changes brought about by semi-starvation can be significant. Many brain imaging studies of anorexia are performed after weight restoration and a period of recovery and normal eating because starvation has such profound effects on the brain.

There have been numerous studies that have reported on psychological changes that occur during refeeding (Konrad et al 2007), but two interesting studies appeared within the past week that seemed to emphasize the role of refeeding in the psychological recovery from EDs.

The first article was from the French journal Encephale, which looked at the relationship between social phobia, anorexia, and the stage of treatment (Coulon, Jeammet, and Godart, 2009). Because the journal is in French, I'm going to have to stick with the abstract, but the results were still interesting. Social phobia has been loosely associated with AN, but the researchers were trying to figure out whether the social phobia might be a by-product of malnutrition rather than an actual trait of the anorexia sufferer. In this sense, it's kind of the proverbial chicken-and-egg question: which came first, the undernutrition or the symptoms of the eating disorder?

And what did the researchers say about how stage of treatment in anorexia affected social phobia? They found a correlation between social phobia and symptoms of AN as well as "total clinical picture" of the patient, but no relationship between social phobia and nutritional status (as measured by BMI). The researchers concluded that "We therefore feel that a diagnosis of social phobia can only be confirmed after an acute state of AN, thus allowing for preferential treatments. Other studies must be conducted in order to continue to explore the links between social phobia and AN."

This doesn't preclude the pre-illness onset of social phobia--in fact, a 2004 study found that approximately one in five ED sufferers met the diagnostic criteria for social phobia before the onset of their disorder (Kaye et al, 2004). However, due to the eating disorder, social phobia can appear in a person who had no previous symptoms of the disorder. So is that social phobia a true, independent disorder, or is it related to undernutrition? This study says that social phobia might be related to undernutrition, but we don't know for sure yet.

The second study looked at the hypothesized relationship between anorexia and autism spectrum disorders (ASDs; Time Magazine had a good article earlier this year on the issue that I blogged about here). Specifically, the study looked at the difficulties people with AN have with respect to the emotional Theory of Mind (eToM), with understanding and interpreting others' emotions (Oldershaw et al, 2009). People with ASDs often have difficulty understanding other people's emotions, and the fact that AN sufferers also had difficulty with this seemed to be a neurological link between the two disorders.

The researchers compared a group of currently ill AN patients with both recovered AN patients and healthy controls, and found that the emotional deficits seen in acutely ill AN patients had essentially disappeared in the recovered AN patients. Furthermore, there were few differences in emotional tasks in recovered AN patients and healthy controls, which indicates that the emotional deficits are more related to the current state of undernutrition than they are a person's temperament.

Conclude the researchers:

These findings indicate almost complete normalization of emotion recognition ability as well as the restoration of eToM in recovered patients, despite the observation of difficulties in both domains in currently ill patients. Findings suggest that similarities between AN and ASD in poor eToM are restricted to the currently ill AN state and such difficulties in AN may be a factor of starvation.

However, other similarities between AN and ASDs remain, such as difficulties with set-shifting and impaired central coherence (i.e., you can't see the forest because of the trees) that seem to extend long beyond recovery. That, however, is its own blog post that will hopefully be up soon.

When it comes to edible calories, I'm pretty much an expert. I can eyeball and guess the calories in pretty much anything, and those numbers seem to stick in my mind for the rest of eternity. Need to know the calories in a stalk of celery or a cucumber? I'm your girl.

A large part of my eating disorder was limiting the number of calories I ate (or at least balancing that with how much I exercised). Life became a series of numbers: calories, fat grams, pounds, minutes exercised. And the more I could limit the first three of those numbers, the better I tended to feel. Though my diet was rather bland and boring, I enjoyed how it "tasted" of control and strength and willpower. I enjoyed how soothing it was to know exactly what I was going to eat and when.

Calories. The fewer, the better. That was my life for the past decade in about five words.

It was relieving, in a sense, to be told what to eat. Either the anorexia was telling me what to eat, or it was my dietitian. Deciding (remember The Paradox of Choice?) was often freakishly difficult, and I still rely on rules and regulations to help me meet my dietary needs. Often I fantasize about someone giving me The Perfect Food Plan that tells me exactly what to eat and when.

