Refuse To Regain

The Judicious Use of Addiction: The Positive Pleasure Experience

by Barbara Berkeley, MD

We are all addicts.  

Our brain works by a system of rewards that are mediated by chemicals like endorphins, enkephalins and endocannabinoids.  Pleasurable experiences "hit" these systems and provide a nice jolt; one we want to repeat.  Thus, craving the experience of playing music, running or watching Dancing With the Stars (my personal yen) is a kind of addiction, especially if we feel withdrawal when we don't do these things or only feel "normal" when we do.  

Because of the limits of our language, there is no descriptor for healthy and perfectly normal uses of the brain's reward system.  The word "addict" is almost always used in the negative. 

Nicholas Kristof writes about exercise addiction in the October 30th edition of the New York Times. He references the work of David Linden at Johns Hopkins regarding pleasure-producing substances:

Professor Linden explains how drugs such as cocaine that light up these pleasure centers (there are several interconnected areas) actually rewire the brain to increase cravings. You can look at magnified photos of rat brains and tell which animal was given cocaine and which wasn’t.

Brain chemistry research also suggests that gambling and overeating can be addictive behaviors, analogous to narcotics addictions. In particular, foods with sugar or fat seem to trigger cravings that then rewire the brain’s pleasure circuitry to amplify that craving.

One study found that rats fed foods like cheesecake and chocolate showed differences in brain circuitry after just 40 days. The impact was that the pleasure centers of their brains were numbed, so they apparently needed to gobble even more cheesecake to generate the same satisfaction. Whether it’s sugar or heroin, the body steadily ratchets up the quantity necessary to provide the same high.

Kristof then asks, "Does this mean the end of free will?"

Far from it.  

Such research gives us the knowledge and power to understand the things that control us, and to return the control where it belongs.  Let's start with the premise that all pleasurable substances can lead to addictive behaviors.  Let's also acknowledge that pleasure is an extremely important part of life and that lifestyles that severely limit enjoyment are likely doomed to fail. 

In writing about his passion for running, Kristof says: "OK I confess.  I might be an addict."  But "addiction" to running is not a bad thing and why should we look at it that way?  Unless a runner is avoiding all human contact, blowing off his job, or running until he weighs 50 pounds, this kind of "addiction" is something that is basically positive. Perhaps we could call it a Positive Pleasure Experience.

It's also intuitively obvious that certain pleasure experiences are more intense and thus much more likely to cause destructive addiction.  On this list are drugs, alcohol and almost certainly the "thrill" foods: sugar, starches and foods that combine fat with sugar.  

Since we all need pleasure and judicious amounts of addiction, why not figure out how to control our doses? Why not also practice complete avoidance of those things that are dangerous and risky?  We advocate this all the time for alcoholics and drug abusers, but are hesitant to come right out and tell overweight people to cut out the sugar, starch and thrill eating.  Yet this approach works beautifully.  Cut the drug and the cravings for it disappear.  Play with the drug here and there and it will quickly reassert itself.  

For those who do decide to cold turkey off S foods, the judicious use of alternate addictions is important. After I started to play tennis 6 years ago, I noticed that I began to get a little high everytime I struck a good, powerful ball.  I began to crave playing and began to feel intensely disappointed when games were cancelled (withdrawal).  I had created a new Positive Pleasure Experience.  When I was out on the court, the furthest thing from my mind was sugar and starch.  

Can you create new PPEs? For certain!  And you can be the one in control of this process.  But you must be patient, because things only become pleasurable when you gain a measure of competence.  This is why most dieters give up on exercise.  They never get to the point where it starts to provide a "hit" to the pleasure centers.  

PPEs can come from painting, writing, being in nature, meditating, conversing on meaningful topics and an endless host of other activities.  Easier and more dangerous hits to the pleasure centers can be obtained through cooking, watching the Food Network, playing video games, signing up for world beer tours, and eating for fun.  

It's your agenda and your life.  Pick your drug.  

 

 

 

 

 

 

 

 

 

 

 

 

Dietary Tribalism: Factionalism Goeth Before the Fall

by Barbara Berkeley, MD

 I started blogging about 3 years ago.  At the time I was a naive, starry-eyed newbie who couldn't wait to share my experiences and opinions with the world.  I had just written a book based on the experiences I'd had with patients over a period of nearly 20 years. As I sat, fingers poised over the keyboard for my first foray into the internet world, the prospect of getting my message out to a larger audience was thrilling.

