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Ask the expert
Eating Disorders

Does sugar affect the serotonin and glutamate in the brain?

I don’t know, but I think the answer is no. I can’t think of any pathway through which anything in sugar could affect the brain, other than perhaps providing more energy but that would be non-specific for a giving transmitter system.
-Howard Steiger, Ph. D., Mini-Psych School 2009

Is there a link between substance abuse and sugar – like heroine addicts who load up on sugar if they can’t get their fix?

One of the main brain substances involved in reward and addiction is dopamine. Compulsive gamblers show a problem with low dopamine levels, as do people who abuse drugs. In the same way, binge eating behaviours seem to impact dopamine levels. Heavy sugar loading might also do that to. People always say “What’s wrong with me? I’m a sugar addict, I can’t say no.” It’s not true. Usually you are seeing somebody who had chronically avoided eating sweet things, cut out carbohydrates, cut out sugars, and then, when confronted with them, they can’t control themselves. I say it looks pretty normal to me.
-Howard Steiger, Ph. D., Mini-Psych School 2009

When anorexic people look at themselves in the mirror, do they see themselves as being fat?

That’s actually one of the myths about anorexia. People say “What is wrong with them? Don’t they see they are thin?” Sometimes, in extreme cases, people will actually distort their body image, but that’s really in the extreme and it’s often when people are so malnourished that their brains aren’t functioning properly anymore. What my patients teach me is that there is a terrible uncertainty: it’s like one moment they feel ok, one moment they might feel fat, and one moment they think they’re too thin. They never know, so it’s so easy to get pushed over the edge by something as simple as one or two French fries. The only metaphor I think of is to imagine if I took you up to the roof of a building and put you in the middle, so you knew you were pretty safe, and the edge was far. But now, I put on a blindfold, put you on the roof, and ask you to take a few steps. You can imagine that that would be a scary thing to do now. Somebody who has anorexia feels that way about weight in her body. She may know she’s thin, she just doesn’t know when fat starts. She never wants to go there.
-Howard Steiger, PhD, 2009

How do you compromise between looking good and being healthy?

There is a naturally accruing process which means we could all have hope. The process is this: as people age, they tend to gain some weight. As people age, body satisfaction goes down especially according to certain social norms of what a good body is. But the investment of having a good body image goes down too. And, it goes down faster than the satisfaction. If you are getting unhappy, get hope: eventually, it won’t matter!

There is another really important side of it too which is that we live in a society that is obsessed with the body. We all have the need to really do a soul search about the kind of values we attach to thinness. It really takes a search on the part of clinicians and parents and young kids, and some of the kinds of social efforts we can make to the things that you saw I was involved in. Eric Stice’s prevention programs, for instance, have people ask “Why is thinness such a big deal?” And, could you imagine a version of attractiveness that doesn’t come in a thin package? I can do that, and I’m sure you can all do that. But we have to sort of challenge our own beliefs.
-Howard Steiger, Ph. D., Mini-Psych School 2009

Is it true that people with anorexia have high cholesterol?

Yes, it can be true. When this is the case, my patients are shocked. They say “I only eat a celery stalk or carrots and how come I have high cholesterol?” It’s actually because, when you are in a state of malnutrition, and that changes the way your body processes fat (its own fat) and you actually look like you have high cholesterol. It’s a bit like the way an alcoholic gets a fatty liver. The solution to it is paradoxically, you eat more, not the usual thing that we do to keep our cholesterol down.
-Howard Steiger, Ph. D., Mini-Psych School 2009

If I am happy with my body now as a teen, do I still have a risk to getting anorexia or bulimia when I am older?

I would like to think that if you really have a good solid kind of connection with your body image and solid values around it, then probably you protected from developing an eating disorder. I hope that you will not go through any experience that would shake that confidence you have or the ability you have to feel good about yourself even if you think your body isn’t perfect. Although, sometimes we do see development of eating disorders later in life, even though we think of them as things that happen to young people or adolescents. If I ask you to think about anorexia, what is your stereotype? Thirteen years old? Fourteen years old? You know that these are really disorders of adulthood, and around 28 is when we see the peak of eating disorders. And we even see them starting in women in their forties and fifties. But, yes, having a healthy body image when you are a kid is a very important fact. Related to that, there are really nice programs that foster prevention by taking teens and having them question the value they place on thinness and weight. It’s been shown that a very short program of that type substantially reduces the risk of people developing an eating disorder over the next three years. So, healthy attitudes are an important piece of the puzzle.
-Howard Steiger, PhD, 2009

What does repetitive dieting do to the brain?

