Updated: Sep 4, 2021
This has been on my mind a few years, as I feel there is an underlying cause we have failed to fully realize. Why would someone intentionally starve themselves, right? It goes against all our survival instincts. More recently I heard it explained that because there is no cure, nor even really any treatment, no pharmaceuticals for anorexia, that anorexia is the one condition in which someone can "choose" to kill themselves and a judge will permit it (euthanasia). Is this just another misunderstood pathology that science dumps into mental health or psychosis in effort to make any sense of the disease?
Anorexia is twelve times more common than cancer. Yep, cancer. Eighty percent of thirteen-year-olds have attempted to lose weight and have some level of body dysphoria. Thirty percent of girls and fifteen percent of boys have eating disorders significant enough that they need medical attention. Kids admit to having fear of gaining weight more so than even a fear of breast cancer even when they have witnessed someone they love die of breast cancer. The incident of #anorexia is increasing, doubling in the last 18 years, with more than 30 million people suffering from an eating disorder at some time in their life. This is getting worse. Anorexia is a deadly disease that frankly, we haven't given proper attention.
Consider that those with anorexia often argue that what they see when they look in the mirror is very different than what we see when we look at them. This causes me to question the #neurobiology of the disorder, questioning if this is truly a condition of will, or control, as has been the long held theory. My belief, and the theory of a growing number of clinicians particularly those in functional medicine, is that anorexia is a neurobiological disorder of abnormal brain function.
People with anorexia have #delusional beliefs regarding food and even their bodies. They maintain a persistent false psychotic belief regarding the self or persons or objects outside the self that is maintained despite indisputable evidence. We know this is genetic and we also know that those with anorexia have inherited factors that lead to the "overexpression of fear-based learning." This fear about their weight becomes so significant and so conditioned, that these people progress rapidly to an absolute, unrelenting morbid dread that necessitates food avoidance. Here is where we need to focus our attention when working to evaluate the underlying cause of anorexia.
Anorexia is a chronic, pathologic fear. This is a state of mind. This fear is overwhelming, similar to the fight-or-flight response that occurs when one's child is missing and a parent searches for them everywhere; therefore, anything the person with anorexia can do to relieve this fear is what they will engage in with vigor. This means starvation, excessive exercising, purging, prescription drugs, more exercise, alcohol, laxatives, #alcohol, some opiates, recreational drugs, more starving and more drugs. This delusion and fear is unrelenting.
This really isn't about the portrayal of women or bodies in the media. It really does seem to be about neurobehavioral health. Interestingly, up to 95 percent of those with eating disorders suffer from another psychiatric comorbidity, whether that is depression, anxiety, obsessive compulsive disorder, substance abuse or personality disorders. I am always a bit leery about mental health diagnosis though, in that these diagnosis are often provided at the onset of therapy rather than after engaging in processing or behavioral modifications or even after an extensive evaluation of one's history and behavioral responses. We can't bill insurance without first having a diagnosis available to bill and many EHRs require that the diagnosis be identified before one can even open a note for charting client statements and history. We are ass-backwards when it comes to identifying mental health challenges and have so few resources that are within reach of those suffering. Having said that, there is little question that eating disorders are part of a very complex pathologic mental state that requires comprehensive evaluation, so whether ruling in or ruling out, think critically.
Thirty-five percent of people who have substance abuse and alcohol dependence also suffer from an eating disorder verses only three percent in the general population. This is the highest predictor of mortality after discharge. Again, these clients seek relief from their fear, their delusions, and very little else seems to stop these obsessive thoughts.
Obsessive compulsive disorder really is the overwhelming co-morbidity in those with eating disorders. Trauma is present in sixty percent of individuals with eating disorders, with 8 of ten or 9 of ten having a history of sexual #assault. We must understand this in the individuals we treat as clinicians.