Then....Whack Bam Boom!  Not a day after my first words hit the virtual page did I start reading that I was a useless dope, a fool who knew nothing and that my book and pretty much all of my thoughts were drivel.

I ran like a wounded puppy to my blog partner Lynn Haraldson who had been on the internet far longer than I.  She was sympathetic but slightly amused.  I got the message.  The internet is the wild west.  Better toughen up girlie.

So here I stand, ready to take your punches.  But really, why should we steel ourselves, waiting to be beaten up for ideas, beliefs and hypotheses?  The reason for these attacks is supremely ironic, especially for those of us who believe in Primal Diet, or returning to more of the behaviors we practiced in our ancient past.  This flinging of verbal barbs and arrows relates to an intense and ancient human desire to be tribal. Unfortunately, I fear that we will be destroyed by this same tribalism if we refuse to acknowledge and dismantle it. 

At its best, tribalism can be fun.  Cowboys and Indians. Color War.  We love nothing more than to divide ourselves into teams and cast the other group as the bad guys.  I can be playing doubles with one woman for two sets and hating the two ladies on the other side of the net.  Then we switch partners and suddenly my previous hitting companion becomes my sworn enemy.  And I really, really do want to sincerely beat her. 

Things ratchet up with professional sports.  Of course we know that Cleveland really doesn't hate Pittsburgh...(or do they??) Sometimes, it's hard to tell whether tribal enmities related to sports are silly or real.  When they explode into occasional violence at events or after championships, we see their actual potential for destruction. 

And then there's politics.  Why must all Democrats believe that all Republicans are useless idiots and vice versa?  We have all come to see the folly in playing the tribal game so intensely that not a single thing gets accomplished. 

Finally, we have the real deal.  Tribalism as it relates to countries, regions, religions and belief systems.  This is where we lose complete track of the idea that we are all human.  Each one of us might just as easily have been born into another culture and wound up on the other side of the fence...the enemy. But this never occurs to us.  For most of human civilization, indulging in our tribal nature simply meant losing a bunch or our men to spears, arrows and clubs.  As weaponry becomes more deadly and more available, the outcome of unbridled tribalism would seem to be obvious.  Yet we make no attempt to examine it or control it. 

Tribalism seems to be in our biology, but it is expressed as an idea.  The idea is that something about our tribe makes us better...more worthy.  It is usually connected to the belief that our tribe is in possession of the one and only truth.

So what does this rant have to do with Paleo/Primal diet?  In my recent forays into the world of Twitter, I've discovered a new and quite vocal community that believes in ancient diet.  Among this "tribe" I am dismayed to see that there appears to be a great deal of proclamation of truth and declamation against those who see things differently.  People with varying opinions are branded as "asshats" and "fools". This is not unique to the Primal Diet believers.  It is also on display in the writings of followers of other diets.  And yet, at least as I see it,  the truth about optimal diet remains the furthest thing from being settled.  It is as complex and elusive as a shadow that recedes into our endless human past. Does any group, whether it be the vegans, the vegetarians, the Primalists, the Mediterranean Diet followers...ad infinitum.... truly have the hubris to believe that they have completely solved the equation?   There is no diet on earth that does not eventually lead to death.  And if there is ever to be one it will have to come with the assist of modern science, since no living species has yet negotiated immortality.  Thus, we come full circle. We are each human and would benefit from listening to and respecting one another.  Of one thing we can be certain, no one of us has "the answer".  It is only together that we can create enough intellectual and spiritual firepower to push closer to real enlightenment.

 

 

 

 

 

 

Are You Hormonally Destined to Regain? Don't Believe It!

by Barbara Berkeley, MD

The longer I hang around the weight loss field, the more I am impressed by successful weight maintainers. Obviously, I have a major interest in the factors that contribute to permanent weight stabilization...since I've devoted a book and a blog to them.  Over the past 10 years, the number of people who have figured out maintenance seems to have grown.  Perhaps this is just because we can speak to one another more readily via the internet.  Or maybe it's because there actually are alot more of us.  Whatever the reason, I have worked with, met, and corresponded with so very many of you....people who have made true, permanent change.  None of you believes it to be impossible (though many of you would say that the job is a tough one).  Certainly none of you thinks that returning to obesity is an unavoidable destiny. 

