The Dark Side of Food Addiction

When it comes down to it, what is the difference between enjoying a terrific meal and the dangerousness of hyperpalatable foods? 

(If you haven’t seen it, go read the Extraordinary Science of Addictive Junk Food recently in the New York Times.) 

Also, looks like a book will soon be out from which the article was taken: Sugar, Salt, Fat (just downloaded it to my kindle).

The Lumineers: Stubborn Love

Drug addiction has three phases. The introduction to amazing hyperpalatable something, the likes of which the brain is primed to find rewarding but has never seen before in such intense form. After the initial binge, there is a withdrawal phase of negative emotions associated with being without the rewarding taste, then the preoccupation and anticipation phase, and a ton of time and energy spent seeking the same sensation as before. In addicts, use changes from pursuing positive reinforcement (chasing the high) to forestalling negative reinforcement (to prevent getting sick from opiate withdrawal. I’ve heard that one a hundred times: “It doesn’t even make me feel good anymore, doc. I just don’t want to get sick.”) This last bit, the physical dependence, really means you have crossed the border from abuse to a true addiction. 

In “The dark side of food addiction” (sent to me by Dallas Hartwig, thank you very much!), the work of Dr. Hoebel is examined. He mostly considered sugar to be the hyperpalatable food du jour, and his views that one could be called “food addicted” are controversial. And in the pursuit of sugar, for example, there are some parallels to that shift from seeking the palatable to seeking an absence of negative, relieving the anxiety or sad feelings of being without the food, and a transition in the brain circuits with the downregulation of certain brain reward systems and amplification of stress or “antireward” systems in the brain.

Obesity, as I’ve said time and time again, does not overlap 100% with food addiction behaviors, and food addiction is not the entire story behind obesity. There are obese people who seem to demonstrate no characteristics of food addiction, and there are normal weight or even underweight people who have very troubling relationships with food. The “Yale Food Addiction Scale” is the main criteria used to gauge levels of food addiction in research. It is a series of questions meant to quantify how much someone overeats certain foods despite efforts to limit eating them, how much the eating interferes with functioning, and how much there are withdrawal symptoms if one abstains from the trigger foods.

The most likely to suffer from food addiction type behaviors are, obviously, the binge eaters and bulimics. This population has a high level of other psychiatric comorbidity, including depression, anxiety, and other substance abuse. In fact, 1/2 of teenage bulimics report suicidal ideation.  Interestingly, in most normal-weight individuals, stress and negative mood states are associated with decreased appetite, which is less true of overweight individuals. Is this little difference some of the reason behind the obesity epidemic? Is this difference why obesity tracks with depression, as does diabetes and the other metabolic disease? Or are there more complications to the comorbidities?* Bulimics have lower mood immediately prior to a binge than on says when no binges occur. So, we are talking vulnerable populations. Not everyone. Could explain while some people remain slender in the modern food environment where food scientists uses volunteers and supercomputers to calculate the perfect crispiness of a Cheeto and the “bliss point” of salt, sweet, and fat.

Who are these vulnerable populations? Scarily, as I’ve discussed before, it may be those who have started out dieting. Attempts to control body weight via exercise, dietary restriction, appetite suppressants, laxatives, etc are associated with increased weight gain in female adolescents, and dietary restriction is associated with long term weight gain in female adults. Drinking diet soda is also associated with weight gain. Self-reported “restrained eaters” tend to over eat more in stressful situations.

High carbohydrate foods (particularly bread, pasta, and sweets)(an aside, rice is almost never mentioned in these papers…is that because these aren’t papers written by Asian/Indian authors or because the rewarding properties of gluten and sugar are creepy? I don’t know) tend to reduce reports of anger, tension, and increase calmness for 1-2 hours after consumption. Thereafter, depending upon the person, you may have a rebound decrease in good feelings. The overconsumption of these foods may also prime the reward and addiction pathways to induce low mood and cravings for the foods when they are not available. I’ve discussed the downregulation of the dopamine receptor and decreased dopamine availability before. 

Unfortunately, a lot of the hard data associated with addiction and withdrawal syndromes to food is found in mouse and rat models. And mice and rats simply don’t crave and eat quite the same way we humans do, though they do appear to prefer that cafeteria diet and, I believe, chocolate ensure. But when you are on a diet or a detox or whatever it is… what do you crave the most, particularly if there is a stressful time of day, or you have a headache (I tend to eat far less when stressed, but I will crave Diet Coke during those times). And in those first days of your New Years’ Resolution, what food do you dream about? Many report dreaming about chocolate, sweets, or cheese.

So what is a solution? Clearly just eating whatever willy nilly doesn’t seem to work to keep the population healthy. And yet dieting induces unhealthy eating behaviors, and dieting that feels restrictive is doomed to failure, precisely because it seems to activate the negative side of these reward pathways, perhaps in response to starvation and stress. 

So one should (mostly) eat foods that one can eat to satiety. For the most part this will nix the designer processed foods meant to entice you to eat more. And many people can get away with special treats every once in a while, just as most people can have alcohol or even a cigarette or two without becoming addicted. The model of “intuitive eating” or mindfulness eating will apply to most people. If you want a special treat, enjoy the heck out of it. Smell it, enjoy the color, take a tiny bite and let the flavor melt on your mouth. Take five minutes to eat a single precious Ho-Ho. (You may find that plasticky chocolate shell and chemicalish cake not as enjoyable as you remembered from stuffing your face as a child). 

