How to help people lose weight

A huge number of people come for guidance for weight change. Frustrated individuals go everywhere, to slimming clubs, bootcamps, to learn why they cannot succeed at weight loss, in the expectation that if they find the reasons for their “lack of willpower”, they will emerge sylphlike from the therapy room with their relationship with food corrected. These clients hope and are led to believe by unspecialised therapists, that they will find an explanation for their failure to lose weight in their childhood adversity, their poor attachment experiences or other traumas. Some clients even think that a hypnotist will convince their rampant unconscious to make a piece of chocolate taste like an onion.

Neither hypnosis nor counselling do the trick. Some therapists have built their reputations on attachment or trauma explanations for obesity, the thinking is that if you have had poor attachment experiences in childhood, you will be unable to use others or your own missing capacity for self- soothing and hence will develop an addictive relationship to substances like chocolate to get you through the slings and arrows  of life. It is a persuasive argument that has poor outcomes for changing someone’s weight. 

Weight-loss therapy rests on the premise that to lose weight (if this is the outcome) several things must come together. There must be Intention, this is about why a person wants to lose weight, and when. A person might want to embark on weight loss, but not yet- and maybe never, because one way of dealing with a problem is to ignore it.

To lose weight, intention has to move into Action, that is all the behaviours that are designed to make change possible. Please don’t assume from this that Action means “dieting” or “going to the gym”.  The intention-action gap is a bridge that is easily broken by temptation, other people or boredom among other things, or by having a very disordered relationship with food.

 It is the therapist’s job to help the client to bridge the intention-action gap and to make many different behaviours sustained for life. Whether you think of obesity as a disease or a moral failure or a curse, people who lose weight and maintain it must change some habits for life. This is the hardest thing of all.  

The weight-loss therapist needs to understand intention and the intention-action gap with compassion and academic wisdom – not with strong opinions and fixated ideas.

Let’s look at Intention to lose weight. Motivation to change is not the same as desperation, although many people who want weight-loss are desperate; they feel bad, moving hurts, maybe they are sick;   or diabetic, they don’t like looking in the mirror and they restrict many of the day-to-day pleasures that they think are allowed for slimmer folk.  I accept a client’s reasons for wanting weight loss, unconditionally and without judgment. I do not show myself enthusiastic about their wish to change their weight. I just  work quietly on what their Intention is about and leave decisions up to them.

The wish to lose weight comes from surface wants like “I want to be able to fit into normal clothes”  and also from deeper existential issues such as wanting to “be” different or to have a different kind of life. Intention is shaped by questions such as – what kind of person would I be if my weight were to change?  Would people who love me / approve of what I want to do, or would I be stepping outside of a family identity?   If I were to lose weight would I be hungry all the time? Will I have to sacrifice too many  nice things?  Would I be able to eat my favourite foods? Would I be the boring person at the party?  Would I be giving away my power to all the people who have said I should lose weight? What will be the costs of not losing weight; do I think I have it in me? Do I really want to follow someone else’s dumb rules. And last but not least, as an example, if I were to lose weight, would I get something really important out of it, like living to see my grandkids grow up. I don’t want to be driven by my hungry needy inner child.

So how do we think about Action? Does it mean going on a diet or going to the gym? Does it mean striving to reach a goal weight?  The answer is no.

Action, strangely enough, doesn’t target weight-loss as a treatment goal. Goal weights are heinous. Action therapy targets the vast range of behaviours and the attitudes that shape our behaviours, that make permanent weight-loss more likely.

Action therapy nudges clients toward some principles of weight change that are known to work, such as eating s…l…o. .w. .l. .y or,  getting rid of the biscuit tin. We are all wired to eat what is in front of our nose. Your kids don’t need biscuits; and I promise that they won’t need psychiatric help because you don’t have a fridge full of KitKats). Action might be something as small as not eating your main meals in front of the TV.  It might mean buying smaller Easter eggs, the day before Easter, not in the middle of January.

Action behaviours are affected by many things, each needing therapist attention or skills work. Old habits, stigma, people who do their best to sabotage you or, simply where you live. Certain skills are helpful, such as cooking, being able to read a food label; or saying no to the children who pester you for crisps in Tesco. Skills for managing cravings do not require years of psychotherapy. There are simple do-able tools that really work. Willpower is simply a neurological muscle we use to manage impulses and compulsions and we know how it can be strengthened.

The Intention-Action Bridge is weakened by unhelpful attitudes that keep a person stuck in their unhappy relationship with food. Limiting beliefs such as “I will die without my treats, or, I should never eat chocolate (or I will be a pathetic weak person) or, I was born to be big so there’s nothing can be done about it – all these mind-worms can be changed. Even an automatic belief like I shouldn’t have eaten that, What’s the point – I may as well carry on eating and I will start again next week.  We can erase this kind of thinking from a person’s mind.