But I was reading the 360 Degrees of Mindful Living blog, and the author, Pavel Somov, wrote about Experiential Calories:

A Nutritional Calorie is a unit of energy. The job of a Nutritional Calorie is to fuel your Body. An Experiential Calorie – to coin a term — is a unit of awareness, a unit of conscious presence, a unit of meaning. The job of an Experiential Calorie is to enrich your Mind.

Of course, the chief thing I restricted in the course of my eating disorder was food. I'm not trying to deny that. But throughout my eating disorder, "restricting" became more than just a way of eating, it became a way of life. I restricted money but not letting myself buy things (or panicking when I did). I restricted social experiences by isolating myself. I restricted fun by always making myself work or do something "useful."

The very first therapist I saw, just as the ED was taking hold and a good 6 months before I had a clue that my increasing food obsessions were in any way problematic, assigned me 30 minutes of "fun" each day. I told her I was too busy for fun, fun was for sissies, I'm already living on 4 hours of sleep- how am I going to manage on three-and-a-half?, I had no use for fun. No, she told me, 30 minutes of fun, every day. Fine, I said, I'll do my fun but you can't make me enjoy it!

Not surprisingly, the thought of spending thirty! whole! minutes! doing! nothing! caused so much anxiety that I never really did it. I never realized this restriction-of-fun had anything to do with my eating disorder. And I never realized how hard it would be for me to begin incorporating other sorts of "calories" in my life.

I've never especially had a problem fueling my brain with Intellectual Calories. I'm a geek. If my brain doesn't get enough Intellectual Calories, it seems that restricting my food calories can't be far behind. But things like Social Calories and Fun Calories and Soothing Calories? They seem somehow bizarre and unnecessary- much like food does when I'm in the throes of anorexia. Yet they very much are necessary (yes, Carrie, just like food!), even though they remain absurdly nebulous.

I think these Experiential Calories are a bit more neglected in eating disorder recovery, in part because it is hard to measure them precisely. But at this past year's NEDA conference, Nancy Zucker spoke of how, even well into recovery, many of her patients' lives seem somewhat rigid or restricted somehow, as if the AN mindset has permeated their lives in every respect, not just food. Obviously, correcting the intake of food calories needs to come first, because a deficit of food calories is immediately life threatening. Experiential calories can wait a bit, if for no other reason than a malnourished person can't take in experiential calories very well. But me and others with EDs need to learn how to regulate both food and experiential calories in our lives.

Guidelines on how many food calories we should eat each day permeate our culture. They're not always right for everyone, but they're there. These Experiential Calories of which I write tend to vary even more between person to person. Whether the Faceless Internet Nutrition Providers will take a hint from the Experiential Calorie folks remains to be seen, but I would love nothing more than a set of rules or guidelines to tell me how much socializing I need to do and how much "fun" I need to have.

I guess this means I need to increase my intake of Flexibility Calories, eh?

Last month, I wrote on Part One of an article from the magazine Psychiatric Times titled "The Cellular and Molecular Substrates of Anorexia Nervosa, Part One." As I promised, I am writing on Part Two now that it has appeared (the original link I found was bad, and I had to hunt down the article, so I apologize for the delay, but here it is!).

The author, John Medina, summarized the first article as follows:

A testable hypothesis was outlined: AN was described as a conflict between an un-acquired biological need to have food and an acquired negative reaction to it. Patients with AN recruit cortical executive reactions in response to appetite cues, reactions that insert a top-down “food-negative” bias into the normal drives for fuel. These executive reactions are consistently overstimulated in AN patients, leading to high anticipatory behavior and obsessive concern with future events. Derived mostly from noninvasive imaging studies, this notion of conflicting priorities (complete with a dysfunctional reward/punishment system) has surprising empirical support.

But it is hardly the complete story of AN. Besides behavioral and cellular concerns, there are also molecular interactions to consider. It is to these efforts that we turn, focusing on the “usual regulatory suspects” of dopamine and serotonin neurotransmitter biology.

