It's something I've been noticing lately in my own life: a growing mastery of basic recovery skills. You know, the things other 31-year-olds take for granted, like the regular consumption of breakfast and not exercising myself half to death. In the beginning of recovery, I couldn't do any of these things unless someone was sitting right there and giving me death eyes to make sure I wasn't misbehaving. Preferably with an Ensure for any infractions.

There's nothing to deflate your ego quite like flipping through your friends' wedding and baby pictures on Facebook while realizing that you one even trusts you to, like, you know, eat.

When I first attempted to eat with no real supervision after attempting recovery, it was kind of laughable. I'd start off getting a small, nonfat cappuccino (more air, less milk!) and say I had some massive, calorie-laden drink. Then I'd switch to coffee or tea while simultaneously maintaining I had that beverage. After all, I wanted that drink. I even might have actually intended to order it, on some subconscious level. But faced with the gargantuan menu and the knowledge that there were calorie-free options just waiting for me, I caved to the anxiety. Then, ashamed that I couldn't do something as simple as order a simple snack, especially after promising on my kitty's tail that I would Behave Myself and Actively Choose Recovery, I lied about it.  I justified this by telling myself that I wouldn't cheat again, that next time, I would have the massive calorie-laden drink.

Repeat ad nauseum.

All during this time, I would have sworn up and down that I could easily handle everything on my own. Easily. "I've got this," I said.  After all, I could publish long feature stories in magazines. Surely I could eat adequately.

Except I couldn't. Each time I tried, I would bite off more than I could chew (is that pun intended? I'm not sure...).  Sometimes, I would be forced to be ready because the insurance company said I was ready, dammit. Others, my treatment team thought I was ready.  And still others, I convinced my treatment team I was ready to take on more responsibility for my own recovery. Each time, the result was the same: it was too much, too soon.  The eating disorder triumphed again.

Ultimately, I began to lack confidence that I could ever feed myself properly again. Maybe I was just one of those few who would struggle forever. Maybe I would never get better.

The problem wasn't me or my (seeming) inability to recover. The problem was the complexity of the task and my available skills to master it. It's like asking a five-year-old to do calculus. I'm sure there are a few Einsteins out there who can, but most of us can't. Not that we won't ever be able to do calculus after we learn addition and subtraction and algebra and infinite sums, just that we can't yet do calculus. We don't consider a kindergartner a mathematical failure if they can't figure out a differential equation. Yet I would be discharged from treatment with a sheet of paper containing a list of foods I was supposed to eat and a pat on the back and have no freaking clue where to go from here.

What I really needed was fewer sheets and more time and practice.  I needed to start way more slowly than most people thought. This grated both my ego and my patience (like I said, nothing like a good career to contrast your epic catastrophes around eating).  So I started with tasks I felt confident about, things like putting milk in my coffee (yes, caffeine is a massive theme in my life) or spending short times unsupervised and not exercising. Then I began to build on that. I could figure out an entire snack or spend a whole afternoon by my lonesome and not lace up my gym shoes.

It took years for me to get where I am now, which is that I can eat independently and not overdo the exercise (though the latter is still the largest struggle for me) even if no one is the wiser. I'm not always perfect, but I can be honest about that, too.  I have mastery over basic recovery skills, whether it's feeding myself or calling a support person.  I'm doing calculus.  It took me a little over 11 years to get there from my 2+2s(kindergarten until junior year of high school), but then I ended up a math minor in college. The successes, whether in recovery, math, or even figuring out how to program your DVR, snowball. They build upon themselves. That's what things tend to do, whether successes or failures.

It took me a long, long time to be able to slow down and take recovery one step at a time. To stop feeling that I "should" be able to do something because everyone else could and it sounded easy, ergo, I should be able to do it.  It's still hard for me to admit that I couldn't do these things, and not always for lack of effort. I can't juggle or do those silly Magic Eye things, either, despite a plethora of people who do have those capabilities. I've accepted that, more or less.  It is what it is.

I guess, in the end, recovery is a process. A long, hard, difficult, pain-in-the-ass process. But I tackled it one step at a time, and I did, eventually, get there.

Thank you all for your kind and wonderful comments on yesterday's post.  They were really helpful for me.

What I've come to realize over thinking about this awful fatigue and hypermetabolism mess is that I need to practice some serious radical acceptance.  Not that I expect that this will eliminate my fatigue, but hopefully, I can scrape up a few scraps of energy that I was wasting on resisting and fighting the current state of events.

So what do I need to accept?  Several things:

1. My need to eat a lot. My mom tells me most people would kill for my metabolism.  I tell her they don't need to bother, as I'm perfectly happy to give it away upon request.  But there's not much I can do about how much food I'm burning off right now.  It's just reality.  It's what I need to do to get better, it sucks, but there's also no real alternative.
2. I'm not going to be as productive as I usually am. This one is really hard for me. I generally hate on myself if I'm not constantly busy. It's fine when I have the energy, am engaged in life, and can plan in some breaks.  That's not my current life.  Again, it's unavoidable.  I'm lucky in that my work schedule is pretty flexible, and a couple of short months financially aren't going to be the end of the world.