Nature or Nurture
Most all women diet, so why aren't all women who diet suffering from anorexia? Why are some more vulnerable than others? There are many theories - genetics, environmental factors, personality traits, trauma, dieting, a preoccupation with body and weight and even nutritional deficiencies. Maybe all these are part of the picture? Bariatric surgery and Celiac disease can also create the groundwork for an eating disorder. Nutrients are deficient in these conditions, which can aggravate genetic vulnerabilities.
We do know, fairly unquestionably, that those with first degree relatives who suffer with anorexia nervosa are ten times more likely to also have anorexia than relatives of unaffected individuals. First degree relatives of people with #bulimia have a twelve-fold greater lifetime risk of having anorexia than relatives of unaffected individuals.
How does this translate into life-threatening eating disorders? Where is the vulnerability genetically? We know that those who are perfectionists or those with obsessive compulsive tendencies have higher rates of eating disorders. There seems to be a relationship with temperament, per se. Interestingly, those with birth complications, any complications, but essentially low birth weight demonstrates a higher incidence of eating disorders.
Puberty does seem to offer that perfect storm. There is a higher need for certain nutrients during #puberty as the neurodevelop is significant during this phase of life. Girls are trying new diets, as are boys. Various diets can be exceedingly restrictive. Stress is high during this time which may initiate the onset of an eating disorder. Consider too though, that gray matter in the brain thickens until puberty and afterwards, the brain has a high demand for fat through about the age of 21 years. There are very apparent myelin alterations in those with anorexia nervosa.
Brain Changes with Anorexia Nervosa
Those with low weight have less brain volume in both gray matter and white matter structures. This makes quite clear that myelation is the issue, specifically FATs, and therefore becomes the first intervention when treating anorexia. Sixty percent of the dry weight of the brain is fat. Although we've had a few decades of public education specific to minimizing fats in the diet, there is a clear difference between unhealthy fats and healthy fats. It is imperative that we understand the difference, because some are absolutely essential. When our body lacks these essential fats, depression and anxiety are increased, suicide is more common along with distorted perceptions, schizophrenia and bipolar disorder is more often present, and individuals suffer greater cognitive decline. Impulsivity, aggression, and conflicts with authority are more prevalent.
By modifying natural fats, we have altered the basic building blocks of the human brain, weakening cerebral architecture and like unstable buildings that come apart in an earthquake or storm, poorly structured human brains are failing to cope with the mounting stress of modern life (Franklin Institute)
Our weight is better regulated when we eat sufficient essential fats. Our appetite is also more controlled. Blood sugar is better regulated and ultimately, we have better cardiovascular health. Polyunsaturated fats are essential to optimal health, both physical and mental.
Inflammation is present when fat isn't, similar to running farm equipment from season to season but never stopping to lubricate its parts. Neuroplasticity is dependent on fat as our myelin sheaths that allow the synapses in the brain to communicate are made of fats. Our hormones and neurotransmitters are created from these same fats. We simply could not function without sufficient fats. Now take a minute and sit on the thought that more than half of all those who suffer from either anorexia or bulimia share that their eating disorder initiated with the start of a vegetarian or vegan diet. There is significant concern with #fat restriction. Membranes must be fluid to function properly.
When we have sufficient quantities of essential fats in our diet, we see a 25 percent reduced risk of death from suicide, a 2.6-fold reduced risk risk of #depression, and a 1.5-reduced risk of suicide ideation. When fish is decreased from the diet, #suicide is dramatically increased. One can imagine the sort of cascading impact of a reduced fat diet on the individual suffering from anorexia. What may have started as a simple desire to reduce some weight, was ultimately worsened catastrophically when they deprived their brains of essential fats.
Inflammation and Anorexia
Low-grade systemic #inflammation is at the root of anorexia. Omega-3 supplementation has shown to improve loss of appetite through an anti-inflammatory effect and through the inhibition of cytokine production. There is a growing body of literature regarding the promotion of appetite-stimulating peptides and neurotransmitters. These are mostly proteins or amino acid based peptides, but the release of them are based on the essential fatty acids.