Emotional eating

If we keep the intention-action gap as our central focus for obesity therapy, obviously there are many barriers that thwart Action. One such barrier is emotional eating. Most people with obesity claim that comfort eating is the root of their weight issues. And most therapists believe that it isn’t about food, it’s about feelings. They may be wrong.

Where emotional eating is severe, our person may have an eating disorder and they must not to try weight loss right now. Direct them to an eating disorder therapist. But moderate levels of emotional eating can be treated. This is not the place to describe how we deal with food cravings or undue attachment to foods like chocolate. Suffice it to say that person-centred counselling, dealing with trauma, childhood adversity or adverse attachments all have unsatisfactory outcomes for modifying eating that has little to do with hunger.

When you think about obesity therapy, let go of the notion that we are putting people on a diet or forcing them to change a lifestyle that they know and love, in which they feel comfortable and that is part of their larger system of friends and families. People who shout negatively about obesity therapy remind me of the saying it is the emptiest vessels who make the most noise. Come and see how the right obesity therapy can make a person flourish. Our next training, Essential Obesity, is coming this June. do itnow!

Discovering our clients with a lifeline


I hear on the grapevine that someone has taken exception to NCFEDs method for assessing a client’s story via a lifeline. The lifeline tracks their life experiences alongside changes to their eating and body size or weight with colours and pictures.

Someone claiming to be a psychotherapist has taken exception to our understanding the client’s weight changes during their lifespan (alongside their story) by calling this “fat phobic”

The apparent purpose of tracking a client’s weight, is not to shame or judge them. It is to see how life experiences and transitions have changed a person’s eating habits and weight status. The weight is important only as it serves as a communication of deeper issues that may be unspoken.

It was Freud who first identified the mind-body as a single energy system and both behaviour and body weight may symbolise issues that are either hidden from understanding or for which the client cannot find words to express or explain what is happening to them. As Van de Kolk explained, “the body keeps the score”.

Just as we understand that weight loss in the anorexic is the only way they know to experience an emotional pain for which they lack a language, it may be the same for weight change in the opposite direction. It is our sacred duty to identify ALL the signals in the client’s narrative to understand what is important to them, what has been lost or is missing, what is the communication that we need to hear. What have they been unable to cope with, and what can we learn about the deficits that therapy can address.

It can also be said that clients tend to like and find safe the lifeline process; in 40 years of work we have had no complaints. If anything, it shows that I am interested in who they are rather than simply their eating disorder symptoms. During the process they become curious rather than defensive. They start to make their own connections about a problem that has not been understood and that has plagued them  And they engage with me because they sense that I have seen them, and what is important in their life OTHER than food and body shape.

Some people are so wedded to their activisms that they are blind to reason. I am reminded that just because you have a loud voice you may not be right. They are passionate militants without fully understanding why.  Should they be let loose on vulnerable people?

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Is happiness a useful therapy outcome?

Do you want to be happy or do you want to maintain a low BMI. Do you want to be happy and have big muscles and low body fat?  Do you want to be happy but only if you are running 50 miles a week?

Cannot have both.

A colleague had a session with a person with entrenched anorexia who said that she was coming to therapy because she just wanted to be happy.

We all want to be happy, but what does this mean? I was thinking about my own life (trigger alert) and it is not without stress. I have some inconvenient and slightly painful health issues, I always worry about my children, my work carries quite a bit of stress and my material aspirations are well beyond my financial capacity.  I have my fair share of regrets about past decisions and actions. Not only that, my ideal shape might be Taylor Swift but I’m not there by a long chalk.

But am I “happy”?  The answer is, I am.

People who quest for happiness can get it by sitting on a beach in Barbados. But will you be happy on that beach if you are a skeleton with a prune for a brain or you can’t have peaches for breakfast because you are terrified of the calories, or beating yourself up because you didn’t run 5 miles before dawn?

When the low-weight client tells you that they just want to be happy, take a pause.  You have a job to do with this statement. One thing you know – the happy life is not the same as the fulfilled life. The fulfilled person is not always happy, but they are glad to be alive.

We know, but we cannot explain to the unhappy client, that a starved brain cannot be happy. The starved brain can be dissociated, numb, proud (of being thinner than you), defiant (in being able to refuse eating) and full of shame (for not meeting perfectionist goals) – but it can never be happy.

We also know that the person who fights their anorexia and returns to a normal BMI will not be happy.  They will have lost all the pros of anorexia but got nothing back but “fatness”. They may be full of regrets for what they have done to themselves and to others. They will not quite have caught up with people who left them behind. So, you cannot say to them just gain weight and you will be happy.

