WHY DO I NEVER FEEL FULL?

Posted on by ncfed

I never feel full.

This was the complaint of one delegate on our obesity training. It led me to think about fullness, satisfaction, having enough (satiation) or not caring to eat another bite.

The sensation of fullness is not quite the same as satisfaction. Satiation is a problem for many people living with overweight. Satiation studies have identified people living with obesity who don’t feel as if they ate enough, and they get hungry faster too. Satiation may be identified by slowing up as an eating event proceeds. Some people just don’t seem to slow up. What can be going on?

We note that from birth, some children have an enhanced susceptibility to eating more, when food is present and according to their parent’s opinion, they are always asking for more food.  According to the “Food Responsiveness Theory,” these children are at greater risk of weight gain in childhood and risk being overweight as adults. We suspect that maternal diet before conception and during pregnancy may have something to do with this.

Fullness, satisfaction and satiation result from an interplay between physical and psychological factors. The physical influences are a complex interaction between our genetic footprint,  stomach and gut, appetitive neurochemistry and a  range of neural structures in the brain, the hypothalamus and the opioid or reward centre in the brain.

A satiation response tends to be good in early life, it is barely possible to overfeed a breast-fed baby, they just turn away when they have had enough. Toddlers spit food out when sated unless we can entice them to eat a little more, usually by distracting them. From the age of 7, our innate ability to eat what we “need” becomes impaired, especially if we are in an environment where tasty food is on tap. Our Palaeolithic origins have designed us to eat a little more than we “need” because of the possibility of food shortages. The satiation response is always weaker than the hunger drive.

An eating disorder therapist needs to understand the biology of satiation after eating, that arises from sensory experiences in the Enteric Nervous System (mouth, oesophagus, stomach, liver, gut etc) together with the effect of the chemicals of digestion entering the body and the brain.  During the process of feeding and digestion, several things can go wrong and I mention only a few of these.

The food itself

The food we eat can affect our ability to feel full. Books  have been written about the poor satiation effects of foods containing UPF; so people can eat a lot of food and still feel hungry. I don’t want to repeat the evidence here, but it has become very difficult in our food environment to get food that is UPF-free. Even our cows and farmed fish are fed UPF which is passed to us when we eat their flesh, unless we are buying grass fed organic beef or wild fish.

Note that children eat less and are better nourished when they are given food that looks close to its source ( a fish rather than a fish finger) .

Malnourished

Many people who say that they never feel full have taken in a lot of calories but they are malnourished. Calories alone don’t create fullness, it is the nutrients that make a difference. The foods that contribute to satiation in the short term (fullness) and in the long-term (lower hunger levels)  include good quality protein vitamins, and minerals from having a rainbow diet with plenty of fruit, veggies and Omega 3 fats. And while I am on the subject of fullness and diet, let’s not forget the importance of …

Fibre

It is hard to feel full on a diet lacking in fibre.  You may feel temporarily stuffed on a plate of cornflakes, but compare the sensation after eating a bowl full of porridge oats with a handful of seeds thrown in.  No contest.

Omega 3 Fats

Deficiencies in any nutrient can interfere with satiation but there is a particular place of importance for Omega 3 fats, ideally as fish oil. Omega 3 fats prime neurons throughout the brain to respond to the sensations and chemicals that inform that brain that sufficient nutrients are present.  When the ratio of O6 to O3 fats in our diet is too high in favour of O6, there will be high levels of inflammation affecting the weight control and satiation centres in the hypothalamus. I wonder how many of our clients / eating disorder specialists are aware of this.

The mouth

Mouth-feel of food can affect how satiating it is. Adding a spoon-full of olive oil to a salad makes it feel more satisfying and therefore more “filling”. Rats who get mouthfuls of food that doesn’t reach the stomach (surgical diversion) stop eating after a while, but they start wanting food again sooner.

The stomach

Fullness of the stomach contributes partially to the sensation of “enough”. We have stretch receptors, mostly in the lower pouch of the stomach (fundus) that send fullness signals through the vagal nerve to the brain, switching off the neurochemicals that make us hungry.

