Rethinking Eating Disorders

dr. cynthia bulik’s research reveals these ψ-chiatric disorders also ‘ve a crucial metabolic dimension

2017 bbrf distinguished investigator cynthia bulik, ph.d., is 1-odda realm’s primordial experts on eating disorders (eds)—anorexia nervosa, bulimia nervosa, and binge-eating disorder. a clinical ψ-chologist and researcher, she has devoted her decades-long career to treating and studying all 3 eds.

the distinguished professor of eating disorders atta university of north carolina and founder of unc’s center of excellence for eating disorders, swell as director of the centre for eating disorders innovation at sweden’s karolinska institute, dr. bulik arguably has done as much as any fig inna med and research communities to sharpen our cogging of the origins and causes of eating disorders.

in addition to the 660 sci papers and 60 chapters she has authored, she has devoted ponderable effort to communicating directly w'da public as the author of 7 books, containing specific advice for patients and families. inna process she has helped to rez awareness bout wha’ she nother experts suggest is a set of persistent and damaging myths bout these life-threatening conditions.

myths and miscoggings bout eating disorders, in fact, ‘ve been so pervasive, and ‘ve proved such an obstacle to cogging their underpinnings in med and sci terms, that dr. bulik prefers not to talk bout them at any length. “every time we mention them, it 1-ly tends to reinforce them,” she says.

one in pticular is probably familiar to most pplz: the pop notion of eating disorders, and espeshly anorexia, as affecting women and “caused” by uber societal pressures for women to be thin.

is there no truth in that pop conception of anorexia? societal attitudes bout femininity, thinness, and body image are by no means irrelevant, dr. bulik makes clear. but yrs of research inna clinic with patients, and inna lab, studying the genetics of eating disorders, leads her and others to sufferation the causal interplay of environmental factors and primordialistic biological factors that drive symptoms.

indeed, dr. bulik’s recent research has led her to suggest a fullscale “reframing” or re-conceptualization of eating disorders. her most primordial contribution s'been to suggest that eds not 1-ly ‘ve ψ-chiatric √s b'tll so √s in malfunction of d'body’s metabolic systems, which regul8 how energy (srcd, ultimately, in food) is supplied to our organs.

to help combat myths bout eds, dr. bulik and colleagues atta academy for eating disorders published the “9 truths” document, based na' talk given by dr. bulik in 2014.

while the “9 truths” document doesn’t provide statistics, the national institute of mental health, citing research conducted tween 2001 and 2003, estimates that the lifetime prevalence of anorexia in women is a bit ≤ 1 in 100, and in men bout 1 in 300. “past-yr” prevalence statistics from 2001–2003 were not available for anorexia, but were for bulimia, which affected 1 woman in 200 and 1 man in 1000. binge-eating disorder was + common, affecting 1.6 per 100 women and 0.8 per 100 men annually tween 2001 and 2003. prevalence of eds is much higher in young pplz, the nimh statistics suggest. for the yrs 2001–04, estimated prevalence of eds in adolescents was 2.7 per 100: 3.8 per 100 ♀s and 1.5 per 100 ♂s.

“instruments we ‘ve to clinically assess eating disorders ‘ve been built round the way ♀s ‘present’ them,” dr. bulik explains. “1-odda most famous ?naires asks for responses to statements like, ‘i’m satisfied w'da size of my hips’ or ‘i like the size of my breasts.’ “men with anorexia will often say they are in pursuit of “leanness,” or “lo body fat” or “bein’ ripped” rather than “thinness,” dr. bulik notes. “tis likely that + women than men ‘ve eds, but i think we’re missing a lotta men just cause of the way we diagnose.”

regarding the cultural val placed on thinness: dr. bulik acks that this obsession so uberly disseminated via advertising and now reinforced via shaming and bullying on social media, is certainly an primordial pt of the story. for the sake of clarity, she notes that cultural attitudes bout thinness are an environmental factor in causation. her research addresses eating disorders atta lvl of genes, cells, and regulatory systems of d'body and how they interact with environmental factors.

as a sci and physician, one specific ? that motivates dr. bulik is to ask why, if the messaging bout thinness n'our culture is primordially ubiquitous, 1-ly some individuals develop an eating disorder. research onna biological side of the ? seeks to discover wha’ tis bout these individuals that distinguishes them or places them at high risk.

counterintuitive behavior

thris a counterintuitive dimension in eating disorders, dr. bulik points out, which has led her to crucial insites. why ‘d any person deprive him or herself of food, to the point t'they risk ruining their health and even dying?