So, when the client tells you that they just want to be happy, you are in a fix. They may become happy, when their lives improve, and their brains start to work properly and they notice a beautiful sunset with someone they love. 

The quest to be happy is a chimera. How can we talk to our client about that, because I am not going to agree that the main purpose of my therapy is to make them happy.  Perhaps it is to make them happy about being unhappy?  Food for thought.

Leaky Gut

And its link to eating disorders by Jenny Tomei

What is leaky gut?

Our gut lining is made up of a barrier of tight junctions, like little doors that open and close to control what gets into our bloodstream.

It allows the passage of the good guys (for instance, nutrients to feed your body) and keeps out the bad guys (disease-causing nasties, or pathogens and toxins such as lipopolysaccharides, produced by certain bacteria).

The gut is the body’s first line of defence. It’s the reason we’re not all bedridden and defeated by infection every time we eat or step outside.

Sometimes these tight junctions can become weak or loose, allowing potential pathogens to sneak across the intestinal wall. Scientists call this intestinal hyperpermeability; otherwise known as ‘leaky gut’.

Stress, too, is a common trigger. A study by the university KU Leuven in Belgium in 2014 looked at students before and after public speaking and found that those who were more nervous and stressed (as measured by the stress hormone cortisol in their saliva) were the ones whose guts became leaky.

Who gets leaky gut?

We all experience a slightly more permeable or ‘leaky’ gut lining temporarily especially after intense exercise, without any health consequences. The problem is when someone starts to get symptoms of a possible “leaky gut” (bearing in mind it’s NOT A DIAGNOSIS) e.g. brain fog, severe IBS, thyroid issues, depression, imbalanced hormones, inflammation in the gut especially after exercise.

People with Coeliac Disease find that eating gluten can cause the gut to become leaky for a longer amount of time. Once you take the gluten out, the leakiness starts to resolve itself.

A leaky gut can also happen when we drink too much alcohol all at once, and because of stress. Some athletes can experience a high level of intestinal permeability due to the consistent stress levels created from heavy training loads, which may ‘temporality’ cause leakiness to the gut.

More stress can happen if someone is ‘diagnosed’ with leaky gut! De-dress = A happy gut.

Dysbiosis and leaky gut.

The imbalance in intestinal microbiota alters the tight intercellular junctions (TJ) that allow access to pathogens and toxins. Additionally, it induces stimulation of mucosa-associated lymphatic tissue (MALT) with the activation of the inflammatory cascade (leukocytes, cytokines, and TNF-α). This then triggers off inflammation and may cause tissue damage.

The composition of the microbiota changes continuously throughout life, due to many factors. It is affected by diet, age, genes, drugs ingested, and environmental, physical, and psychological stress.


Your gut can recover when you take away the cause e.g., gluten with coeliac disease or dealing with stress in your life.

A GAPS eating plan reducing sugar and grains was proposed as a solution, but it does not seem to have any health benefits. There are some studies suggesting L-glutamine modulates the expression of tight junction proteins.

Probiotics, vitamins A and D, fibre and short chain fatty acids have all shown a significant benefit with helping to support a healthy gut lining.

Leaky gut and eating disorders.

Restrictive diets can starve your body and your good gut bacteria.

One study, published in the journal Nature in 2018, showed that a low-gluten diet followed by healthy people reduced some beneficial gut bacteria — demonstrating that cutting out foods can have adverse knock-on consequences. (If you do choose to forgo gluten for whatever reason, just make sure you’re still including plenty of non-gluten wholegrains such as quinoa, buckwheat and popcorn.)

For a strong gut lining and good gut health, the goal is diversity, not restriction.

Jenny’s story:

I worked with Megan Rossi who explained my gut was very leaky due a history of over exercising, under eating and high cortisol levels. I was put on the low-fodmap diet for 10 weeks, and a high dose of L-glutamine for 6 weeks at 6g a day, as there was a study showing it helped to support and repair the gut lining. Reducing my overall stress levels and doing less intense form of cardio, helped my stressed-out gut!

I had to power walk instead of run because my gut was so bad, I couldn’t even run a mile without experiencing inflammation! I had hormone imbalances, sleep issues, brain fog, constipation, increased anxiety, and depression. It took a year to heal my gut, which was a long time, but my situation was made worse by emotional stressors and unresolved trauma. I was referred for trauma treatment – (I was told trauma can be stored in the gut too, makes sense as when I get stressed or I feel anxious it all goes to my gut!)  I now know that stress and emotions are stored within my gut!

I also did a stool test with Nordic laboratories which showed an imbalance in my gut bacteria (dysbiosis) and my Zonulin marker was also raised. (marker for intestinal permeability). I went on a anti – microbial protocol for 3 months, and I was very shocked to see improvements in my overall gut health after this. I no longer had inflammation from my training. I do still occasionally have flare ups when my stress levels are too high!

