Refeeding, A Step at a Time
Re-feeding: What is Normal?
The central and most difficult issue to be dealt with in the treatment of serious eating disorders is the issue of re-feeding and/or the establishment of a healthy relationship with food. The degree to which the patient can do this determines her success in conquering her disorder. The problem is that “normal” eating is a very complicated phenomenon, let alone the intricacies of re-feeding. This is one of the reasons that the “cure” rate for eating disorders is so low.
In some ways, it is more difficult to treat a severe eating disorder than it is to treat alcoholism or drug addiction. There is no such thing as cold turkey when it comes to eating. We have to eat every day, preferably 5 or 6 times a day. Likewise we cannot avoid the situations that trigger maladaptive eating behavior like the alcoholic or drug addict can do in an attempting to recover from their addictions. We eat for many reasons, under many different circumstances. We eat when we are hungry, not hungry, starving or full. We eat to socialize, to celebrate and to mourn. We eat to reward, nurture or punish ourselves. We eat when we are procrastinating, trying to relax or as part of a “working” breakfast/lunch/or dinner. We eat when we are happy, sad, mad, or for some of us, whenever we feel emotional.
Dieting Doesn’t Work
An equally important part of eating is the whole “not eating” thing, also known as “dieting”. Ninety-five % of US women believe that they are overweight and 65% of the general population diets. The dieting mind-set is so well ingrained in our society that some 5 and 6 year olds are worrying about how many calories and how much fat is in their Lunchables. Indeed, so many people in the US are dieting that it is a 93 billion dollar a year industry. There are hundreds of “diets”, diet workshops and diet programs, the vast majority of which fail. In fact, without exercise, 95% of all diets fail.
So why do so many people do it? We try to lose weight out of fear, vanity, pride or guilt or we may diet to feel stronger, more disciplined, superior and/or healthier, or we may just diet because everyone else seems to be doing it. The combination of being bombarded with advertisements to eat along side strong media pressure to be thin is constant in our culture.
All of the above behavior comes under the heading of “normal” eating. For those whose eating problems have risen to the level of a disorder, eating triggers feelings such as euphoria, guilt, shame and intense anxiety. Those suffering from Bulimia or Bulimarexia (restricting, binging and purging or just restricting and purging) engage in mindless eating or bingeing to numb or distract themselves from stressful situations or unhappy thoughts and memories.
Purging by vomiting or abuse of laxatives can last hours, keeping the individual up late into the night or causing her to miss work or school when she cannot resist the impulse to binge and purge during the day. One patient recently described a nightmarish scene in which she could not purge into her toilet because it was broken and so took a chance on using the tub drain as she showered. Unfortunately, the food would not go down that drain either. In horror she continued to vomit into the tub until she was standing in a foot of water thick with vomit. It took her and her mother hours to scoop the vomitous water out with buckets, which they then had to carry to another bathroom and flush down another toilet. The unbelievable part? Though repulsed by the mess, she was astonished and secretly impressed by the amount of vomit that she was able to produce!
Once she has binged (or simply eaten something she is uncomfortable eating) the need to purge is often so compelling that it goes beyond all reason, as in the case above. However this is a temporary “fix”. The purging gives the individual a temporary “high” followed by feelings of guilt and anxiety and a determination not to repeat the experience. Unfortunately this leads to restricting, which eventually leads to bingeing and the cycle begins again.
Sounds like drug and alcohol addiction, doesn’t it? Eating disorders are very much like other addictions, i.e. they are part of a classic addictive cycle. This includes an increase in tension, which the addict believes can only be relieved by the “fix”. In most addictions, relief from the fix is of shorter and shorter duration before the cycle begins again. This is what is known as a very vicious cycle.
Though not as obvious, the individual suffering from Anorexia is also an addict of sorts, i.e. she restricts to overcome feelings of inferiority, helplessness and hopelessness and to make herself feel in control. Often, she can only be proud of herself when she is pushing starvation to the extreme. This is her “fix”. Many of my patients describe the feeling of being able to function or stay alive on as few calories as possible as a “high”. Indeed there is scientific evidence that fasting does cause the release of endorphin’s, which do make us feel good. Not coincidentally, they report to the same part of the brain that drugs and alcohol do.
To summarize, even “normal” eating behavior can be stressful. Disordered eating takes over the individual’s life, much like alcoholism and drug addiction take over the addict’s life, robbing her of her relationships, her independence, her health and in far too many cases, her life. The mortality rate for eating disorders is higher than that of any other psychological disturbance.
Unfortunately, eating disorders are less likely to be understood as addictions, and more likely to elicit a judging stance from the general public, families and even a surprisingly high proportion of treating professionals. It seems as though the more serious the disorder, the more likely it is to be viewed as an attempt at getting attention or being manipulative.
Take, for example, the Cincinnati physician that said to one of our very attractive patients suffering from Bulimarexia, “You’re beautiful and you’re rich. You have it all. You should be counting your blessings. Why would you want to do something as stupid as refusing to eat?”
But the topper might be the psychiatrist that had another very attractive patient stand up at her first appointment so that he could “assess” her physique and make the following brilliant observation “Yup, you have breasts, hips and thighs. In other words you have curves, what’s the problem?” Individuals such as this often view Anorexia and Bulimia or Bulimarexia as vanity issues.
What Causes An Eating Disorder?
The causes are complicated and for most of the people suffering from an eating disorder, not the result of one factor, but many. The well-known causes are societal pressures to be thin, peer pressure, a major set-back at a critical point in the individual’s life, such as a loss or a traumatic event, childhood disturbances and/or dysfunctional family relationships, etc. However, there are also bio-physiological issues that play a significant role, although they tend to be poorly understood.