It's hard for so many people to understand why recovery can be so difficult.  All you have to do is eat, or keep your head out of the toilet, or stop binge eating, or get off the damn treadmill already.  It's one thing to know that this is what needs to be done.  It's quite another to actually do it.

For one, the neuropsychological changes caused by eating disorder symptoms can make it difficult to interrupt the cycle (it can make it almost impossible to see that there's a cycle that needs to be interrupted, for that matter).  For another, behavior change is complicated.  Very complicated.

I worked in public health for several years, and figuring out how to implement successful behavioral change--whether it's anti-tobacco messages or everyone's favorite current dead horse, obesity--was largely an exercise in futility.  It's easy enough to tell people that smoking is bad and you should eat more veggies.  It's also relatively easy to get people to absorb these messages.  It's quite another to get someone to put down the cigarettes and start eating broccoli.

This is known as the intention-behavior gap.  That's the technical name for knowing what you need to do and not doing it.

It's been a frequent issue in my recovery.  I can argue circles around myself to justify things, and come up with great reasons why it's to "hard" to eat lunch or take a break from exercise.  Behavior change is hard.  No one is going to argue with that--at least, no one who's broken a nasty habit or changed a major behavior.

But as I've progressed in recovery, as I've slipped and come clean and learned from my mistakes, I've learned that there are some general actions I could take so that my behaviors would match my intention of ongoing recovery.

I learned about batch cooking one summer when I was living in Baltimore and commuting into Washington DC every day.  It was two hours each way.  Getting home, wrung out and exhausted, at 8pm was not conducive to cooking dinner.  That wasn't an eating disorder excuse, that was just reality.  It would have been easy to turn that into a great reason to simply not eat, or to just nibble on some cereal before I passed out from exhaustion.  A conversation with my dietitian reminded me about batch cooking.  On Saturday or Sunday, I would cook all my meals for the week.  That way, when I got home, all I had to do was shove something in the microwave.  Easy peasy.

There were other things, like (when I was more in binge mode) not eating out of the box, packing my lunch the night before, or turning in my gym key to apartment management.

I've never been all that good at analyzing these things in the moment.  Usually, "the moment" is about damage control and getting more stable.  But looking back, I can generally (okay, with lots of help from my therapist) identify what went wrong.

What are some intention-behavior gaps in your recovery? How can you start to address them?

I am not, by nature, a very confident person.  I doubt myself.  For that matter, I doubt everything.  And so, like many people with eating disorders, I doubted my ability to get better.  For years, I thought I was too messed up to ever return to anything called normal.

I was lucky.  I had family and friends and a treatment team who believed in my ability to get better.  As much as I hated being strong-armed into treatment, I realize now that it was a sign of how much they believed in my ability to overcome anorexia.  They (rather smartly) didn't try to make me become a prima ballerina because the odds that the class klutz could manage a pirouette were pretty slim.  I think they knew, deep down, that I could get better if I had the chance.

There were many things that made a different in my recovery, but I think that was one of the big ones.  I needed someone else to believe in me until I could believe in myself. I tried to get better numerous times, but I could never shake that monkey on my back.  And so each effort, I had less and less belief that it would actually work.  Not surprisingly, each effort had less and less effect on the ED behaviors.

Some of the clinicians I saw doubted my ability to get well.  I was "chronic" and "long-term" and "unlikely to recover."  I had no reason to disagree with them.  But those treatment providers who did continue to believe in me provided me with a ray of hope.  That ray of hope wasn't enough for me to kick anorexia on my own.  I had to be strong-armed into treatment one last time, but nonetheless.

It's hard for people to balance their confidence in your ability to get well and the extreme difficulties that getting better actually takes.  The Pollyanna-ish "Oh, you'll be fine, dear" struck me as rather fake.  An eating disorder isn't a cold.  It's not a take two and call me in the morning illness.  Yet in order to do the hard work, to go to therapy week after week and take your pills and eat the damn food (all that damn food!), you need to know that, somehow, you will get well.

I think people underestimate the effects of confidence.  I finally have confidence in my own recovery, after years of doubt and disbelief.  By giving me no other choice that complete wellness, I could finally get healthy enough to see that recovery was possible.  It sounds almost paradoxical, but it's true.

My parents are out of town for the next week, and I'm on my own in terms of food and eating. Well, not completely on my own, because I have some leftovers, and I have a book full of meal ideas that are meal plan compliant. There's plenty of food in the house, I shouldn't have to go shopping for anything other than produce or milk. So I'm pretty much set in that respect.

What has caught me off guard was how much harder it is to eat by myself. And not just eat, but decide what to eat, and then prepare it, and clean up after it. Not having to be in charge of all of that when my parents are around, I forgot just how much thinking all of this really required.

I can't help but think how easy it would be to start cutting corners. Not that I went into this week looking forward to the opportunity to restrict, which is something I would have looked forward to not all that long ago. I haven't even been having urges to restrict. I don't necessarily want to eat less. Yet somehow I've been finding it hard to eat enough.