A few interesting studies, one from the 1930 found that both linolenic acid and linoleic acid are effective in curing rats from fat deficiency (Burr & Burr). Another study in 2019, found that those anorexics that described themselves as being fat-phobic had more gastrointestinal symptoms than non-fat phobic patients. A meta-analysis in 2017 found a higher n6:n3 ratio and lower EPA/DHA levels at baseline was associated with an increased risk of #mood disorders. Depressed teenagers have lower EPA and DHA. This is a disorder of fat restriction.
One study by Dr. Agnes Ayton evaluating ten individuals suffering from anorexia nervosa who received one gram of EPA a day for three months found that 43 percent recovered completely and the other 57 percent improved. Each of them found weight gain, reversal of growth retardation, improvement in #mood, and improvement in general functioning. Polyunsaturated fats added to their diets lead to increased production of proinflammatory lipid mediators.
Borderline Personality Disorders
Even though we recognize that individuals with anorexia nervosa have co-morbid mental health disorders, too often we are diagnosing these individuals with borderline personality disorder. An eight week double-blind, placebo-controlled study with 30 female subjects previously diagnosed with BPD offered 1 gram of E-EPA or placebo daily and found the EPA significantly reduced aggression and depressive symptoms compared to the placebo group. Patients with poor impulse control, mood lability, separation anxiety, and characteristics of borderline personality certainly are a portion of the population with eating disorders, but again, the profession has jumped a little prematurely to this diagnosis in many. Consider first a fat deficiency disorder.
Individuals with anorexia nervosa are 31 times more likely than any other psychiatric illness to commit suicide. This speaks to the importance of properly evaluating #cholesterol levels, in that our goal is not simply to assure a total cholesterol below 200, but also a level higher than 160 and a sufficient number of good cholesterol in comparison to the less optimal cholesterol. The link between our epidemic of suicide, anorexia, and optimal fats is just too obvious to continue to ignore.
Fat being so important to optimal brain function means we must consider this within our #military. A retrospective analysis of 800 U.S. service personnel who completed suicide in 2002 to 2008 found those with low DHA were 62 percent more likely to have been suicide victims than those with the highest levels (Lewis, 2011). Eight percent of these victims were never deployed or saw a single day in combat. The military is now beginning to supplement soldiers to prevent suicide and depression in the military, as well as impulsive behavior. Interestingly, they are injecting foods such as pound cake and fettuccine alfredo with DHA.
Omega-3 and Suicide
Deficiencies in omega-3s leads to a 50 percent reduction in serotonin and dopamine in the frontal cortex and nucleus accumbens of animal brains. Cancer has been treated with EPA and DHA, as well as AIDS. Essential fatty acids suppresses proinflammatory cytokines which has been acknowledged, but we just don't seem to institute this in the treatment of anorexia nervosa.
When we compare #DHA to #EPA, more than 35 random control trials have demonstrated that there is greater clinical benefits of EPA formulas to DHA or placebo. This research has initiated discussion for adding omega-3 to antidepressants. The risk of progression to a psychotic disorder is significant and has been one of the primary treatments for postpartum depression for more than a decade. Research has even demonstrated this to be effective in the #pediatric population.
It takes at least ten weeks for cerebral membranes to recover. These membranes have highly unsaturated fat membranes, so give this time. Consider that we must change our car oil every three months. When individuals with anorexia understand this supplementation will improve their anxiety and obsessive behaviors, they are willing to take the supplement in spite of its caloric intake; granted, they do tend to reduce their diet otherwise, at least initially. Positive outcomes are still evident.