There’s a whole book about intuitive eating called “Intuitive Eating.”  I must admit I’ve tried to get a number of my binge eating patients to buy this book and practice the principals, but none of them seemed to take to it very much. I found it interesting that the documentary "Weight of the Nation" featured the mindfulness eating approach so much when I had so little luck with it (my medically compromised bingeing patients seem to do better with more drastic measures, such as weight loss surgery or pharmaceuticals that short circuit the reward pathways, and others seem to do better with a "rehab" abstinence approach.) I've had a great deal of luck prescribing mindfulness strategies and therapies to anxious or self-harming patients, but not to binge eaters.

Some people will be particularly vulnerable to certain trigger foods, and if they are indeed addictive, a rehab/recovery model suggests banning the foods altogether, for life. The problem is, in the short term, this method can increase the risk of further bingeing. But in the long term, with the appropriate support, abstaining from these foods may cause them to lose their seductive power.

In my experience there are two sorts of people. Those who can’t bear to be cut off from any particular foods and would rather count calories, and these folks love their fit bits and food scales and weight watchers apps. Then there are those who couldn’t be bothered, who find calorie counting a horrible nuisance, and prefer to avoid certain types of foods. In reality most people who maintain their weight in the modern foodscape are probably one of these sorts of people. Elderly women who’ve been thin their whole lives tell me how they never have dessert, or if they do, they share it with three other people at the table. Almost everyone is restricting in some way, but if they are doing it successfully, they are utilizing a way that complements their personality and hormonal profile, so they don’t feel deprived.

I think it wise to start children out eating real food (breastmilk) and transition them to real food (meat, fruit, veggies, fish, etc.) and limit their exposure to processed designer scary hyperpalatable crap as much as possible until they can be educated as to the dangers and make their own decisions. When they are hooked young, it is a difficult battle. If they are never overweight, they never have to go on a “diet” though like most people they will have to have some limitations on what they do (like most of us have limitations on the number of martinis we have during lunch). Dieting is not a risk-free endeavor and that should be acknowledged, though the most sensible course in my mind is always going for the nutrient rich, whole foods diet for the majority of what one eats, controlling portion size if you must. If your food needs a label to tell you what is in it or what it is, then you should probably be eating less of it. Makes calorie counting harder when the number isn’t printed right there where you can see it. 

Too simple? Probably. We haven’t talked about food intolerances, metabolic syndrome, or anything like that. Just as there are a raft of “paleo diets” from antiquity and we will never be able to copy them, there is no diet that is one size fits all. One can get most of the way and derive most of the benefit from cutting out processed foods (and I include bread and pasta as processed foods). The dark side of food addiction has to come with the acknowledgement that most people when exposed to addictive substances do not become raging, life threatened addicts. And for most, there is a place for some moderation.

*probably

Brand New (Even to You) Post at Psychology Today

Head over there to see: Eat Your Egg Yolks about a new (groundbreaking) study from the American Journal of Psychiatry linking choline supplementation in pregnancy to better brain function in infants. You can also check out Zombieland and Zombieland II.

Photo from Flikr Creative Commons

Emotional Eating

First off, while a lot of the feedback from the Orthorexia series was quite positive (and here is a really thoughtful blog post offshoot from the series), I got some comments and emails accusing me of being silly and judgmental about people’s concern about their diets. So I do want to clarify one point: I care not one whit what you eat*. I do care about you as a human being, but I don’t judge whether you eat skittles for breakfast or you painstakingly raise and consume special pellets of moss species that flourish only on the carefully collected dung of endangered Himalayan goats. If any of those things makes you happy and productive and healthy and wonderful, I’m thrilled. My only concern was to suggest that some folks are trapped a bit by anxiety about what they eat, some to an extent that it negatively affects their lives and functioning. If you aren’t anxious about your Himalayan goat dung moss diet and you are happy and healthy, you do not have a problem. 

Bad Books: Forest Whitaker.

So let’s jump from the frying pan and right into the fire. “Emotional eating” is a soft phrase. There’s nothing to hold onto with it, no mineral deficiencies, no magnesium in receptors, no quick solution. It doesn’t hold the heaviness, wonder, despair and artistry of the human soul soaring in love, suffering in loss. There’s none of the poetry of nuzzling of a baby’s soft skin or hands caressing a loved one or the terror of violence in emotional eating. But I’ve sat with people in the midst of killing themselves with binging. I’ve sat with people who barely eat enough to survive and who can’t eat a meal without shame. Who are facing below the knee amputation for sores from diabetes but walk into clinic with a bag of candy. Emotional eating is an important thing to comprehend, but even the description of it brings along the dreaded spectre of “gluttony and sloth.” I don’t believe the entire Western human race was infected with a sudden onslaught of gluttony and sloth! But let’s look more at “emotional eating.” 

It’s just food. Food is life. Let food be your medicine…one of the reasons I like Dallas and Melissa Hartwig’s “It Starts With Food” so much is that they don’t begin with macronutrients, a long tale of a diet success story, or discussing the evils of different food toxins. No, the entire first section of the book is devoted to the psychology of food and eating, and one of the main criteria for an acceptable “Whole30” food is that it must promote a healthy psychological response. No weird cravings. No sweaty withdrawal dreams. Just eating for eating’s sake and enjoying the flavors, then letting it go and moving on to the next thing in life.

I’ve spent quite a bit of time on this blog discussing the parallels between addiction and binge eating. The book will have whole sections exploring that…but addiction is also a cold and measurable term. Use despite harm. Consuming more than intended. Spending a lot of time and resources finding and using. Using in secret. Sure, most people would agree that is a problem. 