Part of me is just tired at having to think about food so much. I haven't really been thinking of food in the starved, obsessive way that I used to, but I do still deliberate about what to eat much more than most people. And I'm really not totally comfortable making those decisions. I still wouldn't mind having someone pick out my meals for me (assuming I have some input and I wouldn't have to eat anchovies or anything). It's still just very overwhelming, all the food-related things to think about.

Yesterday, I was juggling about four different writing projects, and I really didn't want to have to plan in lunch and snack and dinner. I had lunch at about 1pm, which was pretty normal for me, but then I put my nose to the grindstone, and all of a sudden, I looked up and it was 4:45 and I hadn't yet had my afternoon snack. The last thing I wanted to do at that point was stop what I was doing, go downstairs, and find something to eat. I really wasn't hungry and I had piles of work to get done. In another life, I would have put my head down and bulled on through until someone came and got me for dinner.

I have to remember that I don't live that life anymore.

I did go downstairs and get a snack and take a breather and then I went back to work until it was time for a bike ride and watering the plants. Still, preparing and eating meals doesn't feel completely natural to me. I have the let's-refill-the-coffee-pot thing down pat, but serving myself food feels stilted and awkward. I'm aware that some of this awkwardness has to do with how long it's been since I've actually served myself a full-on meal. But I also can't shake this shame that I'm eating and consuming something. Or that my being in the kitchen and putting stuff on my plate is somehow abnormal and wrong. Logically, I know that there is nothing wrong and that people don't live on air. Yet I'm still embarrassed that someone will see me in the kitchen, actually getting something to eat.

(But if I wasn't getting something to eat or drink, why in the hell would I be in the kitchen anyways?)

It's obvious that I eat. I'm alive, therefore I must eat something. I also don't care what other people eat or judge them for it (unless they smack their lips when chewing. Then I do judge and I don't care.) I'm trying to trust that the horrible kitchen awkwardness will pass. I'm trying to take this one meal and one snack at a time.

I am eating. I am doing okay. And however hard and itchy and awkward it may be, I am doing what I need to do. I have my slips, my moments of not-so-accidentally-undereating. It's hard to give up the idea of the perfect recovery and get back in the saddle again. I'm tired of thinking about meals and snacks. But I have so much going for me now that thinking of food is really a small price to pay for the rest of this.

My appointment with TNT yesterday was at an unusual time (1pm, and she's an hour drive away), so I ended up eating my afternoon snack right after my appointment and had my lunch at about 3:30pm instead. I had driven myself, and it was essentially up to me whether I would eat the snack I had brought with me. I knew I could toss it or hide it or lie about it and no one (except for me) would be the wiser.

I wanted to chuck my snack so freaking badly. Not because I really wanted to restrict, but a) because I could and b) to be a little rebellious. Ultimately, I didn't throw out my snack and ate what I had brought because I was aware that this little stunt would prove a big fat load of nothing.

What I wasn't prepared for was how pathetic and weak I felt by eating my snack.

Yes, yes, I know: I should be proud of how I acted. Maybe I should, but that's not really the point here. I was thrown by how strong the AN "kickback" was for eating something when I didn't "have to" or wasn't being watched. The dialogue in my head went something like this:

Why am I eating this? This is so stupid! Snacks are ridiculous! I am eating way too much as it is. I'm such a wuss, eating when I don't have to or even want to. Isn't that what they tell you on TV- don't eat if you're not hungry? Right? This snack used to be way more than I ate in an entire day, and I was exercising about a trillion times more than I am now. I have gotten so weak. All of this eating has made me weak! I'm so pathetic, all of this eating...

I'm frustrated because I am committed to getting better, and have sacrificed so much to getting that way, that I'm still tormented by these thoughts. I know it's AN thinking, but I have been at a healthy weight (and then some!) for almost 9 months now. You'd think my brain would get the message, no?

TNT is primarily a CBT-oriented therapist, and I know she would want me to slow my thinking down and take a good, hard look at the rationality and usefulness of my thoughts. Some obvious places to start:

• just because I feel pathetic doesn't mean I am pathetic
• eating is necessary for recovery, and it doesn't make me weak
• I eat more now and I also do more now and am happier
• following a meal plan is necessary right now for me
• losing weight and restricting will only lead to relapse, which is something I definitely don't want

I blogged yesterday about Part One of Linda Hill's talk on The Noisy Brain, and, as I promised, here is Part Two of her talk from the 2010 International Conference on Eating Disorders. In the second half of her talk, Dr. Hill talked about the need for structure in AN recovery, specifically with respect to meal planning.

In the world of eating disorder recovery, Intuitive Eating is pretty much the holy grail of recovery. It's not a bad ideal, but eating when you're hungry and stopping when you're full can really only work effectively if your hunger and fullness cues are fully operational. In people with eating disorders, especially in early recovery, this really isn't true. At my last residential treatment center, we were taught Intuitive Eating (which wasn't a bad thing), but then we were also expected to be able to put this into action even as we were still in the beginning phases of normalizing eating patterns. Some people found this effective; I didn't. I failed at it miserably, and I had always blamed myself. Perhaps I didn't want recovery enough. Or maybe I wasn't good enough at fighting the ED voice.

