Living With Food: The Science Supporting Eating Disorder Treatment

Some of the most common medical complications of eating disorders are those related to the heart. Cardiac complications from anorexia nervosa, along with suicide, are the leading causes of death from this diagnosis. Cardiac complications are often present with bulimia nervosa as well, and can also be fatal. Cardiac complications from anorexia are sometimes predictable, but often not. The predictability can arise because symptoms such as slow heart rate, (bradycardyia), and significant changes in blood pressure and pulse between laying and standing (orthostasis) may be present. Both of these symptoms may predict future cardiac risks and dangers. However, the main danger to the heart is electrolyte imbalance in the face of a weakened heart. This, combined with the loss of heart mass, can occur before all the weight loss has occurred. Therefore, it is not just the extremely underweight who are at risk.

In people with anorexia, cardiac changes that appear on an electrocardiogram may also occur. This particular change, called a prolonged QT interval, is also a predictor of fatality for a patient with anorexia. In general, individuals with prolonged QT intervals will require hospitalization. The only way to know if a QT interval is prolonged is by obtaining an electrocardiogram, which should be a routine recommendation in the assessment of an eating disorder.

For patients with bulimia, death from cardiac issues is usually due to changes in their electrolytes, particularly changes in potassium, magnesium, and phosphorus. Because these changes are impacted by purging behaviors, death from bulimia is often sudden and unpredictable. Patients who use ipecac to induce vomiting increase their risk for death from cardiac issues by a different mechanism. Ipecac is toxic to the heart and essentially poisons the cardiac muscle, which can result in death.

Common symptoms someone might experience if they are at risk for cardiac abnormalities include: tiredness, lightheadedness, fainting, heart palpitations, chest pain, shortness of breath, and reduced tolerance to exercise. Anyone with these changes should have an assessment immediately. Although dangerous, cardiac changes can be treated, and the treatment for them is straightforward. They all involve bed rest, stopping all behaviors, and in some cases, hospitalization. If cardiac complications are present, treatment for the eating disorder is an absolute immediate necessity and will usually include refeeding and the establishment of a safe and healthy meal plan. The body is wise enough to repair the heart as soon as it has a chance and the resolution of cardiac complications is an early sign of improvement in the healing of an eating disorder.

A special thank you to our consultant for this post, Dr. Ellen Rome from The Cleveland Clinic Foundation.

Contributions by Sarah Emerman

This letter was written by a client in one of our programs. It is published with her permission in hopes that it will inspire others to seek help and get treatment.

Dear ED,

You’ve hurt me time after time, breaking my heart while convincing me that you were all I needed. You lied to me and convinced me to lie to my parents, friends, doctors and therapists. You’ve told me that I was succeeding, when really all I accomplished was sabotaging myself and my own life.

You crept into my life. Two years ago, you told me to start eating salads for lunch to be healthy and lose a few pounds to be in better shape. I did, eagerly. I lost weight and continued to “eat healthily” but it wasn’t enough for you, it never was.

ED, you ruined my relationship with food. When I was younger, my mom used to brag that I’d eat anything and it was true. You changed that, causing me to feel anxious about certain foods and dictating rules about which foods were “good” and “bad” and how often I could eat them. You convinced me to punish myself when I broke your rules, and you even forbade me from eating my favorite fruit. You made me forget how to eat normally.

You stole my passion and dedication for the sports I played and replaced it with your definition of exercise: mandatory but not fun. You persuaded me that it was ok to not eat before or after practices and that I didn’t need to eat an adequate amount of food in order to achieve my goals. You were wrong. Because of you, I never met those goals and never will be able to. Instead of enjoying time with my friends on a team, you made me exercise alone. And even though I felt dizzy and my chest hurt you wouldn’t let stop.

But of course, you couldn’t stop with food and exercise. You are so greedy that you hurt my body, too. You made my hair fall out and caused my skin to appear pale. You made my brain fuzzy so that I couldn’t concentrate but worst of all, you damaged my heart. You are the reason I spent two miserable weeks in the hospital and you caused my body’s demise.