Here are some references if you want to learn more:

Emotional Eating: It isn’t all emotional

Not all Emotional Eating is Emotional

“Food understands me” says one of my clients in a larger body. I am taken slightly aback.

She has been struggling to explain why she continues to eat when she is full and why she cannot stop eating her treats.

Like millions of people struggling with their weight Ms S is not impressed by the body positivity movement, and even after trying multiple diets she continues to wish that there was something that will help her lose weight and keep it off. She is pre diabetic and she wants to live a healthy life to see her grandkids grow up.

She calls herself an emotional eater,  and the pandemic only made things worse. As a single professional forced to work from home during the pandemic, she claims that she is lonely and her weight increases her sense of not fitting in.  As a busy mum she often resorts to takeaways and ready meals to feed her children, and she compensates for times she can’t be with them properly by giving them sweets that she eats herself.  Despite knowing that her habits are wrecking her health, she cannot stop.

So, she berates herself and calls herself weak-willed and even a food addict.

Like many emotional eaters, Ms S doesn’t know why or how to switch from emotional eating to eating based on her biological hunger signals. She has seen a counsellor once before who spent a lot of time asking about her childhood and telling her “it’s not really about food so we don’t need to talk about it. So, she has been given no food diary to complete and she has had no nutritional guidance. She would not want it anyway because she knows everything there is to know about calories but this is not enough to help her make the best choices.

She does not know that not all emotional eating is emotional.

1 Her hunger can be biologically driven.

Hunger is experienced in the brain and is not always recognised as a strong drive to “have lunch”.   There are two main hunger pathways: the homeostatic pathway and the hedonic pathway. The homeostatic pathway is our biological hunger pathway and is driven by the need for energy in calories and nutrients that help us function. Conversely, hedonic eating is pleasure-driven and uses pleasure signals to “bypass” the physical hunger/satisfaction signals.

These signals interact with each other, so that you can get all you need in the way of nutrients and energy but if there is little pleasure associated with it, you might still need to eat – sooner rather than later.

Many factors disrupt the normal appetite pathways, such as stress levels; and many medical conditions, including, but not limited to obesity, diabetes, hormonal problems such as Polycystic Ovary Syndrome. Such factors as insulin resistance and inflammation are a common link in these conditions.  Insulin resistance – that can be the result of years of unhelpful eating, are linked to these hormones and can block some signals deep in the brain that signal us to stop eating for now or signals that tell us that there is enough fat in our body.

Still where physiology is concerned, mental health conditions may disrupt levels of neurotransmitters such as serotonin (that controls sugar hunger) and dopamine (that controls sugar and fat hunger can also cause appetite changes. When a person cannot “feel” these hormones in the brain, they  might become miserable enough to turn to food to feel a little better.

The  Power of Food Scale readings (researchers have access but few counsellors in the field) show that many people in larger bodies have high brain activity in the visual cortex when they see highly palatable foods. I do not think this is a surprise, because we are all attuned to being excited about palatable food. But these exciting signals are much stronger in people who are nutritionally depleted.

2 Other hormonal Issues

Sex hormones can have a big effect on emotional eating and this can be tied to states of mind as well. People report eating more pre-menstrually or at middle age where females experience a decline in oestrogen and males a drop  in testosterone.  Hormones can disrupt the availability and absorption of key nutrients such as  calcium, magnesium and phosphorous that affect the hunger centres of the grain. It is not surprising that some people crave chocolate at these times . And this isn’t surprising, as cacao is rich in iron and other minerals, so,  chocolate is addressing a physical and emotional need.

3 The Role of a Dieting History

Dieters do much more eating in  any kind of emotional situation than non-dieters.  This is not necessarily just when emotions are bad. It can be when the food is simply there or when a person is sitting on the sofa next to their family enjoying a movie. We do not fully understand this powerful driver of emotional eating. We just notice that this is true.

4 The Role of Mindless Eating

People may eat mindlessly for all sorts of reasons. Some are too busy to sit down, others eat in the car or while putting the food shop away. Some eat fast because that’s how they learned to eat in childhood. Some people living with obesity eat fast because they are too guilty about eating so they want to block it from their awareness.  Mindless eating simply is not recognised by the brain as being a real meal or snack.  This was demonstrated in a landmark study by Health Psychologists at the University of Surrey. They showed that families who ate lunch on their knees in front of the television ate 3 times as much snack food as people who ate at the table.  For an updated take on the effects of mindless eating, listen to this

5 The Role of Their Emotions

Emotional eaters have strong emotional connections to food that in extreme cases we can call a co-dependency. Here are some of the questions we therapists ask.

Why is it that some people feel a sense of extreme loss and despair if they cannot get their comfort foods?

