Not Enough Is Too Much

So the doctor put me on a highly restrictive diet for a few weeks and it almost drove me insane.

I know that sounds like hyperbole, but I’m not kidding. The diet, in preparation for some surgery, was called a liquid diet, but in truth, I was allowed anything up to pea soup consistency. Non-fat yogurt, Jell-O, pudding, Jell-O, sugar-free Popsicles and Fudgsicles, Jell-O, cream soups, Jell-O, broth of any kind, Jell-O, vegetable and fruit juices, Jell-O, Jell-O, coffee or tea, Jell-O, more Jell-O, still more Jell-O, non-fat milk, and Jell-O.

Did I mention I could have all the Jell-O I wanted? Oh, yeah, you bet.

The target was 1,000 calories a day for two weeks before and two weeks after the surgery. I guess for some people that would be tolerable; for some, a month long thousand-calorie-a-day diet is fairly routine. For me it was a bleak and treacherous stretch of woe. I haven’t been on a “diet” for over a decade now and returning to that state of self-induced starvation was like returning to the school where you got bullied and beat up every day, relentlessly, for years until you made good your escape.

When I first entered the Intensive Outpatient Therapy program for treatment of my eating disorder, they told us, “Quit trying to lose weight. Stop dieting. Completely. Right now, not in ‘just five more pounds.’”

You might think this was met with delight, but (like everyone else in the program) I reacted to the directive with doubt and dismay. I had been dieting, in one form or another, for most of my childhood and all of my adult life. The idea of abandoning diets, no matter how useless they had been, was deeply disturbing. It was like getting a shipwreck victim who’s standing safely on the beach to let go of their life jacket. However, when you commit to a program like the one I was in, you’ve already admitted that you’re not seeing things clearly and signaled your willingness to surrender to a different paradigm.

So I stopped dieting and prepared to become a whale. Or a blimp. Something fantastically corpulent.

That didn’t happen. I did gain some weight, but in a matter of a few months—after following my natural appetites rather than some food plan—my weight stabilized. It turns out that, given the opportunity to eat donuts and ice cream all day and night, I naturally chose not to eat donuts and ice cream all day and night. After a while, I was just as likely to crave a tuna and tomato sandwich as a chocolate chip bear claw. Subsequently, as my binge behaviors subsided, my body began to adjust: it got substantially lighter. Weird.

This just in: prolonged restriction of can create a distorted relationship with food, abnormal eating behaviors, and increased weight. Conversely, eliminating restriction will eventually result in a return to natural appetites and eating behaviors. Who knew?

Apparently the United States government.

In November 1944, a researcher, Dr. Ancel Keys of the University of Minnesota, conducted a year-long experiment into the effects of starvation. Known informally as the Minnesota Starvation Project, it involved having 36 men lose 25 percent of their body weight by restricting them to 1,570 calories a day for six months. In addition, they were required to walk 22 miles a week. The subjects were volunteers, conscientious objectors who were pleased to be supporting the war effort without having to enter combat.

The physical maladies caused by the food restriction were as expected. The psychological effects were much more involved and profound than anyone had anticipated. Cognitive abilities became sluggish, depression set in, extreme moodiness, introversion, impatience became the norm. Thoughts of food were pervasive and constant. One participant noticed that when he went to the movies, he didn’t pay much attention to the love scenes but remembered everything the characters ate. Eventually, the unrelenting hunger evolved into deep unhappiness and sometimes rage. Two of the participants broke from the program and were removed. One of them admitted to stealing food, stopping at local soda fountains for sundaes, and eating scraps out of the garbage. Both had to spend a brief time in the University psych ward.

After the six-month restriction period was over, there was a three-month recovery stage where calorie levels were increased. When that concluded, even though none of the men had regained their pre-study weight, they were released. They were cautioned not to eat too much but told they could eat whatever they wanted. Buh bye.

Their physical and psychological recovery was far from complete and they all knew it. On the first day, one participant ended up vomiting on a bus because his stomach couldn’t contain all food he had eaten. Another ate so much, he ended up having his stomach pumped. As one man put it, the fact that their stomachs were full in no way diminished the craving for food.

Think about that for a minute. Your stomach is full but you’re still gripped with unrelenting hunger.

That’s messed up.

All the men recovered fully over the course of a couple of years—however, most reported gaining a substantial amount of weight before returning to their normal pre-study weight.

My point?

While I was on that thousand-calorie-a-day diet, the unrelenting hunger I experienced wasn’t just a physical sensation, it was an emotional minefield. It made me think about all the years I had seen hunger as a friend, the gateway to contentment because I knew if I could keep myself hungry long enough I would lose weight and my life would be wonderful. I could finally be happy. Yet, looking back, it’s clear that keeping myself in a state of perpetual hunger for years not only contributed to my disordered eating, it made me feel depressed and awful and angry all the time.