When you diet, you mess up your brain. I always say to my patients that they should take an anti-antidepressant every time they diet. And they come back saying that they feel depressed and that their mood is unstable. And, they are taking an antidepressant; it is like a heavy smoker using cough syrup. You better off quitting smoking. Dieting negatively affects brain functions – there is no doubt about that.
-Howard Steiger, Ph. D., Mini-Psych School 2009

Can you comment any relationship between cortisol and weight?

Cortisol is the brain stress hormone. And so it is modified by various things including dieting and stress. And cortisol is not only involved in stress regulation but actually has a lot to do with the way in which body fat is distributed, especially around the abdomen. So things that throw off the cortisol system can actually cause people to store fat in a unique way. Stress is one of those things. People who have eating disorder interestingly always have elevated cortisol. And it’s because they are often stressed. They are going through an emotional distress, but also starving is a stressor for your body. And so they put themselves in that state where whatever cortisol levels are supposed to regulate is now deregulated.
-Howard Steiger, Ph. D., Mini-Psych School 2009

Is there any relationship between eating disorders and borderline personality disorder?

We call borderline personality disorder a personality disorder because it’s a syndrome in which people are markedly deregulated. They are highly impulsive, their mood is up and down, and they can be very chaotic; they can love someone one minute, and be really enraged with them the next; they can have really dramatic changes in terms of their own self-image so that they feel really good one moment and suicidal the next. They are highly unstable people. And one of the things that goes into that instability, of course, is their self-image problem. Serotonin plays a role as well. So there can be some connections in some people. If you have this problem, you are highly susceptible to binge eating. So you see a large number of people who developed bulimia who may also have that problem. But it doesn’t mean that you have to have it, not everybody who has bulimia has borderline personality disorder.
-Howard Steiger, Ph. D., Mini-Psych School 2009

What are the warning signs that you should be looking for in possible eating disorders?

There are a number of them. The obvious one is that, in anorexia, people get very thin, so thin that you start to say that it isn’t normal and you realize that there is something going on. Along with that, the person might avoid meal times or show anxiety around anything that involves eating; they may be unable to sample unfamiliar foods while their range of “safe” foods gradually diminishes.

Perhaps you pick up on signs of clandestine vomiting that is going on behind closed doors, or realize that laxatives are disappearing. We see the tendency for people to need to exercise after eating. Along with that, there may be mood disturbances; people become very unstable in terms of mood, or have sleep or concentration problems. It’s a tricky thing because dieting behaviours are normal. And so, both clinicians and those close to the patient always have to make a difficult judgment about when normal dieting behaviours go past normal.

However, you should not be the “vomiting police” if somebody around you has an eating disorder. Express your concern, offer help, offer information, and contact us if you want. We have documents and articles and things that are useful for people with eating disorders to read just as an opening to considering that they have a problem and maybe wanting to get help for it. But, until you do that, they probably won’t.

-Howard Steiger, Ph. D., Mini-Psych School 2009

Can you be both anorexic and bulimic at the same time?

The diagnostic criteria are very confusing so this is a good question. According to the criteria, one either has anorexia nervosa or bulimia nervosa. As I said before, bulimia is seen on a normal weight or an overweight person, not an underweight person. It gets more confusing by the fact that there are two kinds of anorexics: those who don’t binge and purge and those who do. What tends to happen is that people start restricting, and many people eventually deregulate their appetite so they were restrictors and then become anorexic binger-purgers, and then sometimes they become normal weight bulimics after a while because of that process.

People do tend to go in a direction from restricting towards binging-purging. In the next round of diagnostic criteria that is coming out in 2011 the criteria will change to include those who restrict but don’t binge and purge, regardless of how thin or not ,and those who binge and purge, regardless of weight; and then there will be binge eating disorder. For a more direct answer, yes, it is possible to have anorexic behaviour and binge eating behaviour at the same time. In fact, it is very common.
-Howard Steiger, Ph. D., Mini-Psych School 2009

I love to eat, but I am also very conscious about keeping a good body, so I exercise a lot. Is that a problem?

Don’t get me wrong, I’m not against the exercise and I’m not against the eating – these are healthy normal behaviours. But, you can’t push things beyond the limits of reality and our society tends to want us to do that. There is some kind of idea that exercise is always the solution to eating. For example, when you exercise, you increase your body’s caloric needs So, unless you are going to be somebody who says “I worked out a lot today, so I better eat a lot today in order to satisfy my nutritional needs,” you set up an increasing disparity between how much you need and how much you ate. Guess what happens if you do that for long enough? You start to binge eat. So, even though all of our mothers and fathers encourage us to exercise, they also told us to do things in moderation.
-Howard Steiger, Ph. D., Mini-Psych School 2009

Is being extremely thin a sure sign that someone has an eating disorder?