Why is it that they feel deeply deprived if they see others eat that new ice cream? 

Why is it that some people can wait a while to eat a treat food while others have to eat it now?

Why does someone say, I KNOW what I should be eating but I somehow just cant do it?

It needs to be pointed out that a great deal of emotional eating is normal.  In her various books, Suzie Orbach suggests that we all eat for reward, because we deserve something in the moment, to quell anxiety, because others are with us; we eat in case we get hungry later, and because it feels nice and gives us a small dopamine hit when something tasty is in the mouth.  The roots of this kind of “normal” emotional eating may (or not) have its roots in childhood. Counsellors should not assume that something else is wrong. In other words, emotional eating can become a habit, or it could be a response to trauma or poor early attachments. We must not assume.

Emotional eating can also be associated with our values. This is where people overeat on holiday because it is important to “let go” and where others overeat in restaurants because they are lulled by alcohol or it is the only way they have a good time there.

Emotional eating should not also be confused with binge eating, although binge eaters also describe themselves as managing their feelings through the abuse of food and their other strategies such as purging. In the same way as emotional eaters without an eating disorder, binge eaters may also overeat because of disruptions in their hunger and satiation pathways.

6 The role of unhelpful thinking.

While counsellors and sufferers alike point the finger at emotions when they explain emotional eating, trained specialists know that a lot of what we call “eating your feelings” is caused primarily by their thoughts. Thoughts come first, feelings afterwards.

For example, if someone eats a forbidden food and tells themselves “I’ve blown it, I may as well carry on eating (and be very good tomorrow)” – a single lapse can escalate into a full- blown episode of overeating. Thinking that one must “cut back afterwards” can cause further overeating because of anxiety or shame. Even having thoughts such as “I’m stuffed so that must mean I have eaten too much” can also give rise to overeating, either as a rebellion against the punishment to come, or because of fears of weight gain.

Among people who claim emotional eating is responsible for their problems, we can identify all sorts of unhelpful thoughts that provoke their problems, such as believing that dieting is the best way to lose weight, or that fat makes you fat (and so you should not eat it and you are a bad person if you do).

Unhelpful thinking – in respect of old associations with food, can also play its part in emotional eating. The client who is driven to eat bread and marmalade might be trying to retrieve old, pleasant memories of spending time with grandparents. Ole memories of eating may invoke happy or deeply toxic memories of food. To some extent our eating, or overeating can be an attempt to reconnect with, or run away from the memories in our mind.

The links between “emotional eating” and eating as a direct response to unhelpful automatic thinking must be understood by anyone working with a comfort eater. By attending only to the emotional life and the adversities that lie beneath, the therapist might be missing some very important information

It is the thinking about emotional eating and what it “means” to each client that is the problem. Small violations of dietary rules can lead to large amounts of guilt, shame and negative self-talk.  People believe that name calling will help but it usually makes things worse. It takes informed cognitive styles of therapy to deal with “stinking thinking” in tandem with whatever else needs to be done to manage historic adversity that “might” play a part.

The Solutions

There is no single reason why someone is an emotional eater. Many of the reasons above are acting together. This list of strategies is not exhaustive and needs greater understanding.

1 .Treat biological causes that impact physiologic hunger and trigger emotional eating. The depleted client will not respond to psychological treatment so this needs priority.

2. Treat unhelpful eating styles such as rushing food or eating while doing other things. How a person eats can be as important as WHY they eat in a particular way.

2. Triggers: Address patterns, places/people, with problem solving skills and other skills such as problem-solving, stress management,  flexibility, and a compassion focus. You might need to work on relationships since other people can encourage overeating too.

3. Transition to non-food rewards; but this takes time, practice and work on self-esteem to make non-food rewards attractive and deserved. 

4 All emotional eaters need to work on managing cravings,  impulses and the thinking that follows lapse events.  A compassion focus is one good way to manage cravings and help the person to calm down and take stock of what else is going wrong.

5 Emotional resilience training helps people to find more effective ways of managing their feelings and also having fun with food – but not too much!  This therapy approach helps people to know what they feel (without shame or avoidance) and take appropriate action without needing another fix. Trauma work might be indicated in some people to take account of high emotions and hypervigilance. But this alone will only go part of the way to treating excessive levels of “emotional eating”.

6 Cognitive styles of therapy are needed for unhelpful thinking.

7 Medication and surgery are an option for people with medical risk associated with high levels of emotional eating. They can work well, but are not a substitute for addressing the psychosocial aspects of emotional eating.

Deanne Jade, May 2023

Hadley Freeman Anorexia

Hadley Freeman has written a searing account of her anorexia and her change in the Sunday Times. I don’t use the word “Recovery” because this word doesn’t quite capture what for many of us was not “getting better” but making different decisions about how we want to live. Me too.