You can imagine what a relief it was for me to learn that although the concept of Intuitive Eating is very useful, I can't rely totally on hunger and fullness cues to nourish myself. I definitely couldn't early in my recovery, and I still can't quite totally rely on them now. Instead, I need more structure to help me eat properly, and it's not a matter of personal failure but more of a matter of the very issue that made me so vulnerable to anorexia.

Dr. Hill talked about the need for structure in meal planning as it relates to difficulties in decision-making in people with eating disorders. Here's a segment of what she said (I inserted the links to help define some of the more technical terms):

Automatic emotional reactions don't seem to fire well because the insula is blunted. People with anorexia doesn't appear to have a free-flow ability [to move between emotional aspects of decision-making and evaluating long-term consequences]. Their planning ability seems to be firing overly well.

The AN/BN brain is impaired in identifying the emotional significance of stimuli, but it has an increased ability concerned with planning and executing tasks. There is an emotional blindness to decisions. If there is little or no internal regulation to help the person in decision making, it's easier not to decide. I need few to no options to help me in those decisions. [For people in recovery from anorexia], we need to increase structure and limit options for decisions. To compensate for inability to know what to do, the anorexic turns outward to social cues for rules and answers and to experience reward. In EDs, we begin with a meal plan, and then dose food level to match energy level. We take choice out of it.

So instead of saying "What kind of grain do you want with dinner?" it's more useful to ask "Did you want rice or pasta?" The first option is so open-ended and provokes so much anxiety that it's simply easier to skip that carbohydrate. The number of decisions I have to make when figuring out what to eat can be so overwhelming that I have to find ways to make it easier for myself. In my meal planning post, I wrote about how I have managed to work enough variability into my meal plan while simultaneously keeping the number of choices from getting overwhelming. My solution is the mix-n-match method (or what my dietitian jokingly refers to as the Deal-a-Meal) that keeps me from getting in an anorexic rut, fulfills my necessary exchanges, and allows for enough flexibility that I can go to a restaurant.

The balancing act can be rather precarious, and I think the eventual goal is to move off of a formal meal plan and into a more Intuitive Eating pattern. But the idea is that we use meal planning to shore up those areas in which we might have difficulties and let our strengths speak for themselves.

This past week, the ever-fabulous Jenni Schaefer hosted a book club for her new book "Goodbye Ed, Hello Me." Besides the fact that I love love LOVE this book, there was one section that Jenni discussed in the book club that really hit home with me, a segment titled "Just Eat (Seriously.)"

Here's Jenni's short video:



Even now, knowing all that I do about the wisdom of eating and food as medicine, the phrase "just eat" still grates at me. Now, it's not the "eat" part of that phrase that irritates me, it's the "just" part. Whenever I was deep into the eating disorder, I could almost sense my mother wanting to shake me and shriek "Why don't you just eat?" I had lots of reasons then: I'm not hungry. I do eat, you just don't believe me. I ate earlier. I'll eat when I'm ready. I don't feel well. Now I realize the answer to why I wouldn't eat was much simpler, and much more difficult to conquer. I wasn't eating simply because I was scared to. Trust me, if I could have gotten myself to eat, I would have eaten. But I was way too scared to contemplate eating anything.

I think when people who don't know much about eating disorders say things like "just eat," it feels to me like they're treating my eating disorder as a choice. You wouldn't tell a diabetic to just produce some insulin, dammit, or tell someone with epilepsy to just stop having seizures. Not that someone with diabetes or epilepsy is helpless in the face of their disease, but they don't have a choice in the fact that they have their illness, either. I also think it's hard for people with no experience of eating disorders to grasp just how difficult eating is.

And yet, there's a wonderful simplicity about "just eat," similar to the phrase "just do it." There are no shortcuts around eating- you just have to do it. You don't have to like it. You don't have to think it's necessary. You don't even need to want to eat. But you still need to eat. It's just food, after all.

Eating isn't a simple cure for eating disorders. Weight restoration doesn't make you "fixed" or "cured" or whatever. But without eating, recovery becomes impossible.

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!

On my move, I had lots of time in the car in which to listen to music, think, and try to ignore Aria's backseat yowling. To help pass the time and keep me awake, I downloaded a bunch of TED Talks onto my iPod. They were an eclectic mix, from anthropology to physics, but they kept me awake and alert for many hours.

One that left a lingering impression in my brain was a talk by Barry Schwartz, author of the book "The Paradox of Choice." I've blogged on the book before, but there was a brief phrase in the talk that really caught my attention. Schwartz was talking about buying jeans, and how many years ago there was only one style of jeans, and they fit very badly. More recently, Schwartz went out to buy a new pair of jeans because his old ones had worn out, and he found a mind-boggling array of jeans from which to choose. Ultimately, he did find a pair that fit better than before, but with such variety available, any issues with how his jeans fit was his problem, not the jeans'.