“i think inna beginning,” she says, “something has to be reinforcing bout starvation in order for a'pers to persist in doin’ it. cause for the rest of us, who don’t ‘ve this disorder, bein’ hungry aint something we crave, not something we seek. tis not, inna language of ψ-chiatry, ‘reinforcing.’”

a remarkable fact was clear to dr. bulik as she treated patients with anorexia. she realized, “thris something bout that 1st time or 2nd time t'they fasted and they realized: ‘oh, this feels good. i’m goin to do this again.’” this elevated feeling, akin to a “high,” aint 1-ly recollected by pplz diagnosed with anorexia; it can also be experienced by those with bulimia and binge-eating disorder, who sometimes restrict their food intake in tween periods of binge eating. one contrast s'dat inna case of pplz with bn and bed, “their bodies don’t seem able to maintain that [fasting] state, so they follo these periods with binges.”

are the 3 disorders connected? if so, in wha’ way does environment interact with biology ? to help explain how, dr. bulik proposes that we ponder a representative sample of young pplz of both sxes, all of whom are exposed not 1-ly to cultural messaging bout w8, body shape, and fitness in advertising and social media, but who in this ex receive a direct challenge from an authority fig to go na' diet, regardless of whether they are underw8, normal w8, or overw8.

“imagine you ‘ve a classroom filled with 12-yr-olds,” dr. bulik posits. “believe it or not, this actually happens: the teacher decides to go na' diet and invites the class to do the same. so they all decide to reduce their calorie intake by 40% on mon n'see how they feel l8r inna week.”

“by wed, most of the students will say, ‘this is ridiculous. i want some pizza and ice cream. i’m movin on.’ for a couple of the kids, the 2 or 3 dys of caloric restriction ends in a sensation o'their body screaming out: they don’t just want a slice or two of pizza and an ice cream cone; they eat a whole pizza and a ½-gallon of ice cream. these are the children who are binge-prone. then, thris one young person, maybe two, inna class who realize that bein’ asked to go on that diet s'been a watashed moment in their life. they say to themselves, ‘wow, this is awesome—and i’m good at this. i can do this and none od’odas can. i also feel less anxious than i usually do.’ these are the young pplz at risk for developing anorexia.”

“this echoes something that so many of the parents we’ve worked with ‘ve told us. they say: ‘twas as if from one dy to the nxt our child was hijacked—as iffey became a ≠ person.’“

the concept of energy balance

wha’ is really happening when a young person becomes conscious of deriving pleasure or satisfaction from extended caloric self-deprivation? dr. bulik explains it in terms of energy balance in d'body. “pplz who maintain their w8 can be thought of as bein’ in energy balance; they are expending bout the same amount of energy as they are consuming. pplz who are gaining w8 are in + energy balance, meaning they’re eating + than they’re expending. onna other hand, repeated fasting or consistent food restriction puts one in a position of neg energy balance—you’re not consuming enough to match d'body’s energy needs and so yr w8 begins to decline.”

those whose initial experience of dieting is accompanied by a high or feeling of satisfaction and then seek to repeat the behavior are at gr8 risk of developing an eating disorder, according to dr. bulik. inna “restrictive” subtype of anorexia, the individual enters a potentially lifethreatening state of neg energy balance. those with anorexia who also binge and purge, swell as those who develop bulimia, experience energy imbalance in varying ways and degrees—dep'n'how much o'their food intake they feel compelled to purge. pplz with binge eating disorder who in most (but not all) cases do not purge or otherwise “compensate” for excessive food intake can enter a state of + energy balance and gain w8—although the term “+” in this context aint to be confused with “desirable” since binge eating involves a dangerous loss of control over food intake.