But what about the plain old vanilla grazing and thoughtless eating while bored, or the friendship of a bowl of ice cream on a lonely Friday night? Grazing even though you don’t mean to at the holiday party. Not really a massive binge, no terrible secret, but over time these small overages seem to add up and have an unfair cost. So what does it mean to emotionally eat?

In the literature (1) “emotional eating” is equivalent to “comfort eating” or “stress eating.” Obviously, people who eat when stressed derive some sort of benefit from the eating, and for the most part, they are not eating celery sticks and steamed broccoli, or even a wholesome baked potato. When you are stressed or scared or bored what do you want to eat? Sugary snacks, cheesy bread, coffee, Doritos, or wine. Or sometimes the foods Mom used to make (which encode happy, secure memories, presumably).  “Comfort eating” is not clinically defined for happy situations, oddly enough. All the clinical scales refer to eating in response to stress.  However, there may well be sex differences in comfort eating, with men being more positively driven and craving familiar, savory foods, while women are more driven by negative emotions and crave sweets or wine. It shouldn’t surprise you that estimates of the incidence of emotional eating in the population are nebulous at best. Studies have used different questionnaires, different populations, different validities. Emotional eating does tend to happen more in women than in men, and more in adults than in children. Interestingly, in a general survey of the Dutch population taken 25 years apart, in 1983 23% of the population admitted to emotional eating. In 2009, 36% did so.

It is actually more common in these various studies for those under stress to report a suppressed appetite than a desire for comfort foods. Binge eaters are more likely to report cravings for food under stress, and non-binge eaters more likely to report decreased appetite under stress.

Emotional eating has long been used to try to define the cause of obesity in general, starting with Hilde Bruch, the psychiatrist who first wrote books on obesity and eating disorders as psychiatric phenomenon. Since obese individuals were seen more often in studies to eat when they were not hungry, or to have intake divorced from hunger, it seemed a logical conclusion that emotional factors were at play. Measures of dietary restraint (that is, the ability to turn down food even when hungry) are higher in those with high BMIs, and emotional eating (giving up dietary restraint) is seen much more often in people with higher levels of dietary restraint. As in restraint may beget emotional eating on the other side.  Of course, folks with higher BMIs are incentivized to attempt to turn down food, whereas many lucky folks with naturally low BMIs have never needed to exhibit much dietary restraint. It’s a messy business, trying to sort out natural food cues, hormonal dysregulation, and societal influence. But I do think it is a valuable exercise to determine how emotions cue us to want to eat, particularly unhealthy foods, even when we don’t need to.

In animal studies, there are certain protections against stress-induced eating, such as cutting out the adrenal glands (not recommended) or lack of an “energy dense” diet (lack of sucrose or high fat diet availability). In rats, activation of the HPA axis in the stress response is associated with more cravings for sweet foods than for fat. In humans, stress (such as exams or higher workload) has, not surprisingly, been associated in many different types of studies with cravings for sweets and higher energy-dense foods. Fast food consumption and chocolate increases during high stress weeks, fruit intake seems unaffected. Cortisol levels and urinary cortisol excretion are correlated with energy intake, and in women given solvable or unsolvable puzzles along with snacks in a controlled trial, those with the unsolvable puzzles ate more M&Ms and fewer grapes than those who were given solvable puzzles. In a study of women in San Diego, those with higher depression rating scores ate twice as much chocolate as those with normal depression rating scores.

The obvious question when looking at all this negative mood leading to emotional eating data is whether or not comfort eating actually improves mood. Not surprisingly, the data is mixed and the data collection confusing. Binging might actually improve mood because it results in a parasympathetic rebound of digestion, sleepiness, and relaxation. However, in an emotional binge eater, feelings of guilt and shame are liable to come to the forefront as well. 

Chocolate is the most commonly craved food during negative affect, and the sugar, caffeine, and theobromine could actually directly lift mood. Chocolate, eaten on an empty stomach with the high fat content, low protein content, and sugar content could result in an increase of tryptophan being shuttled into the brain, increasing serotonin levels. In rats, craving for chocolate can be shut off with opiate receptor blockers. And in female students, the main food that has been shown to alleviate pain and the main food craved by emotional eaters during a stressful task is chocolate chip cookies. Chocolate could reverse the sad feelings induced by watching a tear jerking film, but the effect was short-lived, only 3 minutes. (I think a fun job would be to dream up stress eating measurement studies). 

More evidence that food can improve mood is found in following people with seasonal affective disorder, who eat and crave more sweet foods during the winter. The cravings are decreased with light therapy.  Per capita sugar consumption is highly correlated with depression rates in countries (Why might that be???  PLEASE someone do a large study on fructose malabsorption and depression.)

Does comfort eating cause harm? Among studies of obese patients, generally less than half consider themselves comfort eaters, suggesting that it is an issue in a minority of people. In several studies (including the Dutch one mentioned earlier), emotional eating has increased with the prevalence of obesity, suggesting a connection.  Emotional eating is also strongly correlated to increased incidence of depression, sensitivity to stress, and impulsivity.