Medina first begins discussing the role of malfunctions in the dopamine system in people with AN, since many anorexics report varying levels of asceticism, anhedonia (the inability to find anything pleasurable), and the difficulties in finding something consistently rewarding. This is otherwise known as the Theme of My Life. These are considered trait features because they often exist before the onset of illness and persist after recovery. Other clues pointing to the dopamine system are difficulties with visual tasks (which can often signal a malfunction in the dopamine system), lower levels of dopamine metabolites in the cerebrospinal fluid even after recovery, variances in the genes of dopamine receptors in the brain, as well as brain imaging studies.

The other major neurotransmitter being studied with respect to anorexia is serotonin. Medina included a diagram (that I've copied here) that portrays the two hypotheses related to abnormalities in the serotonin system that may contribute to anorexia. The first hypothesis is that people with AN have increased levels of serotonin in the brain, which may contribute to the common traits of harm avoidance and anxiety, as well as the general lack of effectiveness of SSRIs in treating AN. The other hypothesis has to do with an imbalance in serotonin receptors which can be altered by both hormonal changes and stress. The evidence for this has to do with the usual onset of AN during puberty/adolescence, and many times the onset coincides with a particularly stressful time in the sufferer's life.


Writes Medina:

Starvation-induced reductions in levels of extracellular 5-HT, for example, might result in reduced stimulation of postsynaptic 5-HT1a and 5-HT2a receptors, leading to behavioral alteration. The resulting dysphoria, normal in unaffected individuals, might be exaggerated in patients with AN.

There are testable questions surrounding these ideas. Forcing AN patients to eat, for example, might stimulate postsynaptic 5-HT1a and 5-HT2a receptor activity. This stimulation would lead to an elevation in dysphoric mood, transforming eating and weight gain activities into traumatic stress-inducing experiences. This might explain the no-win behaviors so common in AN patients. If the patient were allowed to continue to starve herself, anorexigenic information related to neuropeptide alterations (reduced b-endorphins, elevation in stress-related metabolism such as elevated corticotropic-releasing hormone), might exacerbate AN symptoms by driving food-restricting behaviors. Whether eating or starving, the same dysfunctional circuitry would be stimulated, all leading to the symptoms.

... Persons with AN show unique anxiety-related 5-HIAA metabolic perturbations. The weight loss in these patients results in a reduction in 5-HIAA CSF levels. But they concomitantly show dramatically elevated 5-HIAA receptor binding in specific cortical and limbic structures—something not seen in healthy controls. Food might very well be anxiogenic in these individuals.

Which, really, explains both everything and nothing. As Medina says, there is no one neurological system that is both necessary and sufficient for the development of AN. And I hate to rain on anyone's parade, but I doubt it will be just one thing or just one system or just one factor. Human behavior is way too complicated. Still, we have made enormous strides in understanding the scientific basis of anorexia, and I'm looking forward to future research.

Yes, indeed, today will be the very last day I will bug you about voting for ED Bites in the Second Annual People's Health Blogger Awards!

I don't care whether you vote like a baby stoat, a baby goat, a root beer float, a steel-cut oat, or just to float my boat. GO VOTE! Please!

It's super easy- click on the widget below (the "People's Health Blogger" part), which will enable you to cast your very precious vote for ED Bites. You will have to sign up for Wellsphere, but it's easy (all you need is a valid email address) and they don't spam.

Thank you ALL from the very bottom of my heart.

Carrie A. http://www.wellsphere.com/linkOut.s?link=http%3a%2f%2fwww.edbites.com

Several weeks ago, there was a massive to-do over a horrifically Photoshopped image of a Ralph Lauren model. Boing Boing said it best: "Dude, her head is bigger than her pelvis!" And in the image, indeed it was. Ralph Lauren later fired the model, Filippa Hamilton, for being too fat, even though she's a size 4. Last week, documentary filmmaker Darryl Roberts (he directed the movie "America the Beautiful") was supposed to have appeared on Larry King Live until the people at Ralph Lauren allegedly had the segment pulled. Now, the America the Beautiful Action Group has created a Facebook page encouraging people to boycott Ralph Lauren.

