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, 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.
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.
We see a lot of hyperfixation in eating disorder work
How do Fixations Show Up?
People are fixated about the quality of food – is it clean, does it contain meat or dairy, is it good for me?
Fixated about the calories in food.
Fixated about aspects of the body, my stomach is marginally rounder, my thighs are too big.
Fixated about weight: I weight 3 lbs more than I should, I look fat, so I am fat.
Fixated about people “thinner than me” or, in the case of body builders, “stronger” than me or do more exercise than me.
Fixated about people, such as we have a patient fixated with the opinions of a medical mystic who claims to get his information from the spirit world (and maybe he does).
Fixated about what I ate today, was it too much, how can I deal with that tomorrow or punish myself.
Fixated about the opinions of other people, who must be destroyed if they have alternative points of view
How do we understand the fixated patient?
Fixations are beliefs that are strongly wired into the brain and they connect to the “alarm centres of the brain” – the amygdala. Obeying your fixations is one way to stop the alarm centres from firing off. So having a fixation and obeying its rules is one way of staying safe in someone who would otherwise be too anxious. The fixation is thus a way of being safe and woe betide us for trying to take it away.
So we understand fixations as belonging to someone with an underlying problem with anxiety. But we need to ask ourselves, is this anxiety just part of the personality, or it is welling up from deeper irrational beliefs about the self. For example, if I believe deep down that I am a disgusting or immoral individual, I might become very fixated on eating “clean” or “vegan” so that I don’t have to experience that unwelcome feeling of being “dirty inside.”
Deep and negative beliefs are installed inside us at a very early age, often before we have words or even memories of them. So normal psychotherapy often doesn’t root them out. People with low levels of anxiety might say oh I ate a burger today, it wasn’t what I would choose but, it’s no big deal for once. But the fixated individual would consider it a tragedy. Psychologists call this kind of anxiety reducing behaviours “schema avoidance”.
Hyperfixation is a self-fulfilling prophecy. The more you obey or run the fixations, the stronger they become and the more fearful we become of doing the opposite of the compelling voice in our heads. We see this for example in people who exercise excessively. They may KNOW that it is OK to take a day off, but it just doesn’t happen.
There was once a young anorexic girl fixated on her daily exercise, she fell of her bike, fractured her pelvis and was taken to hospital in an ambulance. When she was left alone on the gurney, she slipped out, and although in terrible pain, she went for a run around the block. Unsurprisingly, she was put on a Mental Health Section.
Another of my clients was fixated on alternative therapy as a cure for her cancer, shunned chemotherapy and declared that “doctors don’t know what they are doing”. She died.
I see fixations all around me, in anti-vaxxers, in conspiracy theorists, with activism on social media. Some individuals hyperfixate on a person such as a guru or a terrorist. One thing is common to all of them; they are impervious to rational argument or to persuasion. They may be benign or dangerous to themselves and they can be a nuisance or dangerous to other people.
Fixation as a Symptom
Fixations are described also as monomanias and can be a symptom of
Unhelpful strategies include giving evidence to the contrary – such as persuading the person that their guru is a scammer or that “fat can be associated with diabetes”. Telling someone that they are wrong or trying to stop them from preaching their opinions does not help.
There was once a religious sect in the 18th century who believed that Armageddon was to happen on a particulate day and time. They gathered together to pray and wait for the Apocalypse that didn’t happen. Did they change their view? Not at all. One half believed that the Apocalypse had happened and they were already living in a world-like heaven. The other half decided that the Lord was so impressed with their prayers, that He had put it off for now.
Psychologists have tools for managing fixations. This includes Cognitive Therapy. Cognitive therapy instals doubt and also addressed the value of holding on to the belief – in what way is this belief USEFUL to you? Trauma Therapy such as Eye Movement Sensitisation and Reprocessing, EFT (Tapping) and techniques from NLP can be helpful.
Treatment usually satisfies family members or friends but the fixator is not usually enthusiastic about changing their mind. As one person said to me – “Why would I want to stop minding about Clean Eating if it meant I would start eating rubbish like you do”.