Genetic studies have pointed to issues with dopamine, serotonin, and all the usual suspects with respect to appetite and reward in the brain, but the pathway forward so far as treatment is far from clear. In some emotional eaters, an SSRI is helpful and decreases BMI. In others there is insidious weight gain. Wellbutrin, naltrexone, and topamax have all had some evidence for binge eating reduction. Naltrexone blocks opiate receptors and thus some reward pathways. Wellbutrin modulates the dopamine system (and thus affects the reward pathways). No one is really sure how topamax works but it does seem to blunt appetite and reduce binge eating, and also reduce that tricky problem that some have of night eating. These are not FDA approved uses of these sorts of medications, but there is nothing FDA approved for “emotional eating.” And for some people, literally killing themselves with binges despite major cardiovascular risk factors, or binging and purging constantly, the benefit/risk discussion changes with respect to using medication.

So far as non-pharmacological approaches to emotional eating, I’m aware of two major contenders. One is mindful eating (described in detail in the HBO documentary “Weight of the Nation.”) The other is “Food rehab.” Almost every diet from Atkins to South Beach to Whole30 or 21 Day Sugar Detox has a strict “buy-in” period that is a kind of food rehab, blocking access to trigger foods. I think different sorts of people will benefit from different strategies, and will discuss this further in another post.

*unless you are a murderous cannibal. Then I disapprove.

Physicians and Ancestral Health and BA Training

I spent last weekend in Utah meeting up with my sisters and brothers of the Physician and Ancestral Health organization. We're a group of clinical medicine doctors from all sorts of specialities (though psychiatry is overrepresented, perhaps not surprisingly) who are trying to find safe and evidenced-based ways to integrate evolutionary medicine into our clinical practice. We come together for support, ideas, and friendship (because who else wants to talk about ketones, statins, functional movement, research, websites, canola oil, and the latest paleo diet research?)

I think we are the nascent group (who met for the first time at PaleoFx12 and reaffirmed our friendship at AHS12) for a big upcoming movement in medicine. Personally I would like to see a lot more attention paid to evolutionary medicine, specifically with regards to diet*, exercise, sleep, parasites, and other interesting, cheap, and probably very effective interventions for a variety of modern complaints such as squat toilets and forest therapy. 

*not that anyone can agree on a "paleo" diet but hey, cutting out the processed garbage is 90% of the battle. No grains, soy, peanuts, industrial sugar. Cooked kidney beans here, fermented dairy there, a bit of nightshades here…I'm not too concerned.  Lynda Frassetto who is a formidable genius in person defines the paleo diet as "anything you can eat raw as well as cooked." Though I'm guessing she excludes dairy from that one. For her experiments, she used anything she could get that met the basic requirements and was available at her hospital cafeteria.

Victoria Prince had an excellent summary of the meeting, and I hate to reinvent the wheel. I found the combined focus on academics, organization (though organization is not my personal bailiwick), and functional movement to be invigorating and motivating. @Primalmountain led our movement sessions. We went from lectures to seeing the championship team at Ute Crossfit workout together, and swung a few kettlebells and did some wallwalks ourselves. I beat @RickHenMD for the WOD time but I might have cheated and bailed out early on a few of my bear crawls. We learned about managing crushing systems while championing evolutionary health and went snowshoeing in the beautiful mountains near Salt Lake City.

At most meetings of doctors you are bound to find some useless, narcissistic, competitive losers who ruin the experience for everyone else.  Not at PAH.  These brilliant, motivated folk could actually work with each other, question their own certitude, and learn from each other going forward. Don Wilson is an ObGyn and working on indigenous health in Canada, right on the front lines where evolutionary medicine and comparatively low carb interventions could do a great deal of good. It was a wonderful experience. I'm hopeful that I will be able to get together with the other three northeastern psychiatrists for some nice dinners in the future. And please, go check out Georgia Ede's Diagnosis Diet website as she's been working very hard on it, and doing a lot of good work.

The trip to Utah coincided nicely with some personal changes in my own exercise regimen. After a lifetime of trying everything (from weight training classes in college, personal training, sports illustrated super shape up videos, aerobics, bodypump, running half marathons, step class, etc) I had settled in on CrossFit for the past couple of years, as it was an efficient way to get some personalized attention, intensive movement, and great results. I love my community at CrossFit Torque. However, I have had some shoulder issues, and some of the classic CrossFit movements (sumo deadlift high pull and kipping pull ups) were not shoulder friendly. My need to take some time off the punishing WOD coincided with being approached by the amazing strength and conditioning coach Clifton Harski. I first met him at AHS11 (photographic proof ), conference and the MovNat seminar and he later asked me to write an intro for his upcoming (and no doubt amazing) e-book about V-neck shirts for men. I believe he is calling it "going deep in the V" but let's just say the focus is on making a generation of men healthy, built, and confident, and I'm 100% in favor of that goal. 

Clifton is one of those amazing creatures who can climb a tree and lift baby seal-type things in a workout. I don't presume to question it. He has a bachelors in kinesiology and an internship of MovNat and the keen interest in people and expertise in human movement I've seen in the movement and physical specialists in the paleo blogosphere (Jacob Egbert, Jaime Scott, Dallas Hartwig, and Jesse Dimick also come to mind). 

I've been using Jacob's straps in my workouts which have been very helpful. They are more versatile than training rings and far less confusing than the TRX straps at my gym.  If you want home straps, buy Jacob's! Seriously! Clifton is an amazing coach. I'm not an athlete. I can benefit fully from the online coaching experience by sending videos back and forth and having a few facetime calls to perfect technique.  After only two weeks my shoulder is a happy camper and my overall strength is increasing, partly because the personalized volume training of Clifton's "bootycamp" is so much greater than the CrossFit random programing.