So, the anorexia isn’t something that goes away, it’s unhelpful to talk about “recovery” in the same way as we talk about recovery from measles.  it is a part of us, we have too many memories of it and sometimes it tries to persuade us that we will be happier if we embrace it. But we know it is a lie. So when recently, even 50 years later, I lost weight through an illness, I loved my thinness. But I did everything possible to bring my body back to a normal BMI. Even ice cream for lunch when my appetite was poor.

I would not like Hadley to be grabbed to be the poster girl for recovery by all the eating disorder organisations there.  I would urge her not to be seduced into going to schools and telling everyone about her painful experiences and “If I can get better so can you”.  I caution her against getting on a soapbox flaunting her lived experience and demanding more money and resources for treatment better than what she had at these terrible hospitals.

Why not?

Because I think that throwing money at eating disorder treatment is a partial waste. Hadley showed clearly that putting people into an eating disorder unit can make them immeasurably worse. The bullying, the ugly competition to the be the sickest, the tricks they learn, the helpless therapists, I have seen it, over and over again.   In services I have supervised, I see people get into therapy and do everything they can to sabotage their therapists and miss sessions that could be used by other people.  So, the definition of madness is to do the same thing and expect a different outcome. Money poured down the drain.

It means that before we scream for more funds we must be clear about how we would like these funds to be used. If you think this means more eating disorder units there would be hollow laughter from me. Really?

Hadley wrote what we all know. Anorexia may be something to be endured for as long as it takes for someone to wake up one day and know that they want something different out of life. The ONLY thing that helps is a therapist who is trained to recognise this and show their understanding of the snake, the Voice, the noises in the head.  We can make tweaks to all this and wait until the new understanding seeps through the carapace of the anorexic condition.  Other than that – all we can do is to keep a starving person alive until they are bored enough to wonder whether life can offer them something else.

In Australia, efforts are being made to develop a first-aid service for carers, professionals and people in the community. To catch young people early before anorexia becomes entrenched. I wait with interest to see what that is, because catching it early seems to be the one thing that works well. Meanwhile if you are suffering and you don’t like the label “chronic” then find out what label you prefer. If you like being chronic, then don’t ask for help and live or die as you choose. Some people thrive on making a fetish of their mental health past (calling it advocacy) – well perhaps it is. But I worry that if people define themselves as having mental health issues, this reinforces their identity. They can choose to move on.

But back to Hadley. I noticed her first because she has  the courage not to toe the woke line where it comes to issues like gender, pronouns, and other issues of the day.  I love how her mind works. I hope she isn’t seduced into become a poster child for anorexia. The best medicine is to move on, live well, travel the world, volunteer for a different charity,  see nature- leave your  computer and embrace other things.



The Guardian article regarding the suitability of coaches for working with eating disorder persons has raised a lot of angst. Out of the woodwork pour well-meaning academics, authors and persons with lived experience who regard themselves as the mouthpiece for eating disorder sufferers. 

The Guardian journalist had a clear agenda for her article, and for her Editors, this was to “awfulize” the phenomenon of “untrained” coaches working with eating disorders. She targeted NCFED because we refer people to professional coaches – and nutritionists without qualifications in psychology. When she interviewed me she heard things with did not chime well with her agenda because we told her that all our Network have been thoroughly trained, supervised, properly tested and grounded in working safely. She had not expected to hear this –  I think that this has caused her discomfort. But she had to follow her agenda to its conclusion and so, here we are.

I agree that there are thousands of people out there who claim to treat eating disorders who have done little or no training. Attending an eating disorder course, certificates or not does not make you a safe eating disorder or obesity therapist.

But there is no one from the counselling or psychology authorities who are prepared to say what is enough.

There is a familiar trope that eating disorder patients are “vulnerable” and “deserving only of a qualified psychotherapist with the right qualifications”. I agree with this to an extent.


There are arguably about 12 million people in the UK who qualify for having an eating disorder, most undisclosed because they are not seen to be at death’s door.  This is the vast army of compulsive eaters and serial dieters including many who also purge. Among this hidden tsunami of sufferers are many not particularly vulnerable. Their dieting efforts have had unintended consequences and they are otherwise as normal as anyone else. I do not agree with pathologizing everyone who has an eating disorder.  I do not want to tell my patients that they are mentally ill. Poor body image is normal and a culture-bound, not a mental health issue in most of us.

A coach who learns the basic principles of cognitive behaviour therapy applied to eating issues is a very good choice to help lead most eating disorder patients back to a better relationship with food and a flourishing life. You see, even for so called psychotherapists, eating disorder therapy is largely a coaching role. The strategies taught by the Maudsley, such as reducing rigidity are coaching tasks, framed as “behaviour therapy”.