Does dieting alone cause eating disorders? It seems unlikely, but it almost certainly stokes the fires. The Binge Monster likes hunger. It likes other things, too—despair, self-loathing, imagined inadequacies of all sorts—but hunger, that’s a key motivator. It turns out if you walk around hungry all the time, eventually your body takes matters into its own hands (because, let’s face, between the two of you, it’s the one with the hands) and not only forces you to relieve the hunger, it seeks to regain lost ground.

Since 1950, we have had empirical evidence that the combination of restricting food and increasing physical activity leads to mental distress and weight gain. Yet, the solution to obesity, we are told, is diet and exercise, diet and exercise, diet and exercise, and if you can’t control your eating—if you can’t make that plan work—it’s because you’re not trying hard enough or you’re weak. You lack the will or the character to be healthy.

That’s messed up.

If you couple food restriction with physical activity for a prolonged period of time you get abnormal eating behaviors resulting in weight gain. We know it. We’ve known it since 1950.  It’s the 800-pound gorilla in the room that nobody wants to acknowledge.

I wonder if maybe everyone is ignoring the Gorilla because it’s trying to get from 800 pounds down to 650, so it’s on this diet, see, and it’s been in a really really bad mood lately. Believe me, I know what it’s like.

 

RELATED RESEARCH:

A comprehensive article about this study; so many of the fascinating details ended up on the cutting room floor while writing this post, it’s very much worth the time to look into. Highly recommended.

http://jn.nutrition.org/content/135/6/1347.full#F1

A video presentation at the University of Minnesota website that deals with the study, narrated by one of the participants who gives personal insight into prolonged hunger and the consequences. Make sure you catch the last two minutes.

http://www.epi.umn.edu/cvdepi/video/the-minnesota-semistarvation-experiment/

 

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Where Have All The Young Men Gone?

At one point in my decade long treatment for BED, I was in an Intensive Outpatient Therapy program, which is kind of a step up from standard individual and group therapies but not quite residential (live in) treatment. Five days a week, in the evenings, a group of us reported to the facility for various forms of psychological counseling and group activities. Most of us carried on this way after a full day of work or school. It was demanding, exhausting and, for many, efficacious.

There was, however, an element of the program that didn’t work, or not as intended. Wednesdays we had an hour long group devoted to Body Image, the idea being that we would spend the time discussing our relationships with our bodies, how we felt about how we looked and how it influenced our eating behaviors, how we were impacted by images in the media and how to overcome those triggers.

That never happened.

Oh, we’d try. We’d start out ranting about this commercial or that ad, talk about body acceptance and how unfair social expectations were and how awful people could be. We would be absolutely frothy…for about fifteen minutes. Then it would get very quiet and someone would bring up what their mother said that morning or what their brother or husband had done last night. Someone else would remark how that related to something that had happened when they were a kid and that would lead, in turn, to someone else talking about an older relative who did to them monstrous things no child should ever endure and suddenly we were back where we always ended up in these groups: dealing with the underlying emotional damage that is always the at the root of the compulsion.

Nobody ever said, “I saw an ad in Vogue today and it made me want to binge and purge.” It just never happened. So Wednesday Night Body Image Group turned into just another process group where we talked about the pain that had brought us all there in the first place.

The reason all this came to mind is because I ran across an article about research done at Oregon Research Institute into a particular type of ED prevention program. Nutshelled, the research found that this dissonance-based program changed the way young women’s brains responded to images of extremely thin models and, in doing so, ultimately reduced the risk factors for eating disorders. Using brain scans, the ORI researchers were able to actually “see” the brain responding positively to images of healthy female bodies while the reduction in reward response to thin supermodel bodies was visible, too.

The article set off a couple of firecrackers in my brain. Let me make it clear, I think having young women respond positively to healthy body images is great and I’m all for anything that promotes that. There is a part of me that is uncomfortable with the tail-wagging-the-dog approach of countering media filled with unhealthy images of women by “fixing” the brains of girls so they don’t respond to those images, but the world is what it is right now, so I begrudgingly accept the value.

What bothers me more than that is that it places the emphasis too heavily on body image as a factor in eating disorders. As emotionally satisfying as it may be to demonize the fashion and advertising worlds as the source of all that is evil, they don’t cause eating disorders. To quote the National Institute of Mental Health, “eating disorders are caused by a complex interaction of genetic, biological, behavioral, psychological, and social factors.” In the Jenga stack of ED causes, you can remove the Unrealistic Body Image block and leave the tower standing every time. There are millions of people exposed to freakishly unhealthy body types via advertising and entertainment; only a tiny fraction of those will ever develop an eating disorder.