I'm going to do a post Clifton workout post for follow up, but so far I'm extremely happy. Cost wise, ongoing Clifton online training is comparable to a CrossFit gym payment in my area. The down side is that I'm the only woman doing real deadlifts at the globogym…but I don't mind being stared at all that much. And I like how the volume of the program is leaning me out and giving me strength gains right of the bat, and strengthening my silly shoulder. If you are an athlete, you should probably find a coach who can help you in real time on site. If you are a newbie, you might not need the personalization. But for someone like me, online bootycamp is a great addition, inspiring and motivational. 

Orthorexia Part Three: Risks of Different Diets

Here's Part 1 and Part 2 of the Orthorexia series.

This weekend I was away in Utah at the inaugural Physicians and Ancestral Health conference. More on that later, but I'm linking now to Victoria's take. It was a terrific weekend, and I do want to take some time right now to thank Rick Henriksen, John Barret, and Lucy Flynn for organizing the conference. In addition I would like to thank Jacob Egbert for hosting me and inviting me to check out his incredible gym. We also got to work out at Ute Crossfit and meet some of the athletes who won the 2012 Crossfit Games.  In the midst of all that, I wasn't able to keep up with posting all the comments coming in. All of them should be up at this point.

Cayucas: High School Lover

Back to Orthorexia, a popular term coined by Steven Bratman, MD to describe those pathologically preoccupied with food and diet. His book, Health Food Junkies, is quite an interesting read, and a bit of an indictment of some of the alternative medicine scene (Bratman was an alternative practitioner before becoming an MD, and continued to practice many alternative therapies thereafter).

Anyway, a question arose in the comments of the first post about those of us who follow a paleo or primal-style diet. Is there something about the diet that could lead to Orthorexia? To answer that question, I'll go through some of Bratman's experiences with people in different diets that he thought were especially prone to go over the edge from careful, healthy eating into dietary obsession that interfered with daily life and functioning.

1) Food allergy diets: Bratman found that many people benefited from wheat and dairy removal for all sorts of ailments. But he tells of a number of different sorts of woo-woo sounding tests (bioelectric impedance, energy fields and muscle resistance while holding a vial of a food, and of course the infamous IgG tests*). Anyway, regardless of the method, people would invariably get a list of several foods they had a major intolerance to (almost always including dairy and wheat), and then a longer list of "minor intolerances" of random foods from tomatoes to onions to lamb or parsley or…you get the idea. So the person will get rid of the "major" intolerances and tend to feel a lot better. But there might be some residual lack of energy, or cramping stomach, or mental fog…so they eliminate all the minor foods. In general it is difficult to completely abstain from the off limits food, and people tend to binge or "cheat" and feel guilty, followed by renewed, stricter dieting. Every physical and mental symptoms gets correlated with some sort of food, and diets can get very limited, and life can revolve entirely around food. Ultimately, maybe the person would be happier with residual symptoms and a more varied palate.

I see the food intolerance route as the major avenue into Paleo/Primal Orthorexia. I feel great and my cellulite went away eating paleo…let's try an autoimmune protocol so those funny little red spots on my shoulder will go away…hmm, maybe the histamine in this food is making my nose run, or maybe the FODMAPS are causing that funny cramping I get sometimes…I'm just going to eat pemmican and see how that goes. Now sometimes these dietary trials are fun, interesting, and can lead to positive health changes. Sometimes they are annoying or even debilitating obsessions.

2) Macrobiotics: I had heard of this diet before, but never knew that much about it. The diet is based on Taoist principles and involves vegan foods balancing yin and yang. Mostly that seems to mean eating brown rice, little julienned and lightly sauteed vegetables, and spending a lot of time agonizing over the balance and beauty of the meal. You are also supposed to restrict water to some extent. This diet is perfect for people who get a thrill out of obsessing over food. Bratman practiced macrobiotics for a while, and claimed there is a particular look to people who ate that way:

The skin looks slightly darker than usual; it's tight, without any hanging folds or obvious smile lines. The shape of the face itself seems different, too, perhaps again due to the tightness of the skin. It's more angular, more like a polygon than a circle or an oval.

Like many vegan diets, it can lead to a feeling of lightness that is pursued by the practitioners. Macrobiotics preaches asceticism. Bratman tells a horrible tale of having to call child protective services on one macrobiotic couple who water-restricted their child as part of the diet.

3) Raw Food, Fruitarianism: Bratman felt that the raw foodists and fruitarians were among the most likely to fall into the deadly form of orthorexia, leading to undereating and starvation, or, as one of his patients who only ate raw vegetables did, passing out while driving and dying in an accident. These diets tend to lead to a feeling of airiness and lightness, a pursuit of separation and denial of the physical self. In some ways, the paleo-style diet, being meaty and hedonistic and filling (and more nutritionally complete than any vegan diet, though endurance exercise raw vegans can consume enough calories to get more mirconutrients than you would think) may be the opposite and reasonably unlikely to lead to deadly orthorexia.  However, intermittent fasting can also lead to that light and airy feeling, and one could take that too far.

4) Zone diet: The obsessing over macronutrient ratios, Bratman thought, could lead one into food obsessiveness in general. "Orthorexic Zoners spend much of their day talking about their diet and debating the fine points of their theory like Talmudic scholars using the works of Barry Spears as scripture." (Just replace some names here and you get the paleo/primal-style equivalent).  Bratman does mention the "caveman diet" in his book under "zone" as a "stricter version" of the zone involving eating wild plants (he mentions "weeds ripped out of a nearby wetland and scarfed raw like salad along with fresh deer" What?  He got his information from NeanderThin, which may be as weird a book as I would hope. Any of you read it?). Health Food Junkies was published in 2000. He might have had a field day with his paleo-style diet chapter today…wonder if he's ever been to Paleohacks?