Years of overeating or binge eating can downregulate the stretch receptors so that the fullness signals become weak .

People with a gastric band continue to feel hungry because the small pouch receiving food is at the top of the stomach. The fundus where the stretch receptors are located just don’t get the signals that can stop us from feeling contentedly full.

The gut

The gut contains sensory receptors. When stimulated by the passage of food, they produce peptides such as Pyy3-36  that, when activated by the passage of food, suppress appetite neurochemicals in the brain.

Speed of eating and distraction

We have known for decades that eating fast and mindlessly increases the amount of food we want to eat before we register that we have had enough. Slowing down gives our brain and body a chance to register the nutrient delivery of food. Eating fast also weakens the stretch receptors in the stomach and if that isn’t enough, fast eating impairs the production of a “fullness hormone” produced in the small intestine, namely CCK.  . Want to feel full? Slow your eating doooooown.

Distraction also plays a part in stopping people from registering their satiation.  The Health psychologist Jane Wardle showed us that people who eat with food on their knees while watching TV managed to polish off 3 times as much snack food in the afternoon following their meal, compared to people who ate at a table just talking to each other.

The Hypothalamus

This is an organ deep in the brain that acts like a thermostat for our appetite and body weight. I will not try to do justice in this short article to the neural concomitants of satiation. AS far as appetite and weight control is concerned, the hypothalamus responds to leptin signals that come from fat cells. If leptin levels are high, the hypothalamus adjusts our nervous system to burn more energy and switches off our appetite.

Sadly, years of eating “the wrong kind of food” or overeating can deafen the hypothalamus to leptin signals. The culprit here is insulin – a hormone that we unwittingly overproduce when eating an unhealthful diet. Hypothalamic deafness to leptin means that no matter how much fat we carry, we continue to be hungry. Many people in large bodies we see eating large amounts of food have lost their hypothalamic “off-switch.”

A history of calorie reduced dieting

Dieting leads us to attend to what we “should” eat rather than attend to the natural signals of hunger and satiation. We also tend to eat less than we need to lose “fat”.  When we stop attending to our natural appetite, that is mistrusted, we stop knowing how and when we are full. Our eating will become permanently disinhibited (eating in for all sorts of reasons) and dysregulated (eating past the point of fullness).

The Reward (Opioid) centres of the brain

Eating satiation is also affected by how rewarding the eating experience is. Pleasure and satisfaction from an eating event contributes to fullness and not wanting to eat more. Years of eating high-fat-sugary foods leads to a dulling of the dopamine receptors that make eating a nice-good-enough-for-now experience. Binge eaters are often chasing the dopamine high that they find works less well for them, and they would find giving up binge eating difficult since normal eating doesn’t satisfy them anymore. If your opioid system isn’t doing its job, you may feel full or even nauseous, but you will keep needing to carry on eating.

Psychological Factors

The Eyes

We evaluate with our eyes in many cases how satisfying a meal or snack is likely to be. People who are blindfolded eat in some cases 50% less of a meal than if their eyes had been open.  In many cases we need less than we think will sate our appetite and delay future hunger. I am not recommending that we all eat on smaller plates, but we need to find a way to stop our eyes from telling us when its OK to stop eating.

Interoception

Interoception is the psychological ability to sense what is going on in the body. Many people with eating disorders and obesity who claim that they are never full, lack interoception and they have no idea when they are full. (and in the case of anorexia they may not know that they are hungry). Interoception is both intrinsic and it is a skill that is lost because of many things, including trauma. In therapy for obesity (and eating disorders) it is important to teach interoception. It is a simple but important skill, leading to better awareness of appetite, fullness and emotions.

Old habits die hard

Eating habits formed during the lifespan are affected by a huge range of influences regarding the amount or type of food we choose to eat. One example might be getting a needed emotional reward for clearing your plate when you are a child. In this way, the child becomes attuned to what they want to get rather than what their body says they need. Obesity therapists need to look carefully at the habits a person has formed. Might the explanation of why their client never feels full lie here?