Yet the popular notion that these conditions are caused and driven by the ubiquity of such images persists and that is neither accurate nor healthy. EDs are complex and difficult to understand. Implying, even indirectly, that we can put a dent in the problem by counteracting the images found in the media may be exacerbating the problem by obscuring and dismissing their true nature.

The other thing that set me off about this study and the program it focused on was the complete and utter lack of attention to—or recognition of the existence of—men. Men simply are not. The only acknowledgement that there is a male of the species in the whole thing is a tacit reference in a single sentence from the study that mentions eating disorders being “a key mental health problem that disproportionately affects young women.”

Oh-em-gee! Could you be any more dismissive? I can almost see the contemptuous waving of the hand at the mere mention of men with eating disorders. “Well, you know, actually they disproportionately affect young women, so…pish.”

And so…what? Men don’t count? Apparently, neither the program nor the study could be bothered to examine the impact this methodology might have on the brains of young men. Really now, how hard would it be to modify a program involving positive body imagery for use with men? (hint: not hard.)

It’s so blatantly sexist and discriminatory it’s staggering. Just to be clear, this sort of thing in the world of research is absolutely a two-way street; the marked tendency for heart disease studies to focus exclusively on men is legendary. Still, it’s not okay, it’s never okay. Every article that addresses the subject concludes that eating disorders among men are under-reported. At least part of the reason would certainly have to be the willingness of researchers to dismiss men as insignificant and unworthy of examination…because, you know…disproportionate.

Having conducted my own examination and carefully considered that approach to research and treatment, I’ve reached a somewhat unscientific, but I believe accurate, conclusion: it sucks disproportionately. Perhaps that will get it some attention.

 

 

Stranger in a Strange Land, Part 2: Do You Speak E-D?

I skipped right by it in the first entry but there’s almost certainly no getting around it this time, so let’s address the matter of which particular disorder is my particular disorder. I know you’re dying to know.

Of the five major eating disorders listed in the DSM 5, three of them have entered the popular consciousness (there are a handful of lesser-known but recognized conditions that are classified “other specified feeding or eating disorder” or OSFED). Anorexia and bulimia are the best known of the big three, while the least well-known and most widespread is Binge Eating Disorder. Not really sure why no one ever talks about BED, especially given its ubiquity. It could be that it’s not glamorous enough. Celebrities tend to be anorexics or bulimics. Movie stars aren’t binge eaters, or binge eaters aren’t movie stars (take your pick). You won’t be hearing about anybody’s struggles with Binge Eating Disorder on Entertainment Tonight or TMZ anytime soon.

I need to stop here for a minute and explain something and I hope you won’t be insulted or get disgusted and go check for sleeping kitten pictures on your Twitter or Instagram or whatever. You see, this is the part of the piece where I would typically take a paragraph or two to describe what each of the disorders is and how it functions and maybe a third paragraph with some general this-and-that about eating disorders. It makes sense. But I’m not going to do that and the reason I’m not going to do that lies in a simple yet inescapable truth: if you don’t have or have never had an eating disorder then the likelihood you’re ever going to truly understand what they are and how they function—that you’ll ever fully “get” the people who live with them—is next to zero.

That’s not intended as commentary on your intellectual ability or your levels of compassion and empathy or anything like that. Really, it’s not. It’s not indicative of some flaw in your character. It just seems to be the way it is. I’m not the only one who has observed this cognitive peculiarity. It’s not for lack of trying. God, Buddha, and all their neighbors know I have tried. I have spent hours, many hours, explaining to people—intelligent sensitive sympathetic people who are actively engaged and aggressively trying to comprehend—and it’s like I’m explaining advanced astrophysics in Sanskrit.

Actually, the conversation doesn’t usually last hours. Generally I lose them right about the time I say, “Well, eating disorders really have nothing at all to do with food.” Somehow that seems to be the deal breaker.

The flip side to that general lack of understanding is this: when I walked into a therapy group for the first time —a room filled with women from a wide array of backgrounds, all younger than myself, all with eating disorders—it was like walking into a room full of family members I’d never met before. Certainly, we all needed to adjust to the unusual circumstances, but very quickly there developed a sense of safety and an ease in our communictation. We were like visitors from another planet who had found each other and could speak in their native language and be understood for the first time in their lives. It was an enormous relief and gratifying beyond the ability of words to express.

Unless you have an eating disorder, in which case you already understand exactly what I’m saying. Otherwise . . . my apologies, Earth Person.

Which brings me back to the question of which one of the disorders I brought to the dance and the answer is . . . I’m not telling. The reason I won’t say is this: in spite of the fact that the behaviors are very different and the wounds and suffering they make manifest are as varied and diverse as the people who live through and with them, fundamentally all EDs are the same. Scrape away all the outside trappings—the gender, age, economics, race, religion—and what you’ve got is a compulsive disorder deeply rooted in psychological trauma set off by a vast and often unpredictable array of emotional triggers. Everything else is—if you’ll pardon the expression—icing on the cake.