Fixators on a person are also unwilling to let go of their infatuation. What sets in here is “sunk cost thinking” – if this person is really a baddy, I will have to deal with all the regret about the time, the money and the emotional investment I have wasted. Regret is an emotion that most of us want to avoid.
Our experience of treating fixations thus is that therapy is resisted. Removing the fixation does nothing to deal with the underlying anxiety that can surge to the fore.
Psychedelics
This is a contentious opinion, but I increasingly wonder if fixations can be tweaked by the use of Psilocybin or other psychedelic drugs. Carefully managed, they introduce fixators to an alternative reality. Fixations are about guarding a very fragile sense of self and during a guided “trip”, this sense of self is surrendered so that an alternative self can be installed.
I do not think that this would be helpful for someone with schizophrenia, so a careful assessment has to be done. There is also the question of motivation. A fixator would want to be certain about the outcome of taking a psychedelic drug and may convinced that something bad would happen to them.
The Social Context
Fixations take place in a social context. Family members often confront the fixator – ineffectively- or accuse the fixator or ruining their life. Many behave as if they are treading on broken glass – which is stressful; or the fixator withdraws to avoid more confrontation and pressure. Carers often feel emotionally blackmailed – “Accept me as I am or get lost”. They say that they have no choice other than to collude with the fixator. We see this with all kinds of issues, including anorexia.
Fixations thus destroy family harmony and cause ripples of mental harm to close relatives and friends. Family members can become isolated, neglected, and lonely as the fixator pursues their lifestyle. A person fixated on, say, golf, can leave their family members alone at weekends and fail to attend to their basic day-to-day needs both practical and emotional. Fixators reinforce their fixations by bonding with others who share their views, thus reinforcing their “rightness”.
Groups of people who share an ideology gain a sense of superiority, that is alluring to the fixator who often has a fragile sense of worth. You see, we have special access to the truth, we are not in ignorance like everyone else.
People who live with a fixator need urgent help and support, independently of what is happening to their loved one. At the very least they can say to the fixator, we are for now going to get help for our own feelings about what is going on.
If you are a carer, please don’t frame this up as “we are going to get advice for how to show you the error of your ways” because this is not going to help.
What kind of help carers receive depends on a full analysis of the situation as the family sees it together with any other information we can glean about the problem. There is no one-size-fits-all solution to living with fixations.
Therapy
If you have a loved one with a hyperfixation, we do have family therapists who can support you. Mental health problems are never easy and must be handled one step at a time. If the issue is food, weight, food fads, or over-exercise, call 0845 838 2040 and see how we can help.
Doctors are reporting a rush of patients asking for SEMAGLUTIDE which promises rapid weight-loss. Even psychotherapists working with obesity are asking us about the value of these medications to “kick-start” weight-loss for their patients.
At the National Centre for Eating Disorders we have views about weight-loss medications and we are not provoked into a knee-jerk response. Some people call them “anti-obesity” drugs. Because this term risks causing stigma, let’s for now call these latest drugs “metabolic medications.”
The Risks of Weight Loss
Using tips and tricks learned at slimming clubs or in the media, anyone trying to lose weight on their own, is exposed to a host of dangerous mental and physical risks. Fat is not just “stuff” – it is a metabolic engine that is controlled by many different systems and that is well-defended. People who want weight loss (as is their right) need a thorough assessment, tracing the course of their weight over the lifespan with a sympathetic and knowledgeable therapist who also looks at the family and other aspects of their lifestyle. We need to learn about their relationship with food, to see if there is an eating disorder present. This is because weight-loss never cures an eating disorder and weight-loss efforts can make things worse. For an explanation of why weight-loss efforts can cause and worsen an eating disorder like binge eating or bulimia, another blog is needed.
It is helpful to our readers to point out that not all people in larger bodies have an eating disorder. About 1 in 2 people who seek help for their weight issues have some form of eating disorder; that means many people in larger bodies do not have an eating disorder. Maybe they just like…. ummm (how do I say this) “fat-promoting” foods or they might have genes that make them gain weight more easily. We are not all the same. Nonetheless, people have agency and they have the right to choose how they want to live. They are misled to be told that there is no link between body fat, diet and disease.