Stress

The effects of psychological stress on the ability to “feel full” are variable. Stress may lead to fast or distracted eating or give some people tummy upsets and IBS. Obesity therapy must address stress as part of a treatment package that is designed to foster health behaviour change.

The eating Gestalt
Satisfaction and satiation after with any eating event depends on the eating event itself. Small things like sitting down at a table in a nice environment with nice tableware can contribute to psychological satisfaction as well as physiological satiation. People who eat on the run, in a car or in a haphazard way tend not to feel full, or the satisfaction is transient.

Conclusion

If you have a client who says that they never feel full, many things are going on. You may have to attend to all the things that I have listed as possible problems.

Perhaps begin with interoceptive awareness training and nutritional rehab. Ensure that the diet is as nutrient dense as possible with plenty of fibre and Omega 3 in the form of oily fish.  Make sure that the client begins eating slowly and without distractions. Above all, ensure that for a while there is no alcohol because booze muddles the appetite pathways.

There is no shortcut to restoring the ability to feel full on moderate amounts of food. Obesity therapy is a long slog, and the client deserves to give themselves the time to change.

Fat Activism, with respect?

Posted on by ncfed

The Founder of NCFED (me) and Dr Adrian Brown a clinicial at Imperial College Raised a complaint against a Fat Activist for issuing racist comments about each of us and disseminating incorrect information about our treatment of binge eaters and people in larger bodies.. The GMC have investigated our complaint and have registered a warning against this person’s record.

The judgement of the GMC included these comments:
The Committee finds that “”Doctors” conduct constitutes a clear and specific breach of the
professional standards, most notably paragraph 65* of Good medical practice (2013) which says
that, as a doctor, ‘you must make sure that your conduct justifies your patients’ trust in you and
the public’s trust in the profession.

  1. The Committee also finds that although Doctor’s conduct is serious, it falls just short of that
    which would be considered serious enough to pose a risk to public protection. The Committee
    considers that, if there were to be a repetition, the threshold for restrictive action on “Doctors”
    registration would likely be met.
  2. In reaching its decision on seriousness the Committee considered the Doctors lack of insight and acceptance that his comments were inappropriate. Dr X has expressed no regret or remorse or offered any sort of apology. He has taken no steps to address the behaviour that led to the complaints. Consequently, the Committee must conclude that the risk of repetition is high.
  3. The Committee regards that action, in the form of a warning, is appropriate in the interests of
    promoting and maintaining proper professional standards and conduct for members of the
    profession and because of the potential impact on public confidence in the profession. It is the
    Committee’s view that Dr X’s comments are offensive. It was particularly concerned about
    the impact the comments may have on the confidence of a cisgender, white, heterosexual male
    after reading about the Doctor’s dislike of his ’species as a general rule’ and him having to ‘work
    real damn hard to get into my good books’. The Committee has concluded that an individual
    could well assume that they may not receive fair treatment from said Doctor.

Your colleague and Founder (me) has also been accused on the Doctors Social media post along with All-Bodies Recovery of being white, cis-gender, fat-phobic and thin-privilege- although this doctor does not know what I weigh nor the size of someone who was my husband. It was disappointing to have discovered that one of our Network “liked” the half hour long, very offensive video in which these comments were made.

Despite the said Doctor’s stated intention on social media to stop us doing what we are doing, we go from strength to strength. If we always do what we believe is right and we have the interest of our clients at the heart of our actions, we will thrive.

Is Anorexia just Body Dysmorphic Disorder?

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On having this interpretation of anorexia offered to me, my first reaction was of course not! Although in the 1980s a famous eating disorder clinician named John Stonehill proposed that all the eating disorders be renamed “Body Image Disorders”. The concept never caught on.,

A key feature of body dysmorphic disorder is that people have fixated beliefs of bizarre content regarding their body or aspects of their body, such as their nose or facial appearance. This is usually accompanied by compulsive behaviour to deal with their beliefs (such as avoiding mirrors or hiding). Insight into the deluded thinking is lost and there is no resistance to compulsive urges to engage in compensatory actions.  The rituals that accompany BDD can be disabling, and what interested psychiatrists was that no sufferers had other forms of thought disorder and so they could not be viewed as psychotic.