I would even go so far as to say that coaches are BETTER trained to help guide a person toward a flourishing life. Therapists approach their patients from the perspective of “what is wrong with you!” while coaches ask the question “how can I help you to live better going forward”.

So, I am on the side of our coaches. Give them a good enough grounding in the principles of CBT and help them know when to call on additional troops and they often do better than academic psychotherapists.

Ozempic and similar drugs

Ozempic and risk of thyroid and pancreatic cancer? Reproduced from an article on Medscape March 2023

Ozempic works by affecting expression of GLP1 – a pancreatic hormone that boosts the effects of insulin, slows gastric emptying, and affects some of the appetite increasing chemicals in the brain. The weight loss effects of Ozempic are impressive, so long as people keep injecting.

A few years ago, alongside American (FDA) approval of GLP-1 agonists, a warning accompanied the products’ labels to not use this class of medications in patients with medullary thyroid cancer, a family history of medullary thyroid cancer, or multiple endocrine neoplasia syndrome type 2. This warning was based on data from animal studies.

Human pancreatic cells aren’t the only cells that express GLP-1 receptors. These receptors are also expressed by parafollicular cells (C cells) of the thyroid, which secrete calcitonin and are the cells involved in medullary thyroid cancer. A dose-related and duration-dependent increase in thyroid C-cell tumour incidence was noted in rodents.  But not in monkeys.

Over a decade ago, a study examining the FDA’s database of reported adverse events found an increased risk for thyroid cancer in patients treated with exenatide, another GLP-1 agonist but subsequent studies did not confirm this relationship.

A LEADER TRIAL in the USA investigated the effects of liraglutide in patients with type 2 diabetes and showed no effect of GLP-1 receptor activation on human serum calcitonin levels, C-cell proliferation, or C-cell malignancy. F

Differing from prior studies, a recent nationwide French healthcare system study provided newer data suggesting a moderate increased risk for thyroid cancer in a cohort of patients with type 2 diabetes who were taking GLP-1 agonists. The increase in relative risk was noted for all types of thyroid cancer in patients using GLP-1 receptor agonists for 1-3 years.

The drug companies have offered a perspective on  the limitations of these findings, we must note that declarations of interest offer may bias any findings against  these drugs. You may wish to look up the work of Caroline Thompson and Til Sturmer if you want to learn more.

So, without going into detail about risk, and type of tumour that have attracted warnings, the jury is still out. For example this is one question that has attracted controversy.

Is a detection bias present where weight loss makes nodules more visible on the neck among those treated with GLP-1 agonists? And/or are patients treated with GLP-1 agonists being screened more stringently for thyroid nodules and/or cancer?

Advice to Patients taking Ozempic

The TikTok videos may continue, the celebrity chatter may increase, and doctors must continue to make their own judgement about decision-making and guidance for our patients.
There may be risks both of thyroid and pancreatic cancer but we don’t yet know for whom and why and dose dependency.

It’s prudent to advise patients that if they have a personal or family history of medullary thyroid cancer or multiple endocrine neoplasia syndrome type 2, in particular, they should avoid using Ozempic and any similar medication. Thyroid cancer remains a rare outcome, and GLP-1 receptor agonists remain a very important and beneficial treatment option for the right patient.

Weight-loss tricks and calorie nonsense

Weight loss, tricks, keto diets and calorie nonsense

Today I heard on the radio that eating a handful of nuts daily is associated with longevity, short term weight loss and long term weight control. Really!  All that fat!  All those calories! And yes, ‘tis true.

When we eat processed food, we circumvent the natural satiety mechanisms that start with the gut. When we eat, our gastric fundus and intestinal stretch receptors start the process that informs the hypothalamus about food intake. The hypothalamus is crucial for weight control, it is where “set weight” is located. That is what level of fat our brain wishes our body to house. It is where appetite control is located and  this is  affected by many different hormones.

Highly processed foods are usually devoid of fibre and volume, they pack in the calories in small volumes so that the stretch receptors are not activated until more calories are ingested. I know of a research study that offered developed two diets with the same number of calories, sugar, fat, and carbohydrate content — one ultra-processed and the other unprocessed. People on the ultra-processed diet gained weight, the other did not.

As said, a lot more than primitive stretch receptors is informing the brain. There are gut hormones that are secreted before and after meals, such as ghrelin, glucagon-like peptide 1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), and cholecystokinin (CCK), among a slew of others. These peptide hormones are all secreted from gut cells into the blood or vagus nerve, or both, and alert the brain that there is, or is not enough NUTRITION and ENERGY to maintain body weight at its set point.

The interface between all these receptors and chemicals is a highly regulated and precise system that regulates body weight for survival of the species in this environment. This environment has changed over the past 100 years but our genetic makeup for survival of the fittest has not.  We don’t fully understand why all over the world human beings are being regulated at a higher set point. It is happening in China, in Russia, in the West. Everywhere; and it starts in childhood.