Apart from the greater visibility of successful maintainers, another thing that's new in recent years is the 24 hour news cycle.  The need for constant headlines has created a news machinery that snatches up any juicy tidbit and gives it front page placement for as long as a buzz lasts.  A great source for controversial and sensational news is the stream of endless medical studies that are performed worldwide.  Everyday brings yet another pronouncement, another result.  Many results contradict one another, leaving the non-scientists among us in utter bewilderment.  

Scientific studies are not meant to be looked at in isolation nor are they meant to be accepted at face value. Instead, studies are meant to add to an accumulating body of evidence.  Once the evidence is strong enough on one side, we can make better conclusions about validity. Studies also should be read critically and their weaknesses should be evaluated and discussed.  But the media's reporting of individual study data gives equal weight to each report and provides no critical review.  And because these studies appear in print and on the major television networks, they are taken as gospel by many people.  That’s a disservice to most of us.

This brings me to the study published today in the New England Journal of Medicine about hormonal changes after weight loss.  As soon as this study was released, the results were picked up by all the major news outlets. In anticipation of reaction to the story, I started posting to Facebook and Twitter early this morning. As I expected, I  began receiving emails from patients and those who follow my blog as soon as the media released the study results.   Numerous questions arose in our office practice just this morning.  But this "story" is actually just a single study and what this study says is uncertain at best.

Here's the way Fox News covered this story. 

Let’s look at the first two paragraphs of their article:

The findings of a new study suggest that dieters who have regained weight are not just slipping back into old habits, but are struggling against a persistent biological urge – their hormones.

"People who regain weight should not be harsh on themselves, as eating is our most basic instinct," Joseph Proietto of the University of Melbourne in Australia, an author of the study, said in an email. The research appears in Thursday's issue of the New England Journal of Medicine.

 

In other words: We’ve discovered that you’re pretty much biologically destined to regain your weight.  It’s you against biology and you know how that’s going to go!  So don’t be “harsh” on yourself!!

 

But let’s look at what this study actually did:

 

A group of scientists in Australia took 50 obese people and put them on a weight loss diet for 10 weeks.  At the beginning an end of the diet they measured various hormones that are associated with appetite and the impetus to eat.  They then asked these patients to maintain their weight loss for one year.  At the end of that year, they again measured hormones and concluded that most of the hormones were still changed by the experience of dieting.  The changes were such that they would encourage regain of weight.  Researchers also reported that the maintainers had greater appetite than they did before their diet and thus would have to struggle more with self control.

 

Next let’s take a more critical look at the study:

 

The biggest red flag for me is the way weight loss was accomplished.  The subjects in the study were given a diet of just 500-550 calories/day for 10 weeks.  This was done through the use of OPTIFAST as a liquid diet (along with some vegetables).  (By the way, I’m capitalizing the name because that is the way the manufacturer requests it be written).  

 

 Back in 1987,  I was privileged to be recruited as medical director of a hospital weight management program in Cleveland.  The program had been developed by one of the two physicians who invented OPTIFAST. It was the first program to pioneer its use.  I learned a lot.  While I still use OPTIFAST in my weight management practice today, I would never return to the way we used it then. 

 

In those days, we treated patients with a 400 calorie liquid diet consisting solely of the liquid supplement.  It worked great….during the weight loss phase.  But once the patient had lost weight, the deprivation of a full liquid diet and the low calorie count increased cravings and hunger.  Patients regained.   This happened to many people, most famously Oprah Winfrey, who dragged a wagon full of fake fat onto her stage after losing about 50 pounds and then put it all back on in public view.

 

After some years, OPTIFAST redesigned its product to increase the daily calories to 800.  In my own practice, I have taken its use a step further to ensure good maintenance.  We use OPTIFAST to substitute for 2 meals and a snack and have patients eat a healthy Primarian meal at either dinner or lunch.  This gives us the best of both worlds: excellent calorie control, good levels of protein with low levels of carbohydrate and many weeks or months for the patient to “practice” the type of eating that will be the pillar of their maintenance.  Our patients typically consume between 1000 and 1200 calories per day and get excellent, predictable weight loss while reporting good appetite suppression.