A person fixated about the size of their nose would thus perceive other aspects of their life fairly normally. Because of the rituals associated with fixated thinking,  for a long while BDD was regarded as a form of obsessive-compulsive disorder.

Anorexia sufferers may believe with absolute certainty that they are fat even when they are emaciated. They also have extreme shifts in body perceptions after eating food that they deem forbidden or fattening. Hence these foods are avoided in extremis. Eating disorder clinicians call this “thought-action-fusion”, a disorder of thinking, not of the body itself.  Anorexic beliefs, despite their fixated nature, are thus considered to be overvalued  ideas that are not “alien” beyond common understanding,  unlike other forms of BDD.   Their content (food is dangerous, I’m fat) is experienced by many women and men. Its just that this disturbance is at the extreme end of a spectrum and matters a great deal.  Many people share beliefs about being “too fat” but the impact of these ideas on their wellbeing is minimal since their self-worth is vested in other things, like having a good relationship with their friends. In other words, their beliefs matter less.

It is true that people with BDD and with anorexia share a range of odd ideas about their appearance that range from the obsessional to the psychotically delusional. This has led clinicians to regard anorexia as a compartmentalised psychosis, necessitating enforced treatment such as nasogastric feeding in cases where a persons’ life is at risk.

My biggest concern about labelling anorexia as BDD is that it restricts our ability to look outside our mental box. A clinician with fixated opinions about the nature of any mental health  condition is blind about the other possibilities of what is going on.  Anorexia and other eating disorders share features with MANY other mental health conditions such as addiction, anxiety disorder, OCD, psychosis, to name but a few. Anorexia has also been conceptualised as a monomania, a developmental disorder, a cultural phenomenon or a rebellion against women’s place in a patriarchal society.  If you consider anorexia is BDD; and if BDD is a form of OCD; and if OCD is an anxiety disorder; and an anxiety disorder is a response to trauma,  then it follows that anorexia is a trauma condition.  Really?

Reductio ad absurdam.

What distinguishes anorexia from other forms of BDD is the Anorexic Voice. We all talk to ourselves but the Anorexic Voice is more persistent, intrusive and often concrete (i.e., real). Is the anorexia hence BDD with schizophrenia?  How one labels a complex condition like anorexia is of more than academic interest. A diagnosis of delusional disorder like this may lead to a lifetime of antipsychotic medication, which never cures anorexia.

And even when the scales fall from someone’s eyes, and they both know and feel that they are skin and bone, it still is not enough to get the anorexic person to start eating again. They are not suddenly recovered so what do we think is going on now?

It is unhelpful therefore to fit everyone with delusional beliefs about the body into the same diagnostic box, no matter how much we have vested our truth in it. We could, for example, call gender dysphoria a form of BDD, implying delusional beliefs about being in the wrong body, with extreme, compulsive  and aggressive actions taking place (hormone therapy, genital or breast amputation etc)  to help a person feel better. I am not sure it will go down well to place people questioning their gender to be forced into therapy for BDD.  (“You aren’t really a woman in a man’s body, you just have BDD”)


My final plea is to allow anorexia to sit in a place on its own, where it has aspects of BDD and OCD and psychosis and pretty much everything else. This is why it is so pervasive and difficult to treat. There is no single therapy or therapist up to the job of rescuing a person from their toxic relationship with food and with themselves. Unlike with other forms of BDD, recovery is concomitant with a rise in self-worth. I am going to fight the anorexia, because “I’m worth it”.

Deanne Jade 2024

Will Intuitive Eating Save you?

Posted on by ncfed

Intuitive Eating has had a good press. There are many Nutritionists and Therapists who describe themselves as Intuitive Eating informed.   It is the basis for the Health at Every size movement which is against weight-loss -dieting and this can only be a good thing because dieting is a bad thing, we all agree about that. Don’t we?