5) "Pill Orthorexia" Bratman has a chapter for the supplement fanatics who come in with their bags of pills, looking for the perfect regimen, alternating between different chelates of magnesium and separating the calcium from the zinc and balancing the A, B, C and D…sound familiar?

All in all, finding the perfect diet reminds me of sanding and painting a wall. One can sand and sand with finer and finer grit, and paint layer after layer and obsess over imperfections for many days and weeks. But ultimately, one gets 90% of the way there, and the extra benefit becomes an asymptote that once can chase forever with increasing percentages of "perfection."

My father gave me some good advice when I was going off to college. He told me to try to get the lowest A in the class. That way I would have spent my time efficiently and collect those 4.0s while having hobbies and a life without making myself nuts trying to achieve the highest possible grades all the time. For the most part, for most people, I think diet is the same way.

*I remember in one of Chris Kresser's podcasts he said he sent off blood for two of these tests at the same time (they are expensive, maybe he got a bargain price ;-), and got back completely different results.

Orthorexia in the Paleo/Primal Community: Further Considerations

I knew Friday's post on orthorexia would hit a nerve, but didn't anticipate it would gather steam quite as fast as it did…and (for my moderated blog) a bit of a lively discussion has developed in the comments, raising some important questions and concerns. Thus worthy of a Part Deux. There will be (maybe somewhat irreverent) digressions based on my personal and clinical experiences rather than a Pubmed literature review. So here we go.

Citizens True Romance

1) What about the kids? Are we raising a bunch of gluten-free dairy-free peanut-free neurotic orthorexics?

A subject close to my heart, as the mother of three and five year old little girls, who mercifully have (knock on wood) no health problems or body image issues. In fact, the three year old, who lives life with gusto, invariably runs around the room with her arms upraised giggling whenever she is naked (at least twice a day, with changing back and forth into PJs and clothes and tubby and spilled things, etc.) because being naked and free is clearly just so awesome. Now I know several adult men who still think this way (you know who you are), but I don't know any women who do. Which is sad. Someday soon my kids will start worrying about their thighs. Ugh.

I don't want my children to grow up neurotic about food. On the other hand, when you look at the advertisements and the grocery stores and the incentives out there, popular kid food is pretty wretched, processed, sugary, blue gooey crap. Kids have growing brains and bodies and need appropriate nutrition to fuel that growth.

(Speaking of incentives, one of the things that really bugs me about my daughter's pre-school is that they require than lunches and snacks be brought in recyclable containers. That sounds all good and responsible on the face, but "real food" is bulky, requires more prep, and my little girl has a good appetite. If I try to cram some orange slices in a plastic baggie into the top little space left in her lunch box, I get a supercilious little paper reminder of the rules that comes back in her empty lunchbox. Meanwhile, pre-wrapped convenience food is allowed (I suppose it would be ridiculous to tear the goldfish crackers out of the snack pack and pour it into a little bowl with a plastic top). So, parents being busy and kids being kids and no one liking to get obnoxious notes, most of the kids get pre-wrapped convenience foods like juice and gogurt and little packages of goldfish crackers for snacks because its easy and it fits.)

So all thoughtful parents have to find a line between running after little Jimmie and ripping the cupcake out of his hand as he sobs at the birthday party (unless there is particularly good reason) and raising little sugarized zombies who only eat rice krispie treats, lunchables, and dinosaur shaped fried chicken nuggets. I tend to have my kids eat what I eat when I'm cooking and not make a big fuss about it. But they have cookies and whatever at parties and on play dates and when their father brings one home, and I also don't make a big fuss about it. If the five year old asks me why I don't drink milk, I just tell her it upsets my stomach or something of that nature. I do make it clear that we should eat mostly "healthy food" and that the sugary candy and processed stuff doesn't nourish our bodies and brains like we need, but it can be happily enjoyed as an occasional treat. Now there are many tales of kids with behavioral and health issues that respond to taking some major players (like gluten, for example) completely out of the diet, and those parents have to draw the line a little further than I do.

Bratman's book, Health Food Junkies has some horror stories about moms with food allergies diagnosed with some sort of naturopathic test using electric voltage changes in the skin (or the IgG tests) who put their kids on crazy restricted diets too, and little four year old Jane babbles about not eating chocolate, oysters,  tomatoes and yak meat because it gives her migraines. I think we need to be very careful about restricting diets too much and putting too much importance on every molecule of food that goes into our mouth or those of our kids. That's also why I tend to prefer the Paleo 2.0 ancestral "real food" approach which includes dairy (particularly fermented) and cooked legumes (except most soy and peanuts), potatoes, and rice for everyday eating and things like 80/20 rules so we can enjoy anything we want from time to time and not wig out about it.

2) Orthorexia is just a BS problem for bored yuppies and everyone should just get a new hobby already.