You not only abused my body, but also changed my personality. You depleted me of my natural enthusiasm and optimism and caused me to isolate myself from my family and friends. You made me forfeit birthday parties, girls nights out, and even chance to travel because you didn’t want to me to eat certain foods and you told me I needed to exercise. You took away my sense of humor and instead made me sad and hopeless.

The truth, ED, is that I do NOT believe your lies anymore. I am done with accepting your limits and I refuse to deny myself the right to enjoy foods that I like. I will engage in physical activity without it damaging my body. I want both my body and mind to heal, neither of which you will ever allow me to do. I claim the choice to living a healthy live and I chose to eradicate you from it.

Should you have questions or comments regarding this post please email blog@eatingdisorderscleveland.org.

We have long known that people with anorexia nervosa are often likely to also have comorbid depression. Much of the time the depression is not a separate illness but a result of the physical and biological changes that anorexia produces on the brain and body. Tiredness, exhaustion, malnutrition, chronic worry, and obsession with body size and shape can all make someone more depressed. In addition, on a biological level we believe that the brain’s ability to produce neurotransmitters that effect mood are also significantly depleted by malnutrition. Specifically, we know that serotonin production lessens as malnutrition develops, which makes traditional antidepressant medications less effective. We believe that it is likely that almost all neurotransmitters, which can affect a wide variety of brain function, are depleted with malnutrition. This may look like depression, or just a lack of ability to feel any emotions. 

This month an exciting new study has added to our knowledge of the biological changes of the brain from malnutrition. In a study led by Christina Roberto, at the Columbia University Center for Eating Disorders, Roberto found that individuals with anorexia suffered a loss of gray matter in the brain (which is the active part of the cortex). So, some of the changes we see may be due not only to neurotransmitters, but actual loss of brain mass. On a positive note, with restoration of weight, there is also restoration of gray matter, meaning that many of the brain changes from anorexia, whether neurotransmitter or gray matter itself, often correct as refeeeding occurs.

As we have discussed in this blog many times before, refeeeding is the most important single step for the treatment for anorexia. This new study adds to that data and makes clear once again that trying to talk someone out of their eating disorder is likely impossible as they may literally have lost the brain power to know whats going on. In terms of evidence based care, when looking for treatment for anorexia be cautious of treatments where refeeding takes a back seat to figuring out the why the eating disorder develops. As this study demonstrates, at the start of one's treatment, nutrition and refeeding should be the primary focus for most people.

For more on Roberto's study click here

Contributions by Sarah Emerman

If you have any questions or comments about this post please email blog@eatingdisorderscleveland.org

This post was written by a client at our center. It is published with her permission in hopes that it will inspire others to work towards recovery.

Even though you, ED, made me so sick, I liked it in a way. You were what I treasured for so long. You were mine and you controlled me. I stopped caring about my health and started adoring my protruding bones and my twiggy arms and legs. I felt accomplished for starving myself and eating less than X calories everyday. You made me brag about my illness and deny that I was sick. I liked that feeling of emptiness that you gave me. You gave me something to be proud of. You made me feel and look truly thin for once in my life. You made me numb. You made me tough and strong. You made me stand out.

ED, You also:
Made me drop to a dangerously low weight. Made my whole body weak. Made me depressed and irritable toward others. Made me restrict like no other. Made me lose hair. Made me grow lanugo on my body. Made me get edema. Made me cold all the time. Made me lose my athletic/fit body. Made me very self conscious. Made me get headaches. Made me shake and feel numb. Made me feel faint. Made my arms so small I can fit my hand around the upper part. Took away sleep. Caused nightmares. Messed up my digestive tract. Told me I was worthless and didn't belong in the world. Told me lies. Made me lie, a lot. Made sitting down hurt. Made me not care. Hurt my heart so badly and made it weak. Put me in the hospital. Took me away from school, my friends, and my goals. Took over my time and thoughts. Made me so sick. Made my body twitch. Made me fear dying, soon. Made my clothes fall off me. Made me lose my period. Took away my "glow". Made my chest hurt. Made me orthostatic and dehydrated. Denied the good things in life. Ruined a part of me. 