I won’t tell you which disorder is my disorder because I don’t want you to think of my disorder as the behavior it produces. I don’t want you to think of me as a man who has an eating disorder because he engages in behavior X. If this piece alters just one perception you have of EDs, let it be that. Let it be that when you hear someone mention eating disorders, it doesn’t summon an image of young girls starving or throwing up or gorging themselves, but people—men and women— being taken over by a machine-like impulse for self-harm and who are desperately trying to find the “off” switch. If you can see that inner struggle instead of the outward behaviors, then perhaps we’ll move a little closer to proving me wrong about people’s ability to understand.

I’ll still be explaining astrophysics, I’ll just be doing it in Mandarin instead of Sanskrit.

(If you’re looking for reliable sources for more information on eating disorders, there are a number of websites to choose from. However, it should be noted that as of our publication date, many websites have not incorporated the substantial changes made to diagnostic categories and criteria in the DSM 5 and still have information from the DSM 4 listed. The National Eating Disorders Assoc. website does make note of that fact and links to a list of changes, so it’s there we would recommend you go for additional information.)

Stranger In a Strange Land, Part 1: I Am Who I Am . . . and You’re Not

I am about to make a statement that you’ve almost certainly never heard before. Here goes: I am a man and I have an eating disorder. Here’s another: I am a middle aged man and I have an eating disorder. We’ve got some momentum, why stop now: I am a heterosexual baseball watching T-shirt and sneakers-wearing middle-aged middle-class dude with an eating disorder. And you’re not. Unless you live a very secluded life, in all likelihood you know someone who has an eating disorder, maybe several someones. They may be unaware of, unable to, or unwilling to acknowledge their situation or they may be in recovery, but they are there nonetheless, hiding in plain sight, the condition is—sadly—that common. Do you know a man with an eating disorder? Well . . . that’s a good question. Maybe. Probably. Possibly not. No way to know, really. All of the above. It’s a mystery. Yet, here I am and I can assure you I’m not the only one. Statistically, somewhere between 5% and 15% of those with eating disorders are male, although one Harvard study had the splits at 25% for bulimia and anorexia and 40% for binge eating disorder. It’s all a little jumbled up insofar as some of the studies base their results on the numbers of men seeking treatment and that’s bound to be a very different number than actual number of men who might meet the diagnostic criteria of the DSM 5 for each of the conditions. Nonetheless, I can assure you nobody is at your local high school having a sincere and open discussion with the boys about eating disorders and your local newscast will never do a feature on symptoms men should be aware of, etc. It’s just not something people allow for. Earlier I made of point of stating that I was heterosexual and it does seem to be a fact that—for reasons that have led to much speculation and no science-based conclusions—eating disorders are more prevalent among gay men than straight men. While this makes me that much more of an anomaly, I’m in no way intending to create a divide between myself and my Disordered Brothers. We need to stick together because, lord knows, once we step through the doors of that treatment facility, we’re entering a world designed by and for women and unapologetically operated that way. I don’t want to cast the wrong impression about my experience with the mental health professionals I encountered when I sought help with my condition. I have been in and out of various types and levels of treatment (mostly in) for over a decade now; in that time I have been privileged to be held (metaphorically) in the therapeutic healing embrace of spectacularly talented and compassionate individuals who knew (almost always from personal experience) what I was going through and how to help me find my way, gender be damned. Extraordinary generosity and dedication to healing was what I saw and experienced. The problem is more systemic: forms, correspondence, marketing material, office design, all kinds of tiny things you’d just never notice. There’s no ill intent here, just an enterprise that grew around serving a clientele made up almost entirely of young women. It became the business you’d expect to rise out of those circumstances. Still, having to squeeze myself into that one-size-fits-anyone-without-a-hoo-hoo architecture has risen well above the level of annoying at times. I recall once filling out a very long intake questionnaire at a well-known and highly respected facility; each page got harder and harder to complete because so much of the information being requested was specific to female physiology. At some point I decided to forgo the standard “N/A” and just began skipping questions that involved body parts I didn’t have. I remember distinctly that question 24 wanted to know “are you still having your period?” (To this day I regret not writing, “I’m still spotting occasionally but I just use panty liners on those days.”) So along with having to figure out that I had this disorder (and I did) without anyone ever hinting that it was even a remote possibility, along with having figure out which of the facilities I was trying to screw up the courage to call was least likely to reject me outright based on my testosterone levels (and none did), one result of my having this disorder is I’ve spent a lot of time navigating through a world designed primarily to accommodate people of a different gender who don’t much care that their world is set up in a way that makes the simplest of things difficult for me. Sort of the way women have been living for the last two or three thousand years. Really ticks me off.