 

So what can be said for the hormonal values measured after a starvation diet of just 500 calories per day?  For 10 weeks?  I’m not sure that much can be made of them at all. 

 

Here’s a second problem.  Study maintainers were not asked to eat a specific meal plan.  While it was suggested they eat low fat and low glycemic index foods, this was not monitored.  So there is no examination of whether the type of foods maintainers consume effect the hormones they create. 

 

Finally, the successful maintainers I know work very hard at keeping weight off. While some of them do complain of hunger, a large number do not.  Once again, I believe that the choice of foods after weight loss is the key…an effect not examined here.

 

So here’s my message: don’t be discouraged by studies you see in the media and don’t give them extra weight simply because they are featured on Good Morning America or CNN.  Continue to work on the plan that fits you best, which should hopefully be some form of ancient diet.  And always believe in the evidence of your own eyes and experience.

 

 

 

Halloween to New Year's Day: Joy, Anxiety and Overeating

by Barbara Berkeley, MD

Why do we eat?

In the America of 2011, we eat for the same reasons we buy new TVs, redo our kitchens or replace our perfectly functional cars.  We eat not because we need to, but because we can.  Eating is cheap, pleasurable and soothing.  It's kind of an adult "blankie". 

With that in mind, let's look at when we need a blankie most.  We want to be soothed when we are stressed, when we are reminded of unhappy memories, when the skies are dark, when winter descends, when we feel tired and overwrought.  

In the America of 2011, a supermarket is like a wonder-world of shiny new toys, each one affordable and promising a thrill.  The packages say "Fun! Fun!Fun!" while the labels say, "Heart Healthy" and "Cholesterol Free".  It's ok to be seduced, it's ok to give in.  Heck, it's even virtuous.

Combine these two stimulants to eating and you have the dangerous food period between Halloween and January 1st.   As the skies darken (at least in Ohio) and the leaves fall from the trees leaving depressing skeletons, the food intensity ratchets up.  Seasonal foods make their appearance.  Starbucks puts peppermint back on the menu, along with gingerbread.  Cooking magazines, newspapers and food channels exhort us to bake, bake, bake...as if this will somehow stave off our anxiety.  As we get older, the holidays remind us more and more about our own mortality.  They are still a wonderful time, but we remember how many of these holidays there have been and how many of those we loved are now gone.  Our kids may have grown up and live far away.  They return for the holidays, but no matter what we do, we can't return to the time when they ran down the front steps dressed as ghosts and princesses. We compare today's holidays to those past and to the celebrations of others.  Anything that reminds us of the passage of time tends to make us introspective and unsettled.  

So...let's eat!  Let's drink! 

How do we successfully negotiate such a difficult period and not regain?  The answer lies in creative thinking.  Maintaining a new, healthier body requires a new, refreshed look at life. Instead, most of us tend to repeat the same patterns.  Left unexamined and unchallenged,  life tends to break people down.  But it doesn't have to.  If you as an individual keep creating, keep innovating and keep expanding, the things life removes will have a lesser impact.  You will be more expansive.

Here are some questions for those who want to maintain from now until 2012:

Do you REALLY need to bake this year?  If baking gets you out of control, are you willing to take the daring step of experimenting and letting someone else make the cookies, cakes and pies?  What would happen?

Suppose you didn't have a single piece of Halloween candy this year?  Would your life be different?  Or would it be the candy manufacturers who suffered most?

Imagine that you designed a completely Primarian plan for Thanksgiving and decided that you would fill you plate with turkey, salad, veggies and maybe a dab of cranberry sauce.  Suppose you vowed not to have dessert this year, except for coffee and fruit.  Would your enjoyment of Thanksgiving be less?  

Suppose that you decided to do something really radical this year and ban non-Primarian foods from your home over the holidays.  Suppose that you decided to give yourself a much bigger gift than that new IPhone you've been eyeing?  Imagine that you daringly and creatively decided to stick with a primal eating plan with extremely minimal starches and sugars.  Would you have lost an entire year of holiday joy?