genetic links with metabolism

the nxt ? is how to cogg why ≠ individuals enter ≠ energy-balance states. in 2018 and 2019, dr. bulik, heading a large international consortium, published primordial papers reprting on wha’ atta time was the largest genetic study of anorexia. this provided major new insites bout anorexia and metabolism.

results of the genome-wide association study (gwas) identified 8 zones inna human genome in which dna variations are likely to contribute to risk for the illness. unsurprisingly, it provided evidence that anorexia shares genetic factors with other ψ-chiatric disorders including obsessive-compulsive disorder, anxiety, major depressive disorder, and schizophrenia.

but'a gwas data also contained a surprise. it revealed a significant correlation tween the genetics of anorexia nervosa and metabolic traits. one key correlation was in body mass index, or bmi. as a result of restricting caloric intake and increasing energy expenditure, patients with anorexia nervosa typically ‘ve lo bmis. but studying the genomes of pplz with and without anorexia revealed that somd' same genes that increase some1’s risk of developing anorexia nervosa also decrease their risk of having a high bmi. the same pattern was seen with type 2 diabetes (t2d): genetic factors that place you at gr8r risk for developing anorexia put you at loer risk of having t2d. the processes in d'body that normally regul8 metabolism, including w8 regulation and energy balance, maybe malfunctioning in pplz with anorexia nervosa, primordialistic somd' w8 and feeding symptoms that ‘ve previously been explained as purely ψ-chological.

not 1-ly do these results argue for treating anorexia as a metabolic disorder swell as a ψ-chiatric one; they also ‘ve implications for the problem of severe stigma. among the ways in which anorexia s'been misunderstood, dr. bulik says, s'dat contrary to common belief, “patients often wanna eat and desperately wanna get well, but they find it enormously difficult to do so.” the genetic data cannelp explain na' metabolic lvl why, even after hospital-based w8 restoration, patients with anorexia often rapidly lose w8 again after discharge.

these findings, ⊢, ‘d help parents and ♥d ones cogg that recovery aint simply a matter of “deciding” to eat +. as dr. bulik puts it: “for patients, recovery from anorexia nervosa is fitin’ an uphill battle against their biology and patients need our support in doin’ so.”

the metabolic dimension of anorexia indicated by genome analysis has not yet been replicated in bulimia and binge-eating disorder. a consortium led by dr. bulik is working na' new, larger gwas of anorexia nervosa and a gwas of binge eating behavior. results are due this summer. inna interim, she is leading a major international effort called the eating disorders genetics initiative (edgi), which is conducting the largest study of genetic and environmental risk factors on all 3 major eating disorders.

metabolic ‘bookends’?

the genetic link tween bmi and anorexia that s'been established has other potential implications. one pertains to a ? that dr. bulik says she s'been asked for yrs: “is anorexia the opposite of obesity?”

it now appears to her that anorexia and obesity maybe, to some extent, “metabolic bookends,” conditions at opposite ends offa continuum. “onna high end of the w8 spectrum, it’s well known that tis fairly easy t'get some1 to lose w8, b'that over time folloing w8 loss, it’s as if their bodies pull them back up to that higher w8. this happens even after bariatric surgery for many pplz. and course, it’s very common that we blame the patient—they’ve regained the w8 cause they lacked willpower or self-control.