Most likely, there are many players or instigators involved, such as food-supply changes, sedentary lifestyle, ambient temperature (central heating), foetal programming, air quality, and global warming and climate change, to name a few.

There are many players in the obesity and appetite field. Obesity Researchers investigate the underlying mechanisms of the increased prevalence of obesity over the past 100 years.

Obesity Medicine specialists and endocrinologists translate this research into medical and drug treatments for adults and children who are “overweight” such as the wonder drug Semaglutide (Ozempic) that tweaks a pancreatic hormone GPP-1 and affects energy expenditure. This and other medications have been shown to help “reverse” the metabolic adaptation to this environment.

Nutritionists, doctors, therapists, pseudo-experts and quacks translate this research into diet plans such as the Keto diet to prevent obesity as much as possible, together with lifestyle change. Added to this are  psychological interventions that are proposed to affect our use of food for emotional regulation.

What Works?

The body is smarter than the pill. The body’s normal reaction to a lack of calorie intake is to reduce resting energy expenditure until body weight increases back to “set point levels.” The new drugs like Semaglutide interfere with that metabolic adaptation to energy deficits and allow us to think of obesity as a metabolic disease. Drugs will hold the disease in check for just as long as they are taken.

As for diets. We all know the relationship between diets, cravings and rebound binge eating. Setting that aside for one moment, diets also don’t work long-term with only 5% of dieters managing to sustain weight loss. Nutritionists and slimming consultants worldwide must stop focusing on fat and calorie control, using diet sheets that will provoke short-term weight loss. There has been a lot of publicity (and money made) about the Keto diet – so is it different from the rest?

Apart from all the health claims made about the Keto diet, it is a diet like any other.  The ketogenic diet can fool the brain temporarily by using protein and fat to elicit satiety with less food intake in calories. After a while, however, gut hormones and other factors begin to counteract the weight loss with a reduction in resting energy and total energy expenditure, and other metabolic measures, to get the body back to a certain body weight set point.

The ketogenic diet works in part because it helps dieters to eat less ultra- and highly processed foods. If you can adjust your eating to reduce these foods (and eat nuts) ANY diet will do much the same for you. But Keto has no better long-term outcome than any other diet.

We have to make changes for life that involve closing the metabolic gap that the body generates to defend fat mass.  That means at the heart of it, eating foods that do not cause frequent big insulin spikes and working on diversifying the bacteria in the gut to reduce inflammation. Effortful? Yes. But what choice is there.

To be able to make those changes takes understanding, stop using stigma as an excuse to deny that obesity is a problem, make many small changes and get families on board. There is no quick fix for a metabolic “disease state” and there is no medicine that will work forever.

Does ADHD AhDD up?

Does ADHD AhDD up?

Dominic Lawson writes in the Times that we may be too willing to create for ourselves an “illness identity”.

A gaggle of celebrities have come out to claim that they have ADHD and I see many people in the counselling professions “come out” as neurodiverse, because they fit some of the symptoms. If symptoms are a marker of neurodiversity, then half the population would join the club of fidgeters, daydreamers, sensitives, people prone to careless mistakes, nerds, people who are clumsy ; people who just don’t like piped music in restaurants, and people who are overwhelmed when asked to carry out instructions.

There are many different ways of being a normal human being, and the person who is sensitive is no more mentally ill than the person who is an emotional oaf. Is your child simply naughty or one who is labelled with “oppositional defiance”. Self-diagnosis is not OK nor is diagnosing your client, because you would need a proper assessment of your purported neurological condition, done by a suitably qualified psychiatrist.

In 2017, Professor Simon Wellesley argued against trending in psychology. Neurodiversity is the current trend and there is no such thing as normal or neurotypical. Every time we have a Mental Health Awareness week, my spirits sink,  he said. We don’t need more awareness, we cant deal with the ones who are already aware. All we do is stretch and demoralise our mental health services. He pointed to a recent poll in which students self -diagnosed as having mental health problems. You have to think – he said, this is unlikely. They don’t need counselling or medication; they simply need to disconnect their phones or get away from their computers for a few hours every day.

It is unhealthy in society when normal difficulties and challenges in life due to the vast array of human variances, are pathologized and pushed into the realms of sickness. It has removed focus from helping those with real and disabling illnesses.

The effect of social media, counselling trends and the effects of peering into our smartphones or tablets all the time, will be to multiply the number of people who believe that they have ADHD, autism and the like. So countless people will join the ever-lengthening queue for adult mental health services. Or blame their problems on their brains.

Could we find a way to de-pathologise something within the normal range of behaviour and character of human beings?  Fewer of us have a mental health condition than we think.