The metabolic meds like Semaglutide are not designed to make people feel happier because of how they LOOK. Let’s be honest – looking different is a motivation for many people seeking weight loss. They will say, Oh I want to be healthier or fitter, but what they really mean is, I want to approve of myself when I look in the mirror. The metabolic meds are designed to make people healthier. The question is, do they? Metabolic meds change aspects of metabolism and some drugs can improve cardiometabolic health. To give my readers, clients and professional therapists a balanced view, let’s look at the pros and cons of Semaglutide
Benefits of Semaglutide
Semaglutide is a drug that affects a hormone called GLP-1 that is part of what we call the “incretin pathway”. This slows gastric emptying, making people feel fuller for longer and it affects some of the many hormones in the brain that control appetite. It is a drug that causes fast weight-loss and some people discover that their blood sugar profile improves, they may stop being diabetic.
As long as the drug is taken, Semaglutide also affects weigh-regain mechanisms in the brain. Alongside fat loss, the level of inflammation in the body improves. Very few people understand what “inflammation” means and how it relates to obesity. Inflammation is responsible for a great deal of illness including cancer. Inflammation can also be caused by stress, so for sure, stress and weight stigma can also make you ill.
A great many people think that taking a drug or having surgery to lose weight is cheating. This is unkind, because obesity is a complex metabolic condition that is affected by many things; some of which are out of our control. Each single person is affected differently by genes, our living environment, our personal biome, our early eating patterns, even the behaviour of our mothers when we were in the womb. Now we know that going on a calorie-controlled diet is ineffective and potentially dangerous. But we cannot shrug our shoulders and just tell people that there is nothing we can do and more controversially, that people “should” welcome obesity into their lives.
Even while being sensitive to stigma, I do not remove hope or healing. If, for example, you have insulin resistance or diabetes Type 2, a metabolic drug will level your metabolic playing field and give you a better chance of widening your choices. What can be wrong with that?
The cons of Semaglutide
Metabolic meds do not change a person’s relationship with food, including the ways in which food is used as a fix or a way to regulate feelings. Most of us eat to manage our moods some of the time and some people do more comfort eating than others. Emotional eating is not just “in the mind” – some of us more than others are “wired” to need more pleasure from food. How can I best explain this? – well – it is possible to develop faulty wiring because of long-standing eating patterns. Binge eaters, for example, usually develop resistance, deep in the brain, to the normal signals of pleasure when they have eaten something that they like. Now is not the time for me to explain how we can put this right; but putting it right does NOT involve taking a metabolic drug.
Semaglutide can have a lot of unpleasant side effects like nausea and vomiting. More worryingly, as soon as you stop taking it, the weight piles back on. People wanting weight loss assume that losing weight is enough to make them able to keep it off. In over 99% of cases, weight is not only regained but it is exceeded. The drug can make you end up fatter than you were before and this gives rise to shame and worry. So, I would not do anything that makes a vulnerable client feel worse. My final concern is that we don’t know the long-term effects of manipulating pancreatic hormones. The drug industry is littered with the history of very adverse and sometimes fatal consequences.
So, when one of our therapists tell me that their client wants to take Semaglutide for a weight-loss fix, I tell them “NO”- do not go there for now.
The take-home
I am on the side of happiness and wellbeing. If there was a weight-loss drug that could be taken safely for life, that would help people look and feel better (in their mind anyhow) I would be all for it. I don’t believe in “cheating thinking”, because we are all born with different bodies and different challenges when it comes to what we choose to eat and how our body deals with it.
At The National Centre for Eating Disorders, we do a deep, holistic assessment, to learn more about a person and their relationship with food before we make judgements. Clients in treatment for an eating disorder are discouraged from trying to lose weight and we attend to their body image, their feelings, their mindset, self-esteem and ability to self-care. We do not assault our patients with tyrannical views about how they “should” eat, what they “should” weigh or how they “should” feel about their body size. If they are desperate and craving a metabolic drug, we give them the facts as we know them.