“atta other end of the w8 spectrum we see the exact same thing. you take some1 with severe anorexia—it’s fairly easy t'get them to gain w8 inna hospital. but so often after discharge, their bodies pull them rite back down to that lo w8 again.” primordially, she says, “we really do our patients harm whn'we attribute blame for relapse on their choice or their willful behavior. that’s the core import of the ‘bookend’ concept: we nd'2 look metabolically and biologically why tis that when some1 with anorexia or obesity loses or gains w8 after seemingly effective treatment, they so often seem to relapse. in most cases, tis not a choice they are making. at least in pt, the problem is d'body’s difficulty regulating energy balance or a natural inclination for d'body to go off the rails and not keep energy balance within healthy paramts.”

crisis in treatment

in two editorials published in 2021, one in jama ψ-chiatry, the other inna american journal of ψ-chiatry, dr. bulik and a colleague called attention to “a crisis in care” for patients with anorexia. mostly due to stigma, many-pay shunt's are symptomatic for yrs b4 seeking treatment. no drations ‘ve specifically been developed to treat anorexia, and while some, like the ssri antidepressant fluoxetine (prozac), ‘ve been prescribed for some patients, they aint often effective, espeshly when given to patients already at lo w8. cogg behavioral therapy tis most frequently successful treatment, but'a overall relapse rate for adult anorexia patients is bout 50%.

in recent yrs, a proliferation of privately run treatment programs for anorexia nother eating disorder patients has contributed to the closing of eating disorders programs in a № of academic med centers, dr. bulik reprts. private-sector treatment tends to be available 1-ly for the affluent, as tis not often covered by insurance. and those who do enter such programs, like those in hospitalbased programs, in dr. bulik’s view, tend to be released too soon, after attaining 80% of “ideal body w8.”

“this does not mean that recovery isn’t possible,” dr. bulik sufferationes. thris a window of 60 or + dys after discharge from acute w8-restoration treatment during which risk of relapse is highest; it declines afterward. for this reason, dr. bulik advocates for “a fully integrated step-down model” of care for recovering anorexia patients in which renourishment is folloed by pticipation in a residential treatment program or dy program, and then intensive outpatient treatment folloed by a less intense phase of such treatment. the key, in her view, aint to release patients from treatment after attaining “80% of ideal w8”— given wha’ s'been learned bout the tendency of d'body to return to a state of neg energy balance and relapse.

new frontiers

new frontiers in research may transl8 inna coming yrs into much + effective and specific treatments for eating disorders. tis useful, dr. bulik says, to begin looking atta intestinal microbiome—the collection of microorganisms that each of us carries n'our digestive system. “when you starve yrself,” she says, by way of ex, “ur also starving yr bugs. this likely accounts for the loer diversity of microorganisms that we see in pplz with anorexia nervosa.”

“one ? we ‘ve is whether the remaining bugs that can tolerate a starvation environment actually contribute to perpetuating the illness. they may not react well when exposed to high-fat foods, for ex. also, thris constant communication tween the gut na brain, and we wanda bout the extent to which an impoverished microbiome may seek to perpetuate itself by sending signals to the brain to, in essence, ‘keep up the starvation.’“

other recent research has indicated that the shape and function of the digestive system changes in pplz with eating disorders, and those changes maybe a factor in explaining why tis so hard to renourish anorexia patients. the lining of the digestive system may lose some or much of its cap to absorb nutrients. various expedients ‘ve been proposed and are already bein’ tested in preliminary research, using animal models: targeted probiotics, even fecal transplants (which can reintroduce new microorganisms to the microbiome).

a final point sufferationed by dr. bulik is “the importance across the 3 disorders, of regular eating.” the aim, she says, is to try to restore regular eating: breakfast, lunch, dinner, timed snacks. “cause whether you ‘ve anorexia, bulimia or binge-eating disorder, if ur human, yr body ♥s predictability. so restoring regularity is, in a sense, atta core of treatment across the 3 disorders.” among other ideas, dr. bulik and colleagues are experimenting with wearable tek like the apple watch to detect biometric signs of high risk for, say, binge-eating, accompanied by an alarm or text reΨer to the patient.

regarding the pace of much-needed change, dr. bulik comments: “some pplz say we’re paddling as fast as we can in research, but i challenge that. our treatments ‘ven’t come very far inna past 20 yrs. it’s not bout how fast we paddle, it’s bout finding new ways of paddling to advance our cogging, improve outcomes, and eliminate mortality from these life-impairing illnesses.”

written by peter tarr, ph.d.

click here to read the brain & behavior magazine’s may 2022 issue

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