ED, I'm not sure if I'm ready to let go quite yet. Someday, though, you will be banned from my life; escorted out of my dreams and goals. You will no longer have hold of my entire being. I promise you this ED; your time is running out. You might as well start packing. I'm slowly losing interest and desire for you. It's almost time to say goodbye.

The two letters below were written by our clients to their eating disorders. With their permission, we share these letters to inspire others to seek treatment and fight for recovery. 

Letter #1:

ED:

You are no longer welcomed in my life. Your constant companionship has left me nothing but lonely and hollow inside. You fed me lies instead of the food I really needed. You locked up the voice of my wise mind and hid the key from me. You told me that no one would love me unless I was thin.

Well ED, I did what you told me. I became so malnourished that I lost my hair, my sense of feeling, and my sense of self. You led me on a path of destruction that left me alone and confused. As I was physically and emotionally dying, you encouraged me to continue on this path. 

I am no longer your "friend" ED. I am standing up for myself. Although you told me that I am worthless and I do not deserve my life, I do. I am taking back control from you ED. I found the key to the voice of my wise mind and I am allowing myself to follow it. I am no longer going to feel isolated and abandoned. I am going to embrace recovery and allow myself to live a life worth living. 

Therefore ED, as hard as this may be, I am ending this "bad romance". You have brought me nothing but heartache and sorrow. Goodbye ED. I hope I never hear from you again. If you try to contact me, I will be busy living the life I deserve and have no time for you. Farewell.  

Letter #2:

Dear ED,

I know you bought me those jeans but I'm just writing to tell you that I don't want them anymore. You lied and made me believe that they were a gift when really you were playing tricks with the mirror and disregarding my health as you told me how amazing I looked in them.

I may have felt good as I stepped out of the dressing room then but now I know there are more important things in life than my "great" pair of jeans. You never told me those jeans were dangerous, that by just putting them on you would control me. You never told me that my heart muscle was deteriorating, that it beat slower and slower to the point of almost stopping. No, you distracted me by bombarding me with compliments to make me feel amazing. 

Even though you're not going into medicine and I am, it doesn't take a genius to realize that without a functioning heart there would be no one to even put on the jeans. ED, you don't make any sense, and I'm sick of it so take your jeans back. I'm not going to let you hurt and break my heart anymore.  

One of the thorniest issues in eating disorder treatment is the notion of goal weight. Almost everyone in treatment wants to know what weight they’re supposed to be. The problem with this question is that it presumes the brain can and will tell the body what an appropriate weight is. This, however, is essentially untrue. When a person is healthy, the body finds the weight it needs to be.

For a person with Anorexia, the way the brain tries to control weight is through behaviors. Good treatment therefore means stopping the brain from trying to make the body do what the brain wants to. In eating disorder treatment, a client must learn to trust their body.

Goal weight is determined by your body, and is what your weight will be when you eat a healthy diet, stimulated by hunger, ending with fullness, over a period of time while engaged in an activity level that is healthy for you. The eating disorder has a very hard time believing this. This is one of the reasons a behavioral method of treatment is effective when other methods of treatment have failed. With all of this in mind, doctors and therapists use the term “goal weight” to mean many different things.

Primary care physicians are likely to use the term goal weight to define a weight where medical function (i.e.: heart, kidneys, endocrine system, bones) are functioning normally. This means that a person’s blood pressure and pulse will improve, their kidneys will function, they will experience a return of menses, and they will be on their way to reversing bone loss.

Eating disorder therapists and specialists versed in the current literature on Anorexia will determine goal weight based on research which demonstrates that the more weight a client gains during treatment and is able to maintain post-treatment, the less likely they are to relapse (Kaplan, Walsh, Olmsted, Attia, Carter, Devlin, Pike, Woodside, Rockert, Roberto, & Parides, 2009).

Any one of the treatment members discussed above may use criteria described for another. Centers using a multi-disciplinary treatment approach will form a team that consults from all of those mentioned above to best determine what a client’s goal weight might be.