Let me try to explain this better. If you can only choose from one style of jeans, and they don't fit very well, you are more likely to blame the ill-fitting jeans than the size of your butt. But it's your only choice, so if you want jeans, you deal with the wonky fit. But when there are stonewashed and acid washed jeans, "skinny," tapered, straight, boyfriend, bootcut, and flare legs, when you have very low rise, low rise, mid-rise, at the waist, and above the waist cut, when you can opt for the "slimming silhouette," when the choices seem endless but you still can't find a decent pair of jeans (c'mon ladies, this has happened to EVERYONE), the problem doesn't seem like the jeans but more like the size of your butt--or thighs or waist or hips.

I'm not keen on having to choose. I ate the same cereal for breakfast for over two years because I couldn't choose anything different. I am still terrified of the cereal aisle at the grocery store, not because I consider cereal a "fear food," but because there are just so many things to choose from. It totally paralyzes me. Am I getting the right cereal? Is there something I might like more? Is there something at a better price? Does this cereal have too much sugar? Is the extra two grams of fiber per serving worth a dollar extra at checkout? Is extra protein worth the extra price? What about 20 fewer calories per serving- is that worth the extra dollar? What about less salt?

The cereal I was eating wasn't particularly cheap (though it wasn't particularly expensive, either), and I had already made my choice. So I grabbed the cereal and that was that. No choice necessary. I was so overwhelmed by having to choose that I avoided the choice altogether.

Sometimes when trying to choose a snack, I'll face the same paralyzing anxiety. What should I have? And, if left to my own devices, I've been known to skip a snack not because I was wanting to restrict, but simply because I couldn't decide what to have. Choosing the food--choosing to eat--was easily more overwhelming than the actual act of eating.

The solution, says Schwartz, is not no choice at all, because a long history of despotism and repression shows that people are willing to die for their right to choose government, the course of their lives, you name it. The solution is more limited choice. Not "what do you want to drink?" but "do you want apple juice or orange juice?" Lots of choice, in and of itself, isn't necessarily bad, but for those of us who find choice overwhelming, the task is to lower the anxiety of choosing without over-limiting our options in life.

Below is the whole 20 minute talk by Barry Schwartz. You can download the audio version on iTunes (just search for TED Talks). He's a great speaker.

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.

My brain feels like mush. The cognitive affects of my ED are some of the most annoying for me to face. The physical stuff, I can usually manage. But not being able to think straight, or to read and feel the text somehow evaporate in the short distance between my eyes and my brain--this drives me nuts. Even the simplest of tasks, whether it's brushing my teeth or crocheting, leaves me feeling like this little guy here:



So what do you think a complete geek like me does when she gets frustrated and exhausted? That's right- she turns to PubMed.

I found this study on the reversal of cognitive markers of anorexia with weight restoration rather fascinating for both my current state of mind and current state of body. Granted, the authors studied adolescents on their first presentation for AN treatment, neither of which are true for me anymore. That being said, I'm not entirely sure that these reversals would have been different for longer-term patients, although they may have taken longer.

Like Ancel Keys found in the Minnesota Starvation Study, adolescents in the acute phase of AN showed slower sensorimotor responses to stimuli and were more affected by others' interference. Working memory, however, was not impaired. After weight restoration, the adolescents' performance on the first two tasks were significantly improved, and "relative to controls, they were significantly faster on attention and executive function tasks, exhibited superior verbal fluency, working memory, and a significantly superior ability to inhibit well-learnt responses."

So although eating right now is making me want to bash my head in (metaphorically speaking- my head is pretty darn hard and I would fear more for the wall than my skull), one of the advantages to eating is the reassurance that my brain will work better. If only I could get an off switch for the silly thing...

What helps you along in recovery? It doesn't need to be existential or even particularly significant, just what you cling to when the going gets tough.

People love to say that an eating disorder is an issue of "control," that if you can't control the events around you, at least you can control your food.

I'm not exactly fond of this theory, although there are elements of truth to it. Stress often precedes the onset of an eating disorder, and people typically feel out of control when they're stressed. As well, most people do want to control what they eat. I think this is natural. I'm not talking about "control" here like I will only eat X calories or only fat free foods or what have you. Just that you will pick what--and how much--you want to eat.

Nothing messes with that more than dieting!

However, a new study suggests that preschoolers who are ordered to clean their plates at mealtime* tend to eat more at snacktime.

"We found that the more controlling the parents were about telling their child to clean their plate, the more likely the kids, especially the boys, were to request larger portions of sweetened cereal at daycare," says lead author Brian Wansink at the keynote address of the Carolinas HealthCare System Obesity 2009 Conference in Charlotte, NC on Friday.

First off, I have major criticisms about some of Brian Wansink's work that I won't go into here. Suffice to say, he deals with some shaky assumptions and occasionally questionable methodology. I do find his work interesting, if occasionally dubious. As well, any results being presented at a conference on obesity also make me look a little more closely at what is going on.