If you or someone you know is considering Semaglutide, or bariatric surgery, please don’t take action before having an assessment with a properly trained therapist. This therapist will want to learn everything about your relationship with food and how it has gone astray. Email us at admin@ncfed or call 0845 838 2040.
Alsana treatment service have done a study with dieticians who work with eating disorder clients. They have something to say about veganism and eating disorders. What follows does not apply to people who are vegetarian for religious reasons. Asana writes:
“In a survey we conducted with hundreds of dietitians who specialize in eating disorders, we found that 98% of eating disorder dietitians saw clients who followed a vegan eating style. Of these, 75% of vegan clients realized that their eating disorder was enmeshed with veganism, while 25% of clients realized the eating disorder was separate and veganism was a true value in their belief system”.
We ask, how does a client KNOW whether their veganism is a symptom of eating disorder behaviour. Most insist that they have genuine concerns for the planet, for animal welfare and for sustainability.
The clients whose vegan diet is mostly a symptom of the eating disorder, do not have a therapeutic space to disentangle their veganism from eating disorder thinking. At the start of therapy most insist that veganism is essential to their identity.
At the NCFED we have many thoughts about veganism, while accepting how important it is at first. We want to know whether there are other hidden issues that make veganism a compelling dietary choice. Veganism has been linked to autism, to irrational contamination fears and to early attachment issues between a mother and her child during the developmental stage we sometimes refer to as Kleinian Rage! Freud may have linked eating choices to fears of oral impregnation. We have found that veganism and also vegetarianism can be associated with OCD especially if there is no flexibility in the person. In other words, would even thinking about eating a bit of fish cause a meltdown – or would it be OK if nothing else was available.
The vegan diet can lead to serious nutritional deficiencies such as choline, iodine, B vitamins and imbalances in essential fats that cannot always be rectified by vegan sources (especially Omega 3 fats). The effects on the neurochemicals of mood, metabolism and appetite can maintain eating disorder symptoms.
If veganism is a symptom rather than a true spiritual value for the 75% of patients identified in this study, the route to recovery must include broadening the choice of food. Supplements alone are not a good way to address the potential depletions of a vegan diet, because supplements lack the synergy of nutrients that exist in real food. Some people see supplements as an alternative to eating a balanced diet, and this is also part of eating disorder thinking.
No one has yet come up with a treatment that will confront the thinking that has led to their choices as well as to rebalance their physiology. Recovery is not just about dealing with childhood adversity.
If your client is vegan or vegetarian, recovery may entail getting more variety into their diet. and oh my goodness, how this will be resisted! Can they become a flexitarian, and use some form of animal based foods as a medicine? Will they secretly consider themselves superior to you because they make more ethical choices? This will interfere with your therapy.
If you the healer are vegetarian or vegan, can you congruently help a person to expand their food choices? Will you see yourself as superior to your meat-eating client? This will interfere with your therapy.
Eating disorders are not just about feelings, they are also about food. A restrictive diet is not great for anyone with an eating disorder. The vegan / vegetarian client may need a great deal of informed and compassionate support to disentangle their values from their eating disorder symptoms and be more open with their choices.
I’ve been watching a series called Phil Stutz on Netflix and was so excited because this is how I work. I am always sharing pictures with my clients to explain to them what is going on and keeping them stuck in their body image hell and horrible relationship with food.
Stutz tells us that we all have an interferer self he calls “X” that gets in the way of us being happy. Shakespeare said much the same thing when he wrote about each person’s unique fatal flaw. Macbeth had his fatal ambition and Hamlet’s fatal flaw was his procrastination he just couldn’t make decisions until it was all too late.
Eating disorders shows us our particular and unique X-SELF. We don’t get an eating disorder simply because someone was mean to us or because we had a difficult childhood; the X-SELF that drives us toward our eating disorder could be that our basic nature is sensitive, or an anxious, or that we have a perfectionistic nature. Oh; of course, our life experiences have some bearing on our disorder of choice but even people without traumas develop anorexia, bulimia and problems with binge eating.
The question we must ask ourselves is NOT what caused our eating disorder, we have to face up to WHO is this X-SELF that has decided to obsess about food, calories, the bodies of pop stars and influencers to such an extent that we want to mould ourselves like putty into an ideal shape and size. What is the real X-SELF that is blinding our light.