I can answer these questions because these are changes that I made personally almost 10 years ago.  Here are the answers.

The holidays are just the same.  It's still great to see everyone and it's still sad to miss Uncle Monroe, Uncle Aaron and Aunt Ellie.  It's still great fun to smell the peppermint and have an occasional gingerbread latte (with Splenda).  It's still a thrill to see the holiday decorations go up and to enjoy the lights, the music and the sentiments.  It's still wonderful to eat dinners with friends and family, and not a soul cares that I don't have the brownies or the stuffing.

And here's what's different.  For the past ten years I have not had to worry about my weight, my blood pressure, my blood sugar or my cholesterol.  My weight and health have allowed me to live so much more creatively...running, spinning, tennis.  Sometimes I'm just so grateful that I can easily squat down and pick up something I dropped.  Alot of people my age can no longer do something so simple.  Being lean and eating the right foods means that you are quicker and more efficient in every way.  My brain works better without the S Foods, which means that I can take up Chess, learn how to use Twitter and blog to the point where you are probably sick of me.

These are the greatest gifts.

So as you approach the holiday season, think bold.  Uphold your chosen eating plan..whatever that may be. Consider the possibility that our holiday eating may be motivated less by happiness and tradition than by habit and anxiety.  Enjoy and celebrate by continuing on your journey of self-creation.  To life!

 

 

 

Getting Fat: What You've Been Told Is Wrong

by Barbara Berkeley, MD

If you listen to the loudest voices repeating the most conventional wisdom, getting fat means that you simply eat too much.  It also means that you are a slovenly slug, sitting around when you should be doing something strenuous.  In addition, you are psychologically damaged and using food to salve your painful problems.  Finally, you are a weak-willed incompetent who can't control a simple thing like food. What does getting fat mean?  If you believe what you hear, it means you are a failure.  Not just at one thing, but at many.

This is a great big, destructive, lie.  (OK, let's give the wisdom-spouters the benefit of the doubt and say that they are not lying, just laboring under a major misconception).  

Suppose we consider a complete shift in the way we look at weight gain.  Just hear me out on this.

Suppose that we start to get fat because we have developed an intolerance to certain foods in our diet? Imagine it's akin to an allergy.  You can develop an allergy any time in life, so why couldn't you develop a reaction to certain foods after years of eating them? Let's call these foods PTFs for "Poorly Tolerated Foods".  

Now imagine that you are born with a normal body mechanism that knows just how to handle food.  Your body has mechanisms to handle just about any perturbation.  If you eat 5 bunches of bananas today for example, the potassium load won't kill you.  A neat body mechanism will take care of excreting the excess.  We don't think about how to heal a cut, send antibodies to fight a bacteria, or adjust our body temperature.  Under normal circumstances, we shouldn't have to worry about how to keep our weight stable either.  We are designed with a mechanism (I call this IBM or Intake Balance Mechanism) that does this automatically whether we eat more or less, exercise alot or a little.  While some people have a weight problem from a very young age, many overweight people remember an earlier life stage during which they could eat what they wanted and exercise minimally. What happened to those halcyon days?  Their IBM stopped working when they lost their tolerance to certain foods. The PTF problem messes up the function of your IBM.  It no longer balances intake, but sends these foods to fat storage. 

Now let's further hypothesize that one of the side effects of this intolerance is that these PTFs  provoke a hunger reaction.  In other words, eating a PTF disturbs the normal balance of hunger and satiety so that it feels like taking a shot of hunger hormone. It's demonic, but the effect of eating a PTF is to make you want more of it.  And that craving is a strong one.  At times, almost impossible to control by force of will. 

Finally, let's imagine that most people have no idea of the PTF hypothesis.  With the best of intentions, they suggest that you control your weight by eating exactly what's causing the problem: PTFs.... but by controlling the size of your portions.  They also suggest that you exercise like mad..something which has very little to do with the PTF problem.  So you go on eating these foods, getting more and more intolerant to them and gaining weight.  You exercise like a fiend but don't lose anything much.  You feel hungry all the time and can't understand why you can't control yourself.  You resort to the default explanation:  "I must have a slow metabolism".  Neither you nor any scientist can fully explain or yet define the complete metabolic processes of the body.  But every magazine cover says that diets and exercise can do all kinds of things to your "metabolism", so you believe that this amorphous thing called metabolism is at fault. 