Many eating disorders are driven by cravings that are part of a classic addictive cycle, which may actually be perpetuated by food industry profits. In the early 70’s, the food industry discovered that high fructose corn syrup (HFCS) was much less expensive than sucrose. This was primarily because it was much sweeter. So, in it went into our foods, everything from baby food to hot dog buns and cigarettes! They ultimately took it out of most of the baby food, but it is still in the cigarettes, just in case cigarettes aren’t addictive enough without the sugar!
In Cincinnati, there are many fast food establishments still using HFCS’s in their buns, including; Arby’s, Blimpie, Burger King, Chick-fil-A, Dairy Queen, Jack in the Box, KFC, McDonald’s, Subway, and Taco Bell. You’re not safe at the Cincinnati Kroger’s either, or any of the major grocery chains for that matter, since it is actually harder to find foods at the supermarket without HFCS’s, than it is to find foods with it. For example, there are no less than 10 teaspoons of HFCS’s in a single 12 once can of soda. Likewise they are found in almost all snacks, dairy products, condiments, canned goods, cereals, bread, even supplements and vitamins. In total, the average American eats 83 pounds of corn syrup a year plus 66 pounds of sucrose, for a total of 149 pounds of refined sugars.
What does that mean in terms of unnecessary weight gain? Well let’s do the math: We have 159,360 calories from the corn syrup, and 102,168 from the sucrose totaling 261,528 calories per year from sugar. If it takes 3500 calories more than you use in a given period of time to gain 1 pound, that means that unless you work it off, you could gain 75 lbs/year from ingesting sugar you don’t need and probably don’t realize you are eating. To avoid gaining weight from the HFCS’s added to processed foods, the average person would have to run a total of 438 hours per year or 8 hours per week. The net/net of all of the above is to avoid processed foods, i.e. if it didn’t have a face (meat, poultry, fish, fowl) or come out of the ground (fruits, vegetables, nuts, legumes), think twice about eating it. (The exception would be dairy products, such as yogurt, soft European cheeses, and milk. The lower fat varieties of these foods are very good for you, especially when they are lactose free.)
Sugar and Eating Disorders
photo used under creative commons license
What does HFCS have to do with eating disorders? For starters, sugar has recently been shown to be the main culprit in insulin resistance, which is the precursor to obesity. In this country, obesity has become the nation’s most critical health problem. Ultimately it leads to such chronic diseases as Type II diabetes, high blood pressure and heart disease. These diseases are threatening to dismantle our entire health care system because of their increased incidence and skyrocketing cost of treatment.
Binge eating, bulimia, and bulimarexia are basically sugar addictions, as most individuals suffering from these disorders binge on simple carb’ s (highly refined foods that are often loaded with HFCS’s). Simple carbohydrates convert to sugar in the blood stream. Research has shown that sugar is as addictive as alcohol and/or cocaine.
Recovery from a food addiction (eating disorder) requires a basic understanding of the addictive nature of food and a commitment to replace the offending food(s) with something equally satisfying but less addictive. Otherwise you find yourself in a perpetual and very vicious cycle of restricting or deprivation (dieting) followed by the onset of withdrawal symptoms (food cravings, obsessive thoughts) a build up of anxiety and behaviors designed to quiet the beast, (bingeing, cutting, compulsive spending, binge drinking) and possibly efforts to compensate (purging with vomiting, excessive exercising, abuse of laxatives and/or diet pills). This leads to guilt and a profound sense of failure, which is followed by renewed determination to stop the cycle by not “eating so much” which is a euphemism for restricting or dieting, at which point the cycle begins again.
Unfortunately, many in an effort to avoid the offending food(s) restrict too much and end up avoiding the foods that could break the cycle, proteins or complex carbohydrates i.e. low fat meats, cheeses and fish or fresh fruits and vegetables. Instead they eat foods that actually contribute to the food addiction and cause the cycle to begin again. For example, so many of my patients avoid all protein because of their fear of fat and eat simple carbs, like pretzels or diet soft drinks when they are in restricting, dieting or “being good”. Or worse, they eat candy that has no fat, like jellybeans, thinking that this is a safer snack than a piece of chocolate or a handful of nuts. The chocolate, especially if it’s dark chocolate, does have some fat, but it has fewer sugars than a bag of jellybeans and, because it is dark chocolate, it has antioxidants. And the nuts have a good deal of fiber, which means that they usually have a glycemic load of 0. (This means that they do not enter the blood stream as a sugar and therefore do not contribute to a sugar addiction, which is the primary culprit in the weight gain that leads to obesity).
The jelly beans, on the other hand, and even the diet drink, make the problem much worse because they enter the blood stream almost immediately as glucose, adding to the sugar addiction, which in turn drives more binging behavior. They also have dyes and additives and no nutritional value. The real kicker however, is the long term negative impact that carb loading followed by purging or restricting has on ones’ metabolism, i.e. it slows it down to such a degree that it is almost impossible for the individual suffering from bulimia to eat normally without gaining weight. Until she understands which foods and supplements will stimulate her metabolism instead of suppressing it, she is stuck in this terrible self-perpetuating vicious cycle.
Once she understands how delicious real food can be and how much more of it she can eat without fear of gaining weight if she is exercising and supplementing, she has begun the journey toward a healthy relationship with food and the end of her eating disorder. But this requires courage, patience and lot’s of support from family, friends and allied professionals.
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