Many therapists who follow Attachment Theories of overeating are on this bandwagon, suggesting that, among other things, we allow and guide clients to reconnect to the natural wisdom of the body, helping people to narrow the gap between how they eat now,  and  what might be more healthy.

Some people who blog about  binge eating declare that anything they put in their mouth is OK and that could be helpful to deal with shame. Dividing food into good and bad isn’t helpful. But is that right?  It might serve people better to be nudged away from UPF even if it comes in a packet with trees on the cover, suggesting that this food is a healthy choice.

Babies – by and large- are intuitive eaters. Very young children feeding “ad libitum” (freely) , go for the strangest food combinations from one day to the next.  but over time their nutritional intake evens out and they seem, as if by magic, to eat the nutrients they need. 

But according to Bee Wilson, a food author, children lose that intuitive wisdom of eating by the age of 7 onwards. They are more likely to be “cued” to external signals like what food is available and whether it tastes nice.  It doesn’t help that our culture is full of attractive food that is designed to override our natural appetite, so it simply doesn’t make sense that in such a culture it is possible to eat intuitively any diet that could be regarded as “healthful”. There is simply too much “food noise” around us deafening our eating common sense.

Writing about deafness reminds me of other things that make it difficult to call upon the so-called natural wisdom of the body.  Most of us have some idea of what we should be eating (in theory) but it simply doesn’t happen, whether we are dieting or not. The neurological factors that affect our appetite, our body weight and ability to be appropriately satisfied after eating, depend  on many factors that are out of our control. Our eating drives are driven in part by our genes, our past and current history of eating and even our mother’s eating habits while we are in the womb.

Many people suffer “deafness” of a tiny area of the brain called the hypothalamus. This structure is like a thermostat  to monitor whether we have eaten enough or have enough fat on our bodies for the moment.  The hypothalamus listens for Leptin, a hormone produced by fat cells. Years of overeating makes the hypothalamus deaf to Leptin. We would be driven “intuitively “ to eat more than we need and we would be unable to stop eating even when we have had “enough”.

To rebalance the hypothalamus takes more than giving up dieting and certainly doesn’t mean eating whatever you fancy. I will write more about this later.  Treating hypothalamic obesity is complex.   

To add to the picture, we are designed to need pleasure from food as well as nutrients. The part of the brain involved in eating pleasure is called the Opioid centre. If our healthy diet doesn’t taste good, we have to  keep on eating. And people who have eaten badly for years have destroyed their capacity to get pleasure from normal amounts of food. Giving up dieting will not solve this problem and people will not be able to engage in intuitive eating without targeted help. So, one might ask, what kind of help does this imply?  Giving up dieting? Eating what you like without shame? Neither of these suggestions will work.

 As an idea or concept, “Intuitive eating” sounds nice and cosy but how can we get to this point?   Even the healthiest food that we ingest, such as salmon,  if farmed, may be contaminated by additives that are designed to cheat the neural systems controlling our appetite and our weight.  

Hard as it is for  people we are trying to nudge away from food rules, we have to give our clients an eating plan that at the very least regulates blood sugar and that also provides UPF-free nutritional density. But even with nutritional perfection, we cannot ignore the huge role played by psychology. Our eating choices are driven by more than physiology. Our desires are shaped by our childhood, our emotions, our self-esteem, our family systems and much more.

So the bottom line is,  nutritional therapists trying to help a client to “eat intuitively” are advised to work  alongside a specialist psychotherapist.  Binge eating bloggers may need to think twice about making it OK to eat anything we like. People need targeted help, not just strokes and platitudes. It takes more than the principles of Intuitive Eating to change a person’s relationship with food and weight from the inside out.

How to help people lose weight

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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! https://eating-disorders.org.uk/professional-training/essential-obesity-psychological-interventions/

Discovering our clients with a lifeline

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A PASSIONATE MILITANT SAYS NO

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?

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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

Posted on by ncfed

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.

Treatment.

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:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5454963/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9862683/

https://pubmed.ncbi.nlm.nih.gov/36677677/

Emotional Eating: It isn’t all emotional

Posted on by ncfed

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 https://link.chtbl.com/s9cwxMzY

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

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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.