We have to stop blaming parents for these issues in their children and start to better evaluate what the literature is showing us. We have a nutritional deficit which is impacting neurobehavior. Understanding the role of nutrition and health is not alternative medicine. These individuals are malnourished. If you're looking for help, for a trusting collaborative #relationship, or a path to decrease anxiety or to improve your sleep or gut health, we would love to help you. We can do better. Schedule an appointment with our practice to discuss nourishing the brain and nourishing the mind.
One of the catalysts for the onset of an eating disorder is dieting itself. This is thought to be related to restriction in fats and also the trigger for obsessing about foods. Anorexia experts will recommend avoiding allergy testing or more specifically, not eliminating entire food groups. Excessive focus on the diet, particularly restrictions, can be catastrophic in general. This would also include being incredibly cautious with food sensitivity testing, which is common for functional and integrative clinicians, and admittedly, is hard for me in some regards because identifying triggers of inflammation is also important. When are considering Celiac disease though, this restriction doesn't follow the rule. It is therapeutic.
Keep in mind, anorexia nervosa has a genetic vulnerability. Testing for #Celiac disease is an exception in that unidentified, it creates a precipitant of long-term nutritional deficiency. The intestinal villi are destroyed in those with Celiac disease so that nutrients are not absorbed when eating wheat, rye, and barley. These individuals can not just eliminate gluten. One in 133 individuals are impacted and half of those have no obvious symptoms. It may not even appear until adulthood as it can be triggered by surgery, stress, pregnancy or even a viral infection.
The research is quite clear too, that Celiac disease is related to #psychosis and depression, and even anorexia. A large 2017 study evaluating 18,000 women with Celiac disease compared to 89,000 women's records who do not have Celiac and interestingly, following Celiac diagnosis, 46 percent were diagnosed with Celiac disease. This is significant but is not part of the evaluation of individuals with anorexia in conventional medicine.
Evaluating for malabsorption of multiple nutrients is also important as Celiac is known to create a disruption in the absorption of essential fatty acids, iron, fat soluble vitamins (A, D, E, and K), magnesium, folic acid, B vitamins, calcium, amino acids, zinc, and calcium. Even when Celiac disease is identified and those diagnosed also with anorexia follow the diet exceedingly well, they are still found to have zinc deficiency a year following their change in diet. Evaluating micronutrients is important, as are supplements.
While obesity is a significant concern, the medical profession has come to appreciate that #bariatric surgery commonly leads to mental health issues as these clients are at exceedingly high risk for malnutrition. Self-harm increases, as does gambling, substance abuse, suicide, and anorexia following bariatric surgery. These clients must be very diligently managed as inpatient psychiatric centers have seen an increasing admission of individuals with anorexia who have had previous gastric surgery for weight loss.
Veganism & Zinc
The number of vegans in America grew by 600 percent from nearly 4 million in 2014 to 19.6 in 2017. Veganism in puberty is risky, but either way, a change in diet often precedes the onset of an eating disorder. Veganism is associated with a longer duration of anorexia and a lower weight during their course of illness. Micronutrient support is essential and is even a model for prevention of anorexia. Malnutrition is the concern here, or the trigger, for anorexia.
There are more than 1,200 publications on this exact variable and they consistently conclude that veganism is a risk for anorexia. Interesting consideration though, the vegan diet may be a sort of cover for an individual who has already started the journey of anorexia as this allows them to reduce their calories and fats in a socially acceptable way. It is understood though, that those who avoid meat are likely to perpetuate low #zinc status, destabilizing normal eating patterns, and facilitating the development of an eating disorder. Animal products have the most bioavailable source of zinc. Further, symptoms specific to anorexia are the same as zinc deficiency, and the relationship is so significant, anorexia experts conclude in the presence of anorexia, a zinc deficiency exists.
Bloating is a very common symptom of anorexia, as well as nausea. Our digestive enzymes are zinc dependent, as are protein, fat, and carbohydrate substrates. Zinc deficiency influences the activity of carbonic anhydrase (CA), a prequel for hydrochloric acid, which starts the very beginning of the digestive cascade. If zinc is deficient, digestion is profoundly hampered. Without adequate hydrochloric acid, protein breakdown doesn't occur for the amino acids, so neurotransmitter synthesis is near void. It really doesn't matter what we are eating, without sufficient zinc, we simply aren't processing and utilizing the food that is eaten.