However, from what little I've been able to find of this study, it seems straightforward. Mothers of preschoolers were asked how much they encouraged their children to clean their plates at mealtimes. Then the preschoolers were allowed to eat as many Froot Loops as they wanted at snacktime in day care. The researchers found that the kids who were told to clean their plates ate more sugary cereal.

Yet this sense of rebellion would also seem to hold true in people who diet. Having been there myself, eating something "forbidden" can seem like the perfect way to give the diet police the finger.

Is this a control thing? Perhaps. Could it be that the kids who are told to clean their plates have less sugary foods around and therefore at more of them at daycare? Perhaps. Could it be the actions of loving parents trying to make sure that their children eat a balanced diet? Probably.

But it really drives home the wisdom of Ellyn Satter and how to feed young children, so that they may be "joyful and competent eaters."

*My parents pulled the starving-kids-in-China line on me once, until I offered to ship what was left on my plate over to Beijing. But otherwise, I never remembered having to eat everything.

I had mentioned about a week or two ago that I was going to begin a blog series on the biology of eating disorders. I wanted to start with something about the causes of EDs or something like that, but I think this topic is extremely relevant and so we can just call this the first post in the series.

I did some more research tonight into the biology and etiology of hypermetabolism. So let's start with a basic definition from Wikipedia:

Hypermetabolism is the physiological state of increased rate of metabolic activity. The impact of the hypermetabolic state on patient nutritional requirements is often understated or overlooked. Hypermetabolism typically occurs after significant insult to the body. In hospitals and institutions, the most common causes are infections, sepsis, burns, multiple trauma, fever, long-bone fractures, hyperthyroidism, prolonged steroid therapy, surgery and bone marrow transplants.

And, yes, eating disorders. Specifically anorexia. As someone falls deeper and deeper into anorexia, their metabolic rate slows dramatically. During the Minnesota Starvation Study, resting energy expenditure (also known as basal metabolic rate- the amount of calories needed just to keep your body functioning and doesn't include ANY physical activity) fell by about one-third. The book "Introduction to Clinical Nutrition" says that

Starvation involves metabolic alterations that enhance the chance of survival by increasing the use of body fat stores, by sparing the use of glucose, by minimizing nitrogen loss, and by decreasing energy expenditure.

But when the ill person begins eating again, their metabolism kicks into high gear. Body temperature rises. A person can experience night sweats, which may also be related to hormone function returning to normal.

Why? It seems a remarkably inefficient use of resources. And indeed, hypermetabolism may not be entirely adaptive from an evolutionary standpoint as the body's use of food becomes remarkably inefficient. Even so, the body needs tremendous amounts of energy to replace lost fat and muscles stores, depleted organs, bone mass, hair, nails, you name it. No organ system is spared during an eating disorder.

The amount of calories needed for people with anorexia to return to a healthy weight can vary by illness severity (a lower BMI means more calories, as well as duration of illness), and by illness subtype. One study found that those with the binge-purge subtype of anorexia needed significantly fewer calories than those with the restricting subtype; another study found that calories were about the same. Other variants include your metabolic rate before illness onset. I've known several good friends curse their fast metabolisms quire vociferously during refeeing.

When looking at the phase after weight restoration, caloric needs between people with anorexia nervosa and those with bulimia nervosa turn out to be quite different. One study found that people with AN needed more calories per kilogram of body weight than normal controls, while those with BN needed fewer. It appears that people with a current diagnoses of BN but a history of AN require more calories than those with BN alone. Further, people with the restricting type of AN needed more calories than those with the binge-purge type, both of which were greater than patients with BN (some of the studies cited above show that, for weight maintenance, caloric needs are basically the same for any patient with a current diagnosis of AN).

Some of these differences may rest in premorbid differences in metabolic rate. It makes intuitive sense that a person who finds it easy to lose weight would have a faster innate metabolism. Other reasons calorie needs may remain unusually high for a person even after weight restoration is the sheer amount of rebuilding the body needs to perform. Bulimia is violently destructive to the body, and I would never say differently. However, some of the damage done by anorexia is slightly different, and the body must rebuild and repair essentially every organ in the body. My psychiatrist told me that the nerves continue to repair themselves for up to two years after weight restoration. This can hardly be the only organ system taking a long time to recover.

How long hypermetabolism lasts will probably vary from person to person, and depends on how long you were sick, how your body responded to the damage from your eating disorder, your activity levels, among others. There's no real way to be sure. If your caloric needs are unusually high--even for hypermetabolism--you can have body composition analysis and resting energy expenditure testing done. Personally, I think this is best left to extreme cases since so many of us have a tendency to fixate on numbers.

I hope this helps explain hypermetabolism just a little bit. I can't answer every question, as it's been a long time since my college biochemistry days, but I can always look things up.

I first learned about hypermetabolism in my second treatment stint (first residential stay). Up until then, I didn't know that when you start eating again after a long period of starvation, your metabolism typically goes a little bonkers. This is some pretty useful information.

What I also didn't know was that your metabolism stays elevated long after weight restoration, making this time period even more fraught with difficulties and possibly contributing to the high levels of relapse. I think this is useful, necessary stuff that so many treatment providers don't mention because an eating disorder isn't about the food, or so they say. Except it does become about the food if you can't maintain your weight, or you start bingeing and purging, so I think it should be out there, in the open.