This X-SELF is part of us, it isn’t something that will go away, it takes constant and continual self- awareness, pain and hard work to stop critic-X from interfering with our better life. You won’t get rid of X-SELF by starving yourself or working out for hours in the gym. You just put off the pain.
There are so many ways of having an eating disorder. One sad young woman starves herself, eats in 8-hour windows and spends hours in the gym. She has a meltdown if the scales show that she has gained half a pound (of what).
One sad married woman is addicted to cola and McDonalds; the idea of missing her fix makes her shake with fear. She is 30 stones and desperately unhappy. She lives only to eat and her life has shrunk to the corners of her living room. She thinks that a gastric band would solve all her problems with food. It will not.
One sad man can only allow himself to eat so long as he purges afterwards. He is going to live his life with his head down a toilet. If he is watching the sun rise over a glorious mountain he will be thinking about when he can next eat and purge.
I share many ideas with Phil Stutz and I work in ways like him. He says (among other things) that the meaningful life starts with caring for the body, not using it like a lump of putty to showcase the six pack or the 13-inch waist. Not overeating in an act of defiance against a fat-phobic culture. Oh yes, we can use the tricks of therapy to get someone partly well, like CBT and DBT and MANTRA. But every person with an eating disorder needs to meet SELF-X and learn how to use every tool in the book to stop it from pulling your strings. Hard, occasionally uncomfortable and ongoing work.
Only with guidance from a therapist who can show you the mirror into your soul, can you ever get well. Watch Phil Stutz, and reach out for help, we are waiting. 0845 838 2040
I have just returned from a cruise. Cruises are exciting holidays that are often favoured by older people, especially those who are widowed, because they are safe and there are many opportunities for connection that you will not find in an hotel. Being of a curious mind, and a watcher of the behaviour of other people, I noticed many things about my fellow guests.
The food available on a cruise ship (and in holiday hotels) is vast. Many people use eating as a form of recreation. It has nothing to do with staying alive. Holiday food is like being in a sweet shop, with no one there to stop us from putting our hands in the cookie jar. If you add the cocktails and if you are on a package where all you can drink is included, it is even better.
Many people on holiday eat and drink as if there is no tomorrow. Our enjoyment of a holiday is often conditional on letting go of all the rules and constraints of everyday life. Our Palaeolithic brain drives us to gorge on anything that is placed in front of our nose and the tastier it is, the more we want it. But; Palaeolithic man spent much of his life in starvation mode as well, and we have not learned how to adjust.
Many older people are infirm, they are using walking sticks and the elevator rather than the stairs. They have problems with their hips and their knees and they have trouble getting up or sitting down. Some are riddled with arthritis, that is an inflammatory condition. They sit with their morning coffee, watching the exercisers on the walking deck that every cruise ship boasts. The average deck extends for between quarter and a third of a mile around the ship. The older walkers are not particularly thin but – none are at the other end of the scale.
Health in the elderly is Not At Every Size. Obesity in older people is significantly associated with a range of infirmities that affect health and quality of life. Thinness is not a good idea either. I am told that longevity is best in people with a BMI in the “just overweight” category.
Obesity rates have increased enormously recently, even in more elderly age groups,” said Eva Kiesswetter, PhD, from the Institute for Geriatric Biomedicine at the University of Nuremberg, Germany, at the DGE conference.
In addition to the other well-known consequences, excess weight in the elderly can affect falling risk, pain, cognitive performance, and above all, one’s independence. The infirm elderly can live for a long time, but often in a state of pain, dependency and depression. Some of my companions – most if not all in larger bodies went on a trip, but could not get out of the tour bus and walk around– that is not much fun for them.
The need for vigilance in ageing
Research tells us that increases in BMI are normal through the lifespan partly due to changes in muscle mass and metabolism. To avoid weight gain in ageing is effortful and would require vigilance regarding diet and activity. Vigilance is not the same as dieting. Also, there are concerns about weight loss, even in the elderly. This is because weight loss leads to a decrease in muscle mass or bone density that can be particularly risky for elderly people. Dieting alone is thus unhelpful for older people.