This is,in fact, the scenario that I see each and every day in my weight loss practice.  My PTF hypothesis (which simplifies what I believe about more complex issues involving insulin, insulin resistance and fat storage) is part of a growing movement to understand obesity in a different way, one that is more intuitively obvious and yet still fits with our current knowledge of science. 

The foods that most of us become intolerant to are the very foods that are new to the human diet.  No human being consumed large amounts of starchy carbohydrates and sugar prior to quite recently.  Is it overconsumption of these foods that disturbs the automatic mechanism that stabilizes weight? Who knows? The initial insult might come from food additives, background radiation, plastics in our containers, or just about anything you can posit.  For the moment, what starts the process is less important than this:  if you are gaining weight and your body is not preventing that gain, you have almost certainly developed an intolerance to starch and sugar.  These foods are no longer handled properly by the IBM.

But what of overeating?  Don't we eat way too much?  There are two points to be made.

1. There are people who simply overwhelm the normal balance mechanism by eating SO much that the mechanism can't handle it.  Remember the banana analogy?  If you inject potassium directly into the body in high concentration, you have the Jack Kevorkian scenario.  You'll die, because the normal corrective mechanisms are simply overwhelmed.  This is true for those who overeat massively like some with binge eating disorder or people who attain weights in the high triple digits.  However, even for them, avoidance of PTFs may be a crucial element in recovery.

2. Yes, we eat too much.  But in my view this is happening largely because we eat so many PTFs and they make us hungry.  Those who cut out these foods have no trouble controlling appetite (or much less trouble, anyway).  They are still challenged by seeing, smelling and being offered food, but not by the internal gnawing that says, "Let's EAT" 24 hours/day.

The PTF hypothesis is what underlies the growing Primal/Paleo diet movement. I've been an advocate of ancient eating for years and have practiced a form of it myself ever since I gained 20 pounds in middle age. For years, this change in my eating has allowed me to maintain a weight of 123 pounds on a 5'6'' frame.  I'm not excessively hungry like I was in the days when I used to inhale cookies and York Peppermint Patties.  At 63, I take no medicines, have no joint problems, can exercise with the 20 year olds and no longer fear the tendency to coronary disease that I've probably inherited from my Dad.  I am confident that my arteries were not meant to be clogged.  If I eat the diet that was eaten by people prior to the advent of coronary disease, I feel very certain I will be protected. 

The intuitive part of the PTF hypothesis is the connection to ancient diet.  I made this connection on my own while on a trip out of the country about 10 years ago.  At the time, I was struggling with my weight and had been for several years.  I had the sudden thought that perhaps I wasn't eating what I was evolutionarily attuned to...what my genes expected to be food.  I put myself on what I thought would approximate a hunter-gatherer diet.  I immediately lost 20 pounds and the hunger that went with it.  I then started checking around to see if any one else had figured this out.  At the time, the community of ancient eaters was smaller, but still quite active.  Once I had my personal epiphany, this connection seemed to me so intuitively obvious that I was startled that so few were exploring it.  Is it completely correct?  I can't say.  What I can tell you is that it works.  Amazingly well.

I have now treated hundreds of patients with primal diet variants.  The plan is simple.  Eat what you think a hunter gatherer could have eaten.  Don't eat starches or sugars except for those in fruits (non tropical) and vegetables. Don't eat GRAIN or grain products!  Do eat low fat dairy (that's my variation on strict Paleo) if your weight tolerates it.  I call this variant a Primarian diet. Tailor your Primarian plan to yourself to keep weight stable.   

There.  Your PTFs are gone.  Your balance is restored.  And suddenly you're not a failure anymore! That's because you never really were. 

 

 

 

 

 

This response from Alexie deserves a place in the main blog. I agree with this so completely that it really struck a chord. Thanks so much Alexie.