Which brings me to my point: my metabolism has once again skyrocketed. And I fundamentally don't like it.

Some of the discomfort is related to the eating disorder: feelings of guilt and shame at having to eat so much more than others, wondering whether I'm going to gain weight from this, thinking that it would be an awfully convenient way to drop a few pounds. Some of the discomfort isn't: I'm tired of the near-constant cooking and meal prep, of the obnoxious grocery bills, of constantly having to be thinking of food and eating.

How I have to approach food and eating right now is pretty much the polar opposite of how people in the US are "supposed" to think about food. Low fat is not a smart option for me, and when you need over 3000 calories to maintain your weight, "healthy" isn't so healthy anymore. I don't get to "eat whatever I want" because of my freaky metabolism- if I ate what I wanted, I can guarantee you it wouldn't be this much. Instead, I have to be careful and mindful and responsible and eat what my body needs.

I'm simply frustrated and exhausted. I second guess all of my food choices, all the time. Have I had enough protein? Too much fat? Too many calories? Am I eating too much in the morning, too much at night? Would a bigger breakfast help? Should I include more fruits and veggies? And when I go to buy food- what about the costs? Can I find item X cheaper? Should I spend money on supplements like Carnation Instant Breakfast? What about premium ice cream like Ben and Jerry's? What about everything I was told about how wasteful it was to buy Ben and Jerry's because it was so expensive? Should I ignore that?

I kind of want to bury my head in the sand for a while, and just let this pass.

Reading back over what I've written, it seems like a long "oh poor me!' whine. I don't know- maybe it is. I only wish eating were simpler, less fraught with the moral perils I've internalized. And I keep getting discouraged that there doesn't seem to be an end in sight.

I write more than my fair share of headlines, between my blog, my job, and my freelance work. Yet the real news seemed buried in this little item.

Obesity is a family affair

I clicked on this headline with a bit of trepidation, and learned that yes, a child's weight is linked to their parents via genetics, but also via lifestyle. Which isn't really all that shocking. Any physical trait (known as a phenotype) has input from both genes and the environment, and weight is no different. Neither is height. The study was published in the American Journal of Sociology and you can read the abstract here.

The story was typical of the hysterical reporting on obesity that parents are going to kill their kids of TEH FATZ because Mom and Dad didn't go for a jog every evening. The two largest environmental factors affecting a child's weight was time spent watching TV/video games and number of meals eaten per week.

Whether or not a family regularly skipped meals had a large (sorry!) impact on a child's weight. The more skipped meals, the higher the child's weight. Author Molly Martin had this to say in the news story:

She said there are multiple reasons that children miss or skip meals. One is that the family may simply not have the resources to have three square meals a day, she said. Another is hectic family lifestyle, where the family could be missing a meal because they just don't have the time. Or, for some teens, they may be deliberately skipping meals in a misguided attempt to lose weight.

Whatever the reason, Martin said that when you miss a meal, you'll likely end up hungrier later and may overeat then.

"I think the importance of family meals is something that should be underscored," added Andrea Vazzana, clinical coordinator of the pediatric weight management program at the New York University Child Study Center in New York City.

"Kids that sit down with their family tend to have a more normal weight. Parents can provide structure for the meal, and the meal tends to be more well-balanced. Parents can also set limits around food," explained Vazzana, who added that when parents eat with their kids they can let them know that it's not a good idea to have two helpings of dessert first and then forgo the vegetables.

I just wish this portion had been highlighted more. But the Health Day article was the only one that even gave the importance of meals more than a passing mention. Of all of the media emphasis on "lifestyle factors" in regards to obesity, they could have started out with the importance of regular meals, rather than everything else.

I'm just doubtful that most people will hear about this and pick up on it.

Aria has officially been diagnosed with eosinophilic granuloma, a skin condition that is causing her to itch so badly, she chews her poor little legs raw. Many cases are due to food allergies, and while her steroids have kept it under control, there are long term risks for keeping her on them indefinitely.

So Aria is doing an exclusion diet, eating only a single protein source (either duck, venison, or rabbit) that is unlikely to cause her allergy because she's never eaten it before. I've started her on Hill's Prescription Diet d/d Duck & Green Pea Formula. And she gobbles it up! She also seems to like the venison wet food. So Thumper, for the time being, is safe. But Bambi's and Daffy's time is up.

As I was looking for feeding instructions, I read an interesting paragraph on the back of the bag:

"For best results, have your veterinarian monitor your cat's condition. Most cats will readily eat Prescription Diet d/d Duck & Green Pea Formula Feline. If they do not, be patient and firm, your cat's health is at stake. If your cat refuses to eat for more than two days, call your veterinarian immediately."

Why can't we treat people with eating disorders the same way? That their health is at stake if they don't eat? That two days of improper eating should warrant a frantic call to the doctor? To be patient and firm and encourage them to eat?

Is it really so difficult?

