Sick Enough Interview

Jennifer Gaudiani, MD, CEDS, FAED joined us for an interview on her book, Sick Enough: A Guide to the Medical Complications of Eating Disorders, which was just released. What follows are our questions in italics, and Dr. Gaudiani’s thoughtful responses.

In your opening chapter to Sick Enough: A Guide to the Medical Complications of Eating Disorders, you include information on “cave person brain.” What are some of the ways “cave person brain” changes with starvation?

What I call the “cave person brain” is the part of our brain that manages us as a mammal. It runs the aspects of our physiology that for the most part are out of our conscious control: our metabolism, temperature regulation, blood pressure, heart rate, digestion, and hormones. This is the part of our brain that evolved exquisitely to save us from common famine conditions our remote ancestors faced. That is: one of its primary directives is to keep us from dying of malnutrition. Therefore, “starvation”—meaning inadequate caloric intake compared with what the body needs, and arising from an eating disorder, disordered eating, a diet, a “cleanse,” or so-called “clean eating” with avoidance of whole categories of vital nutrition like carbohydrates—will make the cave person brain shift into gear to save you. Every person’s cave person brain response is unique, but some common ways that the brain tries to spare calories include: chilliness, cold hands and feet, slowed heart rate, low energy, slowed digestion, anxiety, rigidity, poor skin and hair quality, defending of the body weight (that is, failure to lose weight despite caloric inadequacy), and reduction or total cessation of sex hormone production. Your cave person brain is just trying to keep you alive until you have access to adequate food again!

You note the significant danger of cardiac arrest. What makes the heart stop in those with eating disorders?

Many studies have tried to answer the question: what is the deadly physiology that occurs just before someone’s heart stops from an eating disorder? For years the focus has been on an EKG finding called the “QTc” interval, which means the distance between two wave forms on an EKG, corrected for heart rate. For sure, individuals on certain psychiatric medications and/or at risk for low potassium levels from purging may develop a prolonged QTc, which can definitely lead to a deadly arrhythmia and cardiac arrest. However, this is not the case in the majority of cases of anorexia nervosa.

My clinical experience has led me to recognize that low blood sugar (hypoglycemia) may well be the deadly precursor to cardiac arrest in anorexia nervosa. When the heart runs out of fuel, it stops. Hypoglycemia in anorexia nervosa can occur when someone isn’t taking in enough calories and carbohydratesand has depleted their glycogen stores in muscles and liver and they cannot break down their muscles fast enough (or don’t have enough muscle mass left) to make new glucose to run the heart and brain. Thus, I consider hypoglycemia to be a vitally important diagnosis to make, whether symptomatic or not. Even if the blood glucose stabilizes during the day, drops in levels during the night can tragically cause loss of life. Correction of hypoglycemia requires urgent intake of easily-absorbed carbohydrates (like apple juice or glucose tabs) in the moment and sustained nutritional rehabilitation over the long term.

Can you please tell us your parable of “The Fortress” that you share with your patients as they work at the difficult process of recovery?

I like to use metaphors and storytelling in my clinical practice. I was an English major in college and remain a true book-lover. I think sometimes talking in these ways help patients accept certain ideas without clashing with their eating disorder defenses. I tell my patients the story of “The Fortress and the Nuclear Wasteland” when they feel the idea of even trying recovery is too intimidating. I invite them to imagine that I’m standing on the wall of a fortress, overlooking a nuclear wasteland. Behind me in the fortress is a beautiful, fragrant, warm garden, which represents a life in which one nourishes and rests adequately. The wasteland represents their eating disorder. I call to them to come join me in the fortress, just try standing with me and walking in the garden. Many of them wander around in the wasteland feeling too frightened to enter the fortress. Many come right up to the gates and then retreat. I encourage them to come into the fortress and see what the difference is like, because often they are only imagining what recovery would be like, what the loss of the eating disorder would be like, and it’s too fearsome. But once they stand in the fortress with me, they can make an informed decision about which setting is better for them.

Part 3 of your book focuses on patients in larger bodies. Please address the harm done when terms like “overweight” and “obese” are used.