"This is slightly tangential to your point, but I read a lot of blogs where the idea of restricting food in any way is anathema and people talk about HAES and following body cues etc. One thing I think we've missed in all the discussions is the collapse of social rules around eating. We have, in the last twenty years, abandoned thousands of years of food culture. There have only been very specific instances in history where it was OK to eat on the run, or eat publicly while walking down the street etc, or skip communal meals. Yet now we seem to see meals served on a table, with the family all present, as an unaffordable luxury. I wonder how many problems with food would simply vanish if regular, ordered eating became normative again. If eating cake is only done at socially sanctioned times and in socially sanctioned ways (the Sunday visit), then cake ceases to be a problem. Once cake becomes something you can eat at any time of the day or night, you're going to have to expend precious mental energy consciously limiting your exposure to cake. And if you don't, you'll soon be in trouble."

Binge Eating: Eat Without Restriction or EWI?

Here's a question I ask all of my new patients:  "Are you a binge eater?"

About 80% of the men and women I see have to stop and think, yet they do not have anything resembling binge eating disorder.  Many of those who eat the SAD (Standard American Diet) feel that they are under the control of food.  Despite their best efforts, they may find themselves at the other end of an entire bag of Fritos or a full pint of ice cream.  They "wake up", trance-like, with a spoon in one hand and a dazed expression, like an alcoholic after a lost weekend.  Yet this is not binge eating disorder as experts would describe it.  The Fritos gorge is more of a normal variant of eating behavior in America.

The definition of a binger look like this (Wikipedia):

▪   Periodically does not exercise control over consumption of food.

▪   Eats an unusually large amount of food at one time, far more than an average person would eat.

▪   Eats much more quickly during binge episodes than during normal eating episodes.

▪   Eats until physically uncomfortable and nauseated due to the amount of food consumed.

▪   Eats when depressed or bored.

▪   Eats large amounts of food even when not really hungry.

▪   Usually eats alone during binge eating episodes in order to avoid discovery of the disorder.

▪   Often eats alone during periods of normal eating, owing to feelings of embarrassment about food.

▪   Feels disgusted, depressed, or guilty after binge eating.

▪   Rapid weight gain/sudden onset of obesity.

The difference between a normal, out-of-control American eater and a true binger is one of degree, compulsion and emotional tone.  Bingers describe feeling completely out of whack when binging.  They also often feel that they have an “on” and “off” switch.  When they are restricting food by dieting, they can be very, very good at it.  One bite of the wrong food, however, or one day of unbalanced emotion can throw everything off the rails. 

I specialize in treating obesity and not in the management of eating disorders, but inevitably…because of their weight… bingers make their way into my practice.   When I am successful at identifying them, I always recommend that they get counseling from an eating disorders program or specialist concurrent with our treatment.

Herein lies the rub. 

Most eating disorder therapists employ a form of dialectical behavior therapy.  This is a treatment based on helping patients to identify stressors and maladaptive behaviors and finding healthy alternatives.  At the same time, therapists usually advise patients that they must stop restricting food.  Learning to control intake naturally and accept the fact that they may never be as thin as they might like is seen as an important pillar of recovery.

But I have a question about this, and I ask for help from readers in sorting it out:

The on/off nature of binging makes me suspicious that there might be a physiological trigger.  Many bingers have described to me their intense compulsions to eat certain foods and the feeling of being utterly out of control after consumption.  While it’s certainly possible to see the compulsion to binge as a psychological problem, it’s not the only---or even the most logical---explanation.

When I was in my twenties and thirties, I routinely ate huge meals and consumed whole cheesecakes and loaves of bread in one sitting.  I ate whenever and whatever I wanted, in enormous amounts.  Yet no one suggested that I had an eating disorder.  Why not? Because I didn’t get heavy.   If I had been obese as a result of my eating, I would no doubt have developed shame, depression and an entire approach and avoidance cycle around eating.  I would likely have ended up in the office of an eating specialist. 

Recently, one of my patients who has BED was advised to entirely stop restricting food intake.  She gained an unacceptable amount of weight rather quickly.  In discussing it with her, I shared my discomfort with the direction to eat without restriction.  Because of our SAD food culture,  we are surrounded by dangerous food substances, some of which appear to be particularly toxic and addictive to certain people.  It seemed to me that telling such a person to eat whatever he wanted was tantamount to suggesting that he drive a car without regard to the consequences.   Go ahead:  Hit someone.  Crash into a store.  Run a red light if you feel like it.