Further, hydrochloric acid triggers enzyme production in the stomach, including trypsin, chymotrypsin, elastase, carboxypeptidase, lipase, amylase, maltase, sucrase, lactase, and pepsin. Guess what happens when you have low zinc? Insufficient stomach acid. Insufficient enzymes. Stomach distress. Nausea. Bloating. You won't want to eat! Interestingly, when we work with clients with anorexia, rather than focusing entirely on trying to help them gain weight directly, we can ask them how we can help them and address those symptoms.
Depression, Anxiety, and Sleep
Zinc is an essential nutrient involved in several biological processes and modulates the activity of more than 300 enzymes and 2,000 transcription factors. It plays a critical role in immune function, protein synthesis, wound healing, DNA synthesis, and cell division. Zinc is a cofactor for the conversion of 5-htp to serotonin to melatonin.
A study in 2001 evaluated forty-five anorexia patients in an outpatient clinic. Each had their serum zinc levels assayed and every single one were found to be zinc-deficient. Fifty-five percent had abstained from meat for more than a year before the onset of anorexia.
Dietary zinc is a predictor of depression. Two large longitudinal studies found an inverse correlation between zinc and #depression, in that those with high zinc intake had significantly lower odds of developing depression. Another study, a meta-analysis of 17 studies measuring peripheral blood zinc concentrations in 1,643 depressed and 804 control subjects, found mean zinc concentrations were lower in depressed subjects. Other studies have found that women receiving multivitamins with zinc have significant improves in mood, but this isn't the same when the multivitamin lacks zinc. Antidepressants have demonstrated to be less effective, in several studies, when zinc is deficient.
The majority of anorexic clients share concerns about insomnia, #impulsivity, and social anxieties. We know that zinc is required for serotonin synthesis, so we also know it is required to make melatonin. Consider that L-tryptophan is a requirement for serotonin and melatonin synthesis, both which require zinc and these require vitamin B6, all dependent upon the effectiveness of your methylation. More on that later, but know that after six months of zinc therapy (50mg/day), anorexia patients display improvement in depression, anxiety, and taste. An increase in body mass index increase has also been realized with zinc supplementation - by two times the rate! There is more evidence for zinc in the treatment of anorexia than there is for pharmaceuticals, yet antipsychotics is the primary treatment regimen, primarily #zyprexa. In many ways, it has been a miracle drug, but failing to offer zinc fails to treat the underlying issue.
The early 1900s was a time of epidemic proportions of #pellagra. People were filling the psychiatric hospitals. Many others were dying. This continued for thirty or forty years in the early 1900s. The cure was understanding that the diet of the poor, primarily in the south where diets were mostly corn, was deficient in proteins and fats ultimately leading to a B3 deficiency. More than 100K people died and one-third to one-half of psychiatric hospitals were filled with people with pellagra. The fatality rate was 64 percent.
We still see pellagra today due to poverty, alcoholism, homelessness, and psychiatric patients refusing food. Africa, Mexico, Indonesia, and China all have endemic level occurrence. Often when people present with B3 deficiency, it goes undiagnosed as schizophrenia. In the early 1900s, when the inpatient individuals admitted for psychosis were offered Brewer's yeast (B3), they ultimately just walked out of the hospital.
Studies have found that pellagra can be treated with less than a gram a day of B3 and schizophrenia can be treated with 3 to 6 grams per day of B3, offering complete resolution for some of their symptoms which are typically dementia, diarrhea, and dermatitis. Niacinamide is a good option. Consider testing for a B3 nutritional deficiency when you see skin disorders in clients or ask your clinician to evaluate your B vitamins.