I was trained in a medical system where students and residents are taught that high body weight is always a problem to be solved, that it’s an individual’s problem with energy intake and output, and that there’s a simple solution: eat less and move more. I am sorry to say I participated in this kind of thinking for many years, and I must have done harm.

I now understand how scientifically incorrect and harmful this nearly-universal perspective is. For one, terms like “overweight” (over who’s weight?) and “obesity” pathologize bodies and imply that larger body size per se is pathologic and a problem to be solved. This is not true. You cannot tell who is healthy and who is unhealthy based on size and shape. Many studies have concluded that individuals with larger bodies who are the most cardiovascularly fit are the ones who live longest (although this is clearly not a universal goal or desired by all), not the thinner individuals who are fit.

In addition, diets don’t work. Thus, while there are clearly some medical problems that emerge in concert with higher body weight and that studies show remit or improve with weight loss, physician-prescribed diets clearly don’t work. This isn’t a matter of lack of individual willpower but rather of the fact that we are mammals being protected by our cave person brains. I would suggest that from doctor’s offices to the multi-billion dieting industry, it is diet culture and an unswerving devotion to a narrowly-construed vision of beauty, health, or desirability that have caused people to have an increasingly unhealthy relationship between their bodies and food.

My solution is to follow a Health At Every Size® (HAES) philosophy and never focus on weight or weigh patients unless I’m following nutritional rehabilitation in someone who was previously at a very low body weight. I help patients find a multidisciplinary team that is also HAES-informed, where we focus on behavioral change that is linked to the patient’s unique goals and values. I have found that diabetes, sleep apnea, fatty liver, high blood pressure, and menstrual irregularity respond beautifully when patients eat adequate, nourishing, delicious foods throughout the day and move according to ability and desire. I have no idea what happens with their weight, but since I don’t center the problem within the individual but rather within the toxic society that surrounds them, it turns out the weight doesn’t matter.

Can you provide some information on the path from orthorexia to malnutrition?

Orthorexia is a term that isn’t officially found in the Diagnostic and Statistical Manual-5”(DSM-5). It refers to an unhealthy obsession with healthy eating. People become rigid adherents to food consumption defined by arbitrary rules thought to emphasize quality, purity, or health, in a way that interferes with their social or medical functioning. The reality is that while delicious, sustainably-grown, fresh foods are wonderful, and ideally, we eat foods that maximize taste and nourishment for our bodies, overly-rigid eating is disordered and puts people at risk for malnutrition and development of an eating disorder. A desire to eat well can become a rejection of all carbs which can result in fatigue, poor athletic performance, low energy, and an increasing mental fixation on getting carbs that can easily result in bingeing with or without purging or can progress to anorexia nervosa.

Please comment on your lead-in, “Males Arrive for Treatment Just as Sick as Females.”

Males with eating disorders form an underrepresented, marginalized population. Even the common abbreviation for eating disorder, “ED,” may cause a male seeking help to be alienated, since that abbreviation to many males first signifies “erectile dysfunction.” A study I helped write from my former hospital program assessed the 10% of total patients who were males who admitted for care. Those patients arrived with just as much medical compromise as the female patients.

Certain advocates within the field are helping practitioners across multiple disciplines to recognize that males with eating disorders may or may not have the same fears and drives as females, and that we must focus our efforts on making eating disorder treatment welcoming and relevant to their diverse needs.

Furthermore, I recognize that gender is not binary and that individuals of all genders are affected by eating disorders. Care in every setting must manifest competencies in and relevant treatment for patients of diverse genders and sexes.

What are appropriate goals for those who refuse treatment and are facing end-of-life issues?

This is such a complicated question, and it took me a whole chapter and a lot of research and years of patient care to try and give it a thoughtful answer. However, I would say in brief that I believe every individual has the ability and should receive full support to fully recover from an eating disorder. That said, there are some people who are older (usually over 30), have recently completed high-quality standard of care multidisciplinary eating disorder treatment, and who continue to be tormented by their eating disorder without a consistent ability to abstain from behaviors. In this unique, circumscribed population of patients, I believe that a slow, thoughtful, nuanced set of conversations over time can take place in which goals other than those of full recovery may be established and supported. Loved ones are invariably a part of these difficult and important conversations. Every person is different, but I always try to relocate my medical efforts around an individual’s stated goals and values.