I've been advised by some to completely ban Itsthewoo from my blog because she can be quite aggressive, and frankly I have to steel myself whenever I see the email pop up that she has commented, but she can be entertaining and has some penetrating observations. Her original comment was a bit beyond the pale, but fortunately she allowed me to moderate it for "public consumption." I didn't moderate it that much. This comment is a bit of a poke at psychiatry in general and the explosion of diagnoses and are we just trying to medicate and treat everyone to be a brave new world sort of useful worker for their mismatched sock disorder and weird goth teenager disorder and most of mental illness doesn't actually exist.  My response is that orthorexia is a popular term for kind of food/health anxiety that can be very debilitating and, in some rare cases, fatal (Bratman's book, which is very good and has some hilarious statements such as "tofu is healthy" details several such cases). I would also say that just being a little anxious about what you eat or paying attention to what you eat or trying to eat healthfully is NOT orthorexia. It's when healthy eating crosses the line and becomes the entire focus of your life, and that focus disrupts your life or your relationship with your loved ones. Life is short, and there is more to life than food, and food should be enjoyable and sometimes fun, not a always penance or a purification ritual. Orthorexia is almost never as dangerous as anorexia or bulimia nervosa, and I don't think anyone would argue that.

3) Should eating disordered people be handing out advice about eating disorders?

Actively eating disordered folks could give out some pretty bad advice (consider the ana and mia forums, and if you don't know what that is, you are better off and the world is a brighter place for you, though if you are a health care professional or the loved one of someone with eating disorders you should know what that is). I can't get all bent out of shape about people who are in recovery from eating disorders counseling others, because in treatment settings it is often people who have had eating disorders or relatives with eating disorders who dedicate their lives to treating them. Eating disorders are tough, heartbreaking, and difficult to treat, and it takes a special sort of motivation and energy. In general these settings are supervised and work along standard lines, and there are some treatment models quite similar to AA, with peer counselors and sponsors. Should random bloggers be doling out advice about eating disorders and should be people be getting medical/nutritional advice from random bloggers? Random bloggers can and will say whatever they care to, for the most part, and people ought to consider what they take as fact or wisdom from the internet, obviously.

4) Is low carb dieting (and, particularly, the mythos behind low carb dieting, that carbs=insulin=burnt out pancreas and diabetes and foot ulcers) a fast lane pass to an eating disorder?

I'm reminded of the "Ask the Paleo Experts" panel at PaleoFx12 where I suddenly became a "Paleo Expert" because Chris Kresser hadn't been told (apparently) that he was supposed to be on this 8:20am panel, had slept in a little, and I was around and available. This incident occured at the height of the carb wars (sigh) and I put in my little push for bananas and starches as most bodies can very efficiently and happily process glucose with little to no problems, and being metabolically flexible (being able to process both fats and glucose with pleasantly clean and efficient mitochondria) is associated with the healthiest people. Nora Gedgaudus, Jack Kruse, and Ron Rosedale sort of cluck-clucked that very young sorts of people (and I do look very young) could unwisely consume the poisonous glucose that obviously ages you and kills you dead…but that the wise elders would never consume starch (in the winter for one, pretty much at all for the others). Yes, I think that sort of view can instill some unwarranted anxiety and fear in people. On the other hand, low carb and ketogenic diets can be very helpful and useful for certain conditions. In my practice I've seen some people get pretty anxious and overly burnt out and and troubled who came in on essentially zero carb diets who tend to be happier and healthier eating starch. I don't know if it was the carbs that made them better or the lack of worrying about carbs that made them feel better. I tend to favor higher-end low carb diets (like perfect health diet) and higher-carb end ketogenic diets (with MCT oil/coconut oil supplements to allow for more carb consumption) because they tend to be more flexible, easier, and less restrictive of a wide variety of foods.

5) Does Paleo dieting put you at particular risk for something like orthorexia?
I'm running out of time this morning! I feel like Robb Wolf and his carbohydrate manifesto. This one has a lot of interesting bits so I will wait to address it in Part Three.

Orthorexia in the Paleo/Primal Community

Far be it from me to steer entirely clear of the paleo drama when it pops up, despite my best intentions. An issue and question has been put forth that I feel I should address as the resident psychiatrist around these parts. Bear with me as I trace the trail of drama…it all began with Dr. McGuff, Dr. Davis, and Jimmy Moore going on former KKK Grand Wizard David Duke's podcast over the past couple years, which led to some outspoken criticism on Evelyn's blog and elsewhere. Then Jimmy Moore put out a post about 10 things the "paleo community" should address as I suppose he felt put-upon by the criticism and needed to fire off a salvo of his own.

In the comments of that post, Angelo Coppola was critical of Jimmy's premise but, amidst all that, came up with something very important that I don't know has been discussed all that rigorously in the "paleo community:"

"Recognizing and addressing eating disorders among those who are trying Paleo approaches" 

Angelo went on to say: As far as eating disorders, this is an extremely important topic to start talking about. And if we're going to talk about it honestly, we'll have to talk about how low-carb and Paleo can lead to or contribute to disordered eating. I have 4 daughters being raised in a home with some pretty strong ideas about food, so this is a very real issue for me."

Stacey also commented: "That said your point is extremely well taken on eating disorders. After being on the front-side of this paleo movement I've learned that QUITE a few of us have had eating disorders in the past. I believe some continue to use Paleo as an orthorexic approach to eating, which of course is unhealthy and off-putting for the general public."