Every person suffering from an Eating Disorder reacts differently. There is cause for concern, however, when a person has an unusual relationship with food, loses weight and becomes anxious or depressed, introverted or evasive.

Can Anorexia be partially caused by genetic factors?

Anorexia can be partially determined by heredity. A study of 31,000 Swedish twins showed that 56% of the risk came from genetic inheritance at birth. For example, there seems to be a region on Chromosome 1 that differentiates people with and without Anorexia. The abnormality on this chromosome is linked to personality traits like compulsivity and anxiety (common in Anorexia). The same genetic vulnerability is also associated with increased risk of depression.

Is an impulsive person at higher risk for Bulimia ?

Bulimic behavior may be linked to impulsive personality traits via a biological pathway. Impulsivity is linked to alterations in the activity in the brain of serotonin (one of the chemicals that transmits brain signals). Abnormal serotonin activity can make people susceptible to impulsivity, moodiness, anxiety, and problems with satiety—or bulimic episodes. Impulsive people are therefore more susceptible to becoming bulimic.

Could people who are extreme health food fanatics have an eating disorder?

There is a new term being used called “orthorexia.” It means being completely obsessed with the nutritional content or health content of food, how many vitamins it has, what it is made of, etc. People get totally obsessed with that, which proves the point that people can become obsessed with almost anything. Especially in a society that makes us very conscious of what we eat. I wouldn’t say that people who have that concern have an eating disorder, but, just like the answer to the question about when a diet becomes an eating disorder, I would say that it is when someone’s preoccupation with weight, eating, and body image starts to take so much space in their life, and to affect their behaviours so much, that it really starts to do damage. And, in the same way, you can damage your life by being orthorexic. And sometimes, orthorexics are unable to eat; they will become emaciated because they are so scared to eat anything that isn’t healthy; they don’t have anything left on their list of “safe” foods.
-Howard Steiger, Ph. D., Mini-Psych School 2009

Is medication the only answer to eating disorders?

When a patient suffers from Anorexia, Bulimia or other type of Eating Disorders, treatment does not involve “genetic reconstruction” or giving medication alone; psychotherapy, and nutritional interventions that help people master their terror of eating and their obsessions with weight, are used to treat these diseases.

What kind of treatment is available for binge eaters who don’t purge?

There are known treatments but I have to say that the healthcare system hasn’t developed very good specialized programs for people who have binge eating problems or binge eating disorders. Our program here treats anorexia nervosa and bulimia nervosa. As it is, that means that we are overwhelmed by the need that exists in the community. And those disorders require slightly different treatments from binge eating disorder. Weight loss clinics know something about treating binge eating disorder. The community organization ANEB offers groups support for people with binge eating disorder. Good physicians and people in general hospitals also know how to approach binge eating disorder. As for the ingredients, you’ve got to help someone stop dieting. Dieting sets up binge eating. Helping people introduce structured meals that are well-balanced is important, as is a modest level of exercise. There are certain medications that also help people contain the impulse to binge eat. In extreme cases, medications like topiromate or a mood stabilizer can help people inhibit their appetite until they get things back under control.
-Howard Steiger, Ph. D., Mini-Psych School 2009

How would you motivate someone with an eating disorder to seek help?

It’s again about the idea of not coercing or forcing people. Usually, friends, relatives, and concerned family members need to be courageous enough to be open about their concern. So you might say “It looks to me that around food you seem very scared or it looks like there is a problem. Would you like to talk about it?” If the person is open to it, try to help them become aware that these are things for which there are solutions and help available. So that’s one piece of it.

The other piece of it is to respect and understand the fact that people don’t do things like that until they are ready and they are not going to do it on your agenda. So this sometimes means containing your anxiety and respecting and trusting the person to find their way gradually. The limiting factor on that is when you see somebody really looking in danger, terribly emaciated, or fainting on the living room floor; that’s when you make sure that some kind of professional intervention occurs.

Force feeding people doesn’t accelerate the recovery. It’s a journey that people have to take. For some, it’s painstakingly long – it’s always longer than you want it to be. And so, as a family member, friend, or caretaker, you have to be willing to let that process unfold in full.

-Howard Steiger, Ph. D., Mini-Psych School 2009

Is there a high percentage of people dying from eating disorders?