Kiesswetter and her colleagues in Germany investigated which weight-loss interventions had a positive effect on elderly people’s physical functionality. The team incorporated 49 studies into their evaluations. They found that a combination of nutritional and activity interventions produced the best results. This combination can improve functional status and moderately reduce body weight without causing a loss in muscle mass, according to the findings.
Gerontologists also tell us that eating extra (complete) protein is helpful for the average older person, helping to sustain muscle mass particularly if someone also spends a little time moving on their feet. Sugar is unhelpful to older people. This isn’t dieting, it is self-care.
Elderly people with a normal BMI can also become ill but are less likely to be “inflamed”. Difficulty moving makes old age FEEL much older than it is; apart from what we know to be the associated health risks.
QOL in the elderly is being able to stand up gracefully, move about flexibly, sit down softly, get dressed easily and to go for long rambles with family and grandchildren. Age has its challenges but our body is a companion to the mind and both need care.
A number of academics and researchers have come together to advise that obesity should be recognised as complex, progressive, chronic, multifactorial disease. It is a disease for which there is no effective treatment other than strategies that could make it worse, such as changes to diet and lifestyle. All the names one gives obesity – “disease”, “weakness”, “moral failure” etc, cause stigma, and stigma makes the problem worse. Because of this, it is proposed by some people that the word “obesity” should be banned and fatness should be celebrated.
At the moment, whatever you feel about it, the word “obesity” simply refers to an arbitrary and often inaccurate measure of the amount of fat on a human body. There is a certain level of fatness that is associated with better health, but not in everyone. I get that. Thin may also mean sick. Unexercised also means sick and smoking also means sick. But not in all.
There are levels of fatness which – with or without stigma – are associated with poor health. And it for this reason that I am conflicted. Because, removing the effects of stigma will not remove the effects of obesity.
There is an inconvenient truth that the fatter a person is, the more they are at risk of diabetes, some endocrinal cancers, inflammation, cognitive impairment, liver disease. There is a lie at the heart of ‘Health At Every Size’. Yes, I do know that stigma increases the health effects of a fatter body. And the more I list the effects of obesity, the more defensive I feel.
It was proposed by my erstwhile colleagues that we can reduce stigma by calling obesity a metabolic disease rather than a moral issue. But how are these academics planning to create this change in the short-term, when most people in the community really don’t share this definition of obesity and would prefer not to live in a larger body? I think that it is important to throw off the shackles of stigma and celebrate any human shape, but, despite the body-positive movement, we aren’t there yet. Children asked to say what they most worry about STILL put weight gain near the top of their list. We are also still getting fat stigma in micro-doses everywhere.
Last month for example, I went to see Back To The Future. I couldn’t help but notice that the villain was fat, the hero was slim and the love interest was not plus size. Even if “disease labelling” makes health professionals take treatment more seriously, I am uncertain whether feeling diseased will help anyone feel happier or more at peace with themselves.
As an obesity trainer, I have pondered how to help health professionals manage the overweight client without bringing stigma into the room and without agreeing or disagreeing about whether a person “needs” to lose weight. I think that we need to respect the client, while also doing a proper assessment to understand their motives and outcomes and to make sure that nothing else is wrong. If they are overweight because they have a seriously disturbed relationship with food, this needs to be dealt with first and there is no quick-fix for a longstanding eating disorder.
It has been argued that eating disorder professionals shouldn’t touch the client wishing to lose weight, because weight-loss efforts are associated with compulsive eating. This frankly is simply an opinion I disagree with. The eating disorder specialist is schooled in neuroscience, nutrition, physiology, and psychology. With this knowledge we know enough to do a holistic assessment of the person wanting weight loss. A relationship with food is by nature complex; and it evolves in the crucible of the client’s life events and relationships. By getting the client’s story, their health, the history of their weight loss efforts, their lifestyle and aspirations, we are better able to guide him or her on what to do next.
The latest thinking on weight-loss therapy does not involve dieting, deprivation or going to the gym. But here I end my blog because, that is another story for another time.