Let's begin by more precisely defining Orthorexia, a term originally coined by Steven Bratman, MD* in a 1997 edition of Yoga Journal. Dr. Bratman is a very interesting fellow who served as a chef and organic farmer in a largely vegetarian commune in upstate New York, then trained as an alternative medicine practitioner, then as an allopathic MD. Originally he subscribed whole-heartedly to the idea of "let food be your medicine." He tinkered with vegetarianism and macrobiotic diets, and noticed that he could make a lot of very positive changes in his patients. However, in the process of living in the commune and working as a clinician, he came across many folks who were obsessed with the purity of their food. The following is from his book, Health Food Junkies, which is out of print but still available at Amazon.com if you are interested (and I think makes the point rather well that being a chef in a commune can be a thankless position):

Like all communes in those days, ours attracted food idealists.I had to prepare several separate meals at once to satisfy the unyielding and contradictory dietary demads…The main entree was invariably vegetarian. However, to placate a small but very insistent group, on an end table placed at some distance there could always be found a meat-based alternative…Since…30 percent of our vegetarians refused to contemplate food cooked in pots and pans contaminated by fleshly vibrations, our burgers had to be prepared in a separate kitchen…

…For the raw-foodists we laid out sliced raw vegetables in endless rows. Once, when a particularly enthusiastic visitor tried to convince me that slicing a vegetable would destroy its energy field, I felt so hassled I ran at him wildly with a flat Chinese cleaver until he fled. Meanwhile, the macrobiotic dieters condemned the raw vegetables for different theoretical reasons.

"Ortho" is the Greek term for straight, correct, and true, and Dr. Bratman created the term "orthorexia nervosa" to mean a problematic fixation on eating healthy food. He also developed a questionnaire to help diagnose it, and recognized that by prescribing diets to patients in order to fix health problems, he could cause patients to develop anxieties and obsessions with food. A major side effect of using diet as medicine. Orthorexia is not an official DSM-IV eating disorder, and there is no "validated" research questionnaire to use to study it, so the articles in Pubmed are few and far between (they tend to use Bratman's questionnaire as it is the only one available). In fact, orthorexia nervosa might be most properly considered a subset of obsessive compulsive disorder rather than an eating disorder per se (the whole eating disorders category in the DSM is a hot mess anyway, so I hate to quibble over the semantics).

So what is a "problematic fixation" with eating healthy food? For some folks, it has a meaning similar to too much masturbation… someone who thinks about it or practices it more than you do. But like all psychiatric conditions the cardinal issue is that the obsession interferes with normal functioning or relationships or causes pathology, such as anxiety. If you don't have celiac disease or a serious gluten intolerance and going to a family party causes you great anxiety because you are worried that Uncle Brad cut the cucumbers with the same knife he used to slice the bread, you might have a problem.

Orthorexia can have a number of different forms…for some it involves what they eat (eg only certain foods), sometimes it involves the preparation or creation (no eating food cooked in aluminum pans or any food ever exposed to pesticides). While orthorexia is not as immediately dangerous as anorexia or bulimia, there are cases where it has been fatal. It can also be very disruptive to life, for example among those who cannot consume anything they did not prepare themselves, so can never eat at parties or restaurants and have to carry food everywhere. Those who proselytize about healthy eating can also find themselves losing friends and even jeopardizing family relationships.

Are folks in the paleo/primal community more at risk for orthorexia? Well, obviously. Here we have a pre-selected population of folks who tend to be on the obsessive side who care a great deal about food, and many of them have had great health benefits from some dietary changes. It's very tempting to look to solve the next health problem with a tweak in diet or supplements. Unfortunately, one could tweak forever, with additional restrictions in diet leading to smaller and smaller benefits, no benefits at all, or even health problems derived from the diet. One can easily eat too little and intermittent fast too much on a strict paleo/primal diet, causing hormonal problems as the starvation response kicks in. One can also develop nutritional deficiencies from a very restricted diet. And some folks will delay going to the doctor for a serious medical problem, trying to find a solution by surfing the internet and eating zero carb (or only raw food, or cutting out every last molecule of fructose, or eating only this or that…).

Last year, Lindsay wrote a great post about her struggle with paleo-inspired orthorexia, and she has very graciously allowed me to interview her for my upcoming book about eating disorders. Her cautionary tale details exactly how trying to tweak her diet to cure some niggling health problems led to a problematic fixation on food and "pure" eating.

Is just eating paleo/primal "orthorexia" on its own? Absolutely not. Nowadays pretty much everyone has to care at least a little bit about what he or she eats. For example, if I don't pay some attention, I tend to gain fat, and I have two choices, to be fairly aggressive about calorie counting and portion control, or to restrict the kinds of foods I eat. Calorie counting annoys me and makes me think too much about food. If I stick to mostly paleo-style eating, I don't have to worry too much about counting, and I can go out to eat and "cheat" every once in a while without having to diligently make up for it. Whether or not you believe me, seeing as how I write a blog dedicated primarily to looking at nutrition and mental health, eating "paleo" allows me to think a lot less about food and my personal diet.

Should people with previous eating disorders be eating "paleo" or "primal" or in any sort of restrictive way? For some eating disordered folks (check out the Friday success stories at Mark's Daily Apple), eating paleo/primal has freed them from food obsessions and health problems. For others, an overly strict paleo approach might be a ticket back to majorly disordered behavior.

And there are certainly some very good reasons to obsess about what goes into your mouth,  for example life-threatening allergies or celiac disease.

If paleo or primal-style eating takes up a disruptive amount of time, makes you unduly anxious or is causing major problems in your life, you might want to consider some professional help. Most therapists are adept at dealing with anxieties, and there are also many phobia or OCD specialists who can help, particularly in larger metropolitan areas.

Dr. Bratman runs a very interesting and informative website, Orthorexia.com