It has been said that the greatest tragedy of modern medicine is failing to properly diagnose B12 deficiency. It has significant effects on our mood and metabolism. B12 is vital in our ability to methylate. When homocysteine is higher, we have higher incidence of stroke, dementia, and depression. When homocysteine goes up, cortisol goes up. Methylation is reduced and epigenetics starts to be a factor, which can have a profound effect on gene code transcription. With decreased methylation we will also have decreased neurotransmitter synthesis and major neurotransmitters, such as dopamine, serotonin, and norepinephrine.
B12 affects mood, more specifically it affects brain function. The symptoms of B12 deficiency are quite variable. Chronic fatigue is potentially one of the more common, but dementia, hallucinations, violent behavior, mania, depression, apathy have also been resolved with identification and treatment of B12 deficiency. Neurologically, clumsiness and weakness have been thought to be multiple sclerosis, when in fact, it was a B12 deficiency. Pernicious anemia, irritability, personality changes, diminished sense of touch or pain, and gastrointestinal problems are additional symptoms of B12 deficiency. Individuals with anorexia can certainly demonstrate these symptoms, as well as anxiety.
B12 in vegetarians is concerning. This often causes relapse or even the onset of the eating disorder, and slower weight restoration. One study found the frequency of depression at 31 percent for those who were B12-deficient and vegetarian but only 12 percent in #omnivores. There is some thought that this is related to methylmalonic acid (MMA) which elevates in vegetarians.
Lower levels of B12 is associated with less success in the utilization of fluoxetine for the treatment of depression. Overall treatment for depression is reduced, while a higher baseline of vitamin B12 has demonstrated a greater response to standard depression treatment. Vitamin B12 is inversely correlated with depression scores in unmedicated depressed patients.
Talking to Clients about their Diet
We really do need to talk to clients about their diet choices and convictions. There are a number of options and certainly, vegetarianism and veganism don't have to be avoided entirely, but a vegan diet during adolescence, particularly with a family history of anorexia or binge eating would be concerning.
I suppose I like to recommend a plant-based diet more so than vegan, but even with a vegetarian diet, we can typically obtain sufficient vitamins and minerals although sometimes supplementation is necessary. What I find exceedingly interesting though is that in one study, zinc status was evaluated with supplementation and without, but keep in mind these were hospitalized patients, so they all received nutritional therapy and diets. The findings within the placebo group were that upon discharge, their zinc levels had all dropped. This makes sense though because with their new diets, they had greater enzyme demand which would reduce zinc. This sets patients up to fail. However, in the supplemented group, all zinc levels increased.
The hallmark of anorexia nervosa is relapse and more relapse. Inpatients with anorexia are smart. They know how to gain wait to get released and sent back to school. When we discharge them in these deficient states, we are setting them up for failure. Animal meat is the best source of dietary zinc!
We can't blame the parents anymore. We can't always blame the family dynamics. We can't really blame the culture and the magazines and Instagram. This is the old paradigm in understanding anorexia. Today we know better. We need to dig in and understand the genetic and environmental dance. We need to get into the biology underlying why anorexia presents in some individuals. Parents and family members are allies in understanding the genetic or biological vulnerability.
The key though, and maybe read this twice, is that #nutrition is the first priority and then gaining insight into emotional, psychological, and behavioral results comes later. We simply won't see psychological progress until nutritional rehabilitation has begun. Zinc evaluation and management really is critical for these clients.
Not Always that Easy
An expert functional medicine clinician shared a case study of a client who he had offered zinc to help address the underlying cause of anorexia and her response was, "I started taking the liquid zinc and after three days I had an appetite... I felt hungry... I was scared... I stopped the zinc." This is complicated - both psychologically and biologically. We have to really understand the dance to be successful with these interventions. Focus first with what the client wants addressed, as often, they don't want help with their anorexia or with weight gain. Build a relationship.