I have not joined this Facebook group for a variety of reasons, one being the fact that I never bought any of his stuff anyway, so my boycott of the company would have precisely zero effect on their bottom line. The other major reason is that I really, really, truly dislike how negative ads like Ralph Lauren's are conflated with causing eating disorders.

In an open letter to Ralph Lauren, Roberts writes that:

I’ve had the pleasure of meeting tens of thousands of young girls while promoting my documentary “America the Beautiful.” To look in the eyes of over 100,000 college women and hear their pain (body image, self-esteem) has been an experience that I will never forget. I’ve also heard from over 80,000 parents that are in pain because they have to hear from their sons and daughters in pain. It does truly become a generational cycle.

I’m sure that you’re fully aware that a lot of the American population feels that the unhealthy ads in magazines are damaging to women. The damage comes in various forms; body image problems, low self-esteem and for some of the women, they get a full blown eating disorder like your niece Jenny.

{snip}

Believe it or not, [adults and parents] get hurt as much as the young girls that read the magazines and look at the ads. “How? You wonder.” When a young girl reads these ridiculous fashion magazines and gets triggered into a full blown eating disorder, who do you think gets left holding the bag for the $30,000 a month treatment? I’ve met parents that have had their entire savings wiped out and some have taken out second mortgages on their homes to pay for the treatment of their young daughters.

Although Roberts says that he was told by an ED expert that 50-80% of the risk for developing an eating disorder is genetic, the message here is clear.

I'm all in favor of supporting a boycott for Ralph Lauren because he's engaging in false advertising (which is what I think the dramatically altered images really are), for being denigrating towards women, or for just being a douchebag. All of these are quite possibly true.

All of these have NOTHING to do with eating disorders.

Yes, our thin-is-in culture plays a role in triggering eating disorders, but the holy-is-in culture played a role in triggering eating disorders during the Middle Ages. I'm not saying that we should support or participate in this culture (it's damaging even if you exclude any triggered eating disorders), but we can also oppose it for reasons that have nothing to do with EDs.

Writes Sue Sierralupe of the Oregon Natural Health Examiner:

The National Organization for Women (NOW) is one of the many organization demanding a change in advertising policies that encourage eating disorders. NOW has prioritized encouraging women's self esteem with Body awareness education, "Love your Body Day" and a posting of ads offensive to women and ads that are supportive of women. NOW has asked Ralph Lauren to apologize encouraging unrealistic body images that lead to eating disorders.

...Most cases of anorexia and bulimia are symptoms of unhealthy self esteem. According to the Women's Center for Healthy Living (WCHL), "Anorexia and bulimia are characterized in part by a refusal to eat and repeated attempts at dieting. Even if individuals suffering from anorexia or bulimia are a normal weight, their body images are distorted, causing them to continually attempt weight loss. The thought process of those suffering from anorexia or bulimia is that if they only weighed a certain number, life would be "good" and they would feel good about themselves. The truth is that weight cannot and does not determine your self-esteem or self-worth."

Which is pretty much bass-ackwards. I don't oppose NOW for trying to promote women's health by ads that aren't sexist and offensive. I rather think that's a good idea. But EDs aren't just a feminist "up yours" to the patriarchy done in a nice feminine way. They're an illness.

Many people with EDs have a history of low self-esteem because they also suffered from perfectionism, and nothing saps your self-esteem like the feeling that you are never good "enough." Yet the one thing that absolutely wrecked my self-esteem was my eating disorder. The truly pitiful self-esteem happened after; it wasn't great before, but it wasn't literally and metaphorically in the toilet, either. EDs aren't about the vapid pursuit of an ever-decreasing weight. They're about scrambled neurotransmitters, about how ED symptoms can help mediate feelings of anxiety and depression, they're about genetics, and a vicious cycle that doesn't seem to stop. Furthermore, the symptoms of body dysmorophia and "feeling fat" are a relatively recent phenomenon- they weren't consistently present before the 1800s, and didn't comprise a majority of AN cases until into the 1900s.

Ultimately, Sarah Ravin said it best: this focus on EDs as just really extreme body image dissatisfaction "trivializes the anguish that eating disordered people experience."