The bottom line is this: no one knows what you’re “supposed to” weigh and no one can predict what you will weigh. Many doctors and therapists will be able to provide numerical guide posts along your way to healing, but no one will be able to tell you what your body truly needs to weigh. There are too many variables and every person is different. Ultimately, the goal is health and happiness.

Kaplan, A. S., Walsh, B. T., Olmsted, M., Attia, E.,Carter, J. C., Devlin, M. J., Pike, K. M., Woodside, B., Rockert, W., Roberto, C. A., & Parides, M. (2009). The slippery slope: Prediction of successful weight maintenance in anorexia nervosa. Psychological Medicine, 39, 1037-1045.

Next week: Therapy fails patients, patients don't fail therapy

Contributions by Sarah Emerman

Given the complexity of the brain, and the reality of everyday life, all of us are prone to some psychological issues. All psychiatric disorders may therefore have long term implications.

Anytime a person has had any psychological issue, whether it be anxiety, depression, panic, substance abuse, or an eating disorder, they’re always at greater risk for the return or relapse of this disorder. Recovery involves many things. Treatment must then be seen as having multiple phases.

For eating disorders these phases include:

·    Medical stabilization - Insuring that the cardiac, brain, bones, endocrine (i.e.: the return of menses) and other systems are intact.

·    Refeeding - Gaining an appropriate amount of weight, usually 95% of pre-morbid weight to prevent relapse.

·    Behavioral control - Stopping or reducing binging, restriction, purging, over-exercise, and pill usage.

·    Feeling better about oneself - Increasing self-esteem, better body image, general increased levels of happiness and the ability to experience multiple different emotions.

·    Changing the way a person thinks about food, body size, and shape

·    Having the life a person truly wants to have

One will see a therapist or be in a formal program for a significant amount of time, often measured in years. A person will also need caring and connection for the rest of their lives. Formal eating disorder treatment is likely to last one to five years given the complexity of the multiple stages of healing. All of the above happens in the context of building a supportive, knowledgeable, community that one will be able to experience for the rest of their lives. Each phase of treatment takes a variable amount of time, but no one who has ever suffered from an eating disorder should ever be without their community of care and support. In this way, although significant advances towards recovery may happen in as little as one year, healing should be seen as life-long.

Getting into recovery from an eating disorder is an extraordinary and rewarding experience. From the perspective of evidence-based therapies, particularly DBT, recovery is a path a person follows, not an end to be achieved. As an eating disorder gets better, a person gets to appreciate and enjoy their lives more and more. They come to fully inhabit their lives. For people with and without eating disorders, the process of achieving and continuing to be the person we most want to be is a joy we work towards forever. 

Next week: How do we determine goal weight?

Contributions by Sarah Emerman 

I was at my block party last night and fell into a conversation about being in your 40's with an eating disorder. Turns out a friend, Meagan (note- all names have been changed in this blog post), who is a dancer, has been pulling away from a friend of hers because her friend's eating disorder was just too intense. Her friend has been hospitalized a number of times, is still unable to acknowledge her ED, likely is in renal failure, and is probably going to die soon. Another neighbor, Tina, happened by and with some sense of disgust started explaining that she, Tina, couldn't understand eating disorders, had no food issues, loved to run just for the endorphin high, and wasn't eating at the party because she had already had dinner beforehand. I felt like Meagan at that point, just wanting to pull away. (It was a party, after all.) I made a few attempts to say that everyone has food issues and that it wouldn't be so strange if Tina had a couple of things to work on, and so on, which only served to end the conversation.

So why is this important? Because it is so clear that your best chance to get better is to get help early, have aggressive and effective treatment, and get on with your life.  If you are 45 it probably means there was nothing close to effective treatment when you were young. If your illness didn't get better through caring, family, eating and fortune, you are likely very ill now. But there is still help for many. If you are younger, or know someone who is, get yourself or them into treatment now. Don't expect anyone to just figure it out. The thoughts, feelings and behaviors are too deeply set. Don't wait to see what will happen. The odds are high that what will happen is getting worse, not getting better. There is effective treatment now. You can get better.  Now I have to go follow up with Tina.

Next week: Why don't all therapists use effective treatment?

Contributions by Sarah Emerman