Anorexia is associated with the highest mortality rate of all mental illnesses. Eating disorders have a very high potential to become chronic and have harmful medical and psychological consequences. According to the National Institute of Nutrition, 10% to 15% of people with Anorexia or Bulimia die of their disease. But Anorexia, Bulimia and Eating Disorders can be treated.

Is the ideal healthy female body pear-shaped?

It is important to know that being too thin is no healthier than being overweight and that weight fluctuation is more damaging to the health than being overweight.

Are eating disorders serious diseases or just a fad among girls who want to look like models?

Anorexia and Bulimia are Eating Disorders. They are complex mental illnesses that can be treated. They can also affect men, and the average age of people affected is 28.

Are more men dissatisfied with their bodies too?

For men, it’s not the thin ideal, it’s the bulk ideal. They need to be strong, muscular and have six packs. This ideal sells protein shakes and all kinds of things. Even now there are cosmetics that men can buy. There’s money to be made in making men satisfied with themselves. And men then become targets. The industry pursues boys and it becomes an epidemic. But they aren’t always the target that girls are. However, they are going after little boys and making them feel like they should be unsatisfied about themselves.

- Mimi Israël, MD, FRCPC, Mini-Psych School 2013

Are we seeing eating disorders and body image problems in other cultures besides North Americans?

I just read a study showing that young women from the United Arab Emirates have become totally obsessed with their body image because they are being exposed to the same cultural ideals as we are and they also have their own pressures about identity and self-assertion. The study found that anorexia in that country is about 10 times the rate in Britain. So it’s clear that culture can protect you until our North American culture gets in your way. Nowadays, it’s quite hard not to be exposed to our culture.

- Mimi Israël, MD, FRCPC, Mini-Psych School 2013

What is the overall influence of social media on body image and how far can it go?

Social media could have a very big impact, and for the moment what I have read is not encouraging. The average girl spends about one and a half hours a day on Facebook or MySpace. Social media is really a means of social comparison. The peer pressure on these platforms is very high. You’re measured by how you look, how many friends you have, what your friends look like, and the pictures you post. Again, for vulnerable girls, this can put them at risk and can affect their self-esteem. They can feel pressure to live up to these ever-present standards.

- Mimi Israël, MD, FRCPC, Mini-Psych School 2013

Is there any evidence that SSRIs may help people with an eating disorder?

SSRI means Selective Serotonin Reuptake Inhibitors, a type of antidepressant. The first one was Prozac; another example is Celexa. People used to think that these drugs help people with an eating disorder because they make them less depressed. And, that may be partly true. But, then we started to see that you don’t need to be depressed to benefit from using these medications. Being depressed is not a predictor of it. There is tons of evidence to show that the level of serotonin activity has a direct impact on the urge to binge, or to partake in binge-like eating behaviour. We’ve done studies with something called “triptofan depletion”. Triptofan is one of the amino-acids. Your brain makes serotonin out of triptofan. We have used a procedure that was developed by Simon Young at McGill in which the person has to drink a milkshake that blocks triptofan from going into their brain. So, temporarily, it lowers your serotonin activity. If you have bulimia, this makes you have a bigger urge to binge. So in some way, serotonin is directly linked to your appetite.

-Howard Steiger, Ph. D., Mini-Psych School 2009

What makes adolescents the most at risk, especially adolescent girls?

Adolescence involves many changes at many levels. It’s clear that adolescence is accompanied by changes in body weight and shape. You develop female characteristics and develop curves. It’s also a time of emotional instability and hormones take over. It’s a time when you have to develop your own identity, and a time when peer pressure is extremely high. What your friends think matters way more than what your mother thinks. There is pressure to fit in, to look good, to be socially desirable, and to be sexually desirable. Again, if that collides with the thin ideal, which is “This is what I should look like and this is not what I look like,” this actually has a very negative impact and girls will be much more vulnerable to doing something to change and will experience a lot of peer pressure to do so.

- Mimi Israël, MD, FRCPC, Mini-Psych School 2013

How does dieting actually cause an increase in eating disorders?

It is very hard to lose weight. That’s because we all have a set point, or a weight that you’ll naturally be just by eating normally and following your hunger cues. If you exercise more, you might be hungrier; if you eat too much, you might be a little less hungry the next day. The body regulates itself naturally. When you diet, you’re forcing your body into an unnatural mode. It’s very hard to maintain the result because you’re fighting nature. And when you actually succeed for a week or two or a month to keep your weight down from unnatural tactics, your brain goes into starvation mode. It thinks, “What are you doing to me?” So when you start to eat normally, your body wants to store a little bit for the next time you pull a number like that.

- Mimi Israël, MD, FRCPC, Mini-Psych School 2013

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