Note: if you have any pet-related questions, check out the Mar Vista Vet Pet Library. It's a great resource. I'm writing them an email to thank them for all of the information they've put online.

*I never thought something could smell worse than her tuna-flavored kibble, but this does. And let's not mention the litter box fragrance... ::shudder::

It's well-known that people in recovery from restricting anorexia--even after weight restoration--need significantly more calories just to maintain their weight. Some of this may be an ongoing metabolic dysfunction; some of it may also be the body continuing to repair itself, although the repair is not reflected in weight.

It also, in a word, sucks.

I've been weight restored for about a year and a half now, and I'm pretty active, all things considered. Still, I need to eat a lot more now than I ever remember needing to eat. Physically, it's not all that easy. And it's not exactly cheap. The biggest toll, however, is emotional.

For almost a decade, I prided myself on eating less than everyone else. Now, I have to eat more. I've gotten the comments of "Oh, you're so lucky to be able to eat whatever you want." But if I ate whatever I wanted, it wouldn't be this much, let me tell you. Eating what I need to is a total reversal of everything I've thought and done these past years.

In our culture, women are NOT encouraged to dig in and eat up. Food should be approached with caution. It can make you fat, after all. And I don't think there will be "Hungry Women" entrees in the freezer aisle anytime soon. There is a kooky diet site called "Hungry Girl," but it's basically low-cal substitutions for the foods you really want. Want some Halloween candy? Try a "pumpkin crunchie," a little meringue thing. So if a woman IS hungry, she certainly isn't going to honor that and have a Snickers bar.

So here I come, into this environment, not only receiving a quasi-cultural cringe, but also from the inside. I can't help but compare what I eat now to what I ate at the height of my eating disorder. And I feel this knee-jerk response, this intrinsic oh-you-fat-weak-pig, that makes me panic just a little. Knowing that these abnormal caloric requirements are normal and have been verified in a research study could very well be keeping me sane- and in recovery.

Yet I keep eating. I don't know what else there is to do. I am trying to surrender to the process, to run with it. Grudgingly, perhaps, but I also know it's the only way out.

Immoral parenting.

Interesting subject, no?

Now that there is so much parenting advice out there, if you don't do all 50 million things, then you're basically screwed.

Thankfully (for both my and any as yet unconceived children of mine), I am not a parent. I'm a mommy to my kitty, but that doesn't involve nighttime feedings, diaper changes, or pregnancy, so it's not quite the same.

Given the subject of my blog, I'm most concerned about how parents are judged on how they feed their children. I went to McDonald's, ordered a Happy Meal (Chicken Nuggets every time), drank juice at will, ate cookies regularly, had some sort of sweet almost every day, etc, etc. Today, this would make my mom a bad parent.

"Shame on you! You don't make your children exercise! You let them eat fast food! You let them drink juice! And pop!*"

Yet I never turned into an unhealthy person because of it. My health only seriously declined when I did the opposite of those things. As for my brother, well, let's just not go there. But his problems weren't related to what my mom fed us, either.

There was a commercial on for one of those cash advance companies and their ploy this time was, "You want to see super plays at Little League, not supersized fries."

I have nothing against Little League. I also have nothing against fries. They're trying to make a mom or dad feel guilty that they feed their children fries so they pay this huuuuuuuuuuuge fee to have time to get a "nutritious" meal and make it to a baseball game. In the long run, a fry is a fry. They're not immoral, nor are the people who eat them. I love fries, especially if you toss them in that powdered ranch dressing mix. I'm a fairly moral person. I don't cheat or steal. I always wear a seat belt. I at least try to be courteous. I meet deadlines. These were not things I learned from abstaining from fries for almost 7 years.

Not feeding your children- that's immoral. Or only feeding your children celery sticks. The line between immoral and harmful is vague. However, if you happen to have DNA that puts your children outside of the charts, you're hurting your child, and if you don't put them on a strict diet and exercise plan, you're destroying their health for the future.

People say the US has all of this horrible health. Yet infant mortality is low, we have a long life expectancy, deaths from infectious diseases are on the decline. Most people who die of heart disease have low cholesterol, and weight really isn't correlated either. Countries in Africa where food supplies are low and/or unstable, that's where you see problems. Having too little food is always always worse than having too much. So many products ::cough cough Alli cough cough:: are targeted at the 'overweight,' who actually have the lowest death rates. And if you're the parent of an 'overweight' child, you must have done something wrong.

The old saying is that "You are what you eat." So if carrot sticks are held up as this sort of Gold Standard of foods (or broccoli, or blueberries, or whatever) on both a nutritional and moral level, if you don't eat tons and tons of them, you're not only unhealthy, but you're a bad person. I don't vet this. Hitler was a vegetarian.

So let's have separation of church and state, body and business, and food and morality.

POST-NOTE: You're telling me Dr. Sanjay Gupta of CNN is a freakin' brain surgeon! Ha! Check out this chilling California ad campaign. It makes me sick!

*Where pop=soda. It's a Michigan thing. I ordered pop when I was in Atlanta and they gave me fries. I'm still scratching my head at that one.