I have always had a problem with critics of diet (the “diet is a four letter word” folks) because I think they base their objections on a misinterpretation of the idea of restriction.  Restriction has a pejorative feel.  It’s a tough word that doesn’t feel good to us.  But suppose we substitute the words “eat with intelligence”.  To eat with intelligence, one would need to know the foods that react well with ones body and those that are dangerous and destructive.  It would only make sense to avoid the latter at all costs.  Some would call that restriction, but I would call it EWI. 

Bingers, like all humans, undoubtedly come in many permutations.  For those whose binging is primarily emotional, based on previous trauma or an offshoot of significant psychological issues, an approach that asks the patient to learn dietary modulation without restriction may be appropriate.  However, I suspect that for many people binging may occur in those who are highly sensitive to the chemical reactions of certain modern foods in their brains. For these people,  learning to EWI rather than eat unrestrictedly would seem to be a much better treatment.

I am very interested in the experience of bingers and eating disorder specialists who may read this blog. Has DBT worked for you?  Have you learned to eat “unrestrictedly” while controlling your desire to binge?  I am completely open to having my theory taken down.  Let me know if I’m wrong or if your experience suggests I might be onto something.  Please write to me here or on Facebook at Refuse to Regain: Barbara’s World, or on Twitter at BBerkeleyMD.  

 

Chris Christie's Weight: We Have Met the Enemy and He Is Us

by Barbara Berkeley, MD

The past week has seen a (dare I say it?) feeding frenzy around the issue of New Jersey Governor Chris Christie's weight. With a possible presidential bid in his future, Christie's size has become the topic du jour. Is a corpulent candidate less fit for office than a lean one?  Does an overweight president better reflect who we are as a country in 2012?

While you'd have to be blind not to notice that Christie is a big guy, no one had called particular attention to it until Eugene Robinson of the Washington Post launched the first salvo this week.  Robinson's article, which linked Christie's weight with a lack of discipline and ended with the advice to "eat a salad and take a walk" was roundly criticized...even by fellow liberals.  Guests on MSNBC's Morning Joe who are normally sympathetic to Robinson piled on.  "This crosses the line", one complained.  But while Robinson's piece might be interpreted as a partisan low blow, it actually raised important questions about our perceptions of obesity. It also exposed the deep ambivalence we have about our growing national waistline.

In yesterday's New York Times, the admittedly weight-challenged food writer Frank Bruni added his voice to the Christie controversy.  Bruni vigorously wrote that a person’s size should not factor into decisions about his capabilities. “Girth doesn’t equal character”, he said.  Human beings have foibles after all.  Did Clinton’s womanizing or Obama’s smoking make them less effective as leaders?  If your answer is no, you can’t assume that Christie’s obesity will have any impact on his ability to act as President.  

A third, and more dismissive view of Christie’s weight came from Michael Kinsley writing for Bloomberg View.  Christie should be discounted, he wrote, “unless he goes on a diet and shows he can stick to it.”  What about the argument that all humans are imperfect?  He’s willing to forgive Obama and Clinton, but when it comes to Christie’s big belly he is less sanguine. 

So why should Christie’s weight be more than we can bear in a president?......One reason is that a presidential candidate should be judged on behavior and character, not just on policies

Controlling what you eat and how much is not easy, and it’s harder for some people than for others. But it’s not as difficult as curing a chemical addiction. With a determined, disciplined effort, Christie could thin down, and he should -- because the obesity epidemic is real and dangerous. And the president inevitably sets an example.

Spoken like someone who has never tried to lose 50 or 100 pounds.

More importantly, Michael Kinsley deployed the C-bomb: character.  Kinsley is not alone in believing that being overweight is a character flaw.  This is an awfully tough position to voice aloud.  To begin with, it defines 70% of America as weak-willed, food-obsessed incompetents.  Yet this is the guilty, politically incorrect belief of many people who have been lucky enough to avoid obesity.  Believe me, I know. As someone who is of normal weight but deals with obesity, I hear the voices on both sides of the divide.

Three very different voices.  Three different views.  Or are they?  What is most interesting about the Christie debate is the degree to which all parties agree.  It is within this area of agreement that we can find the true nature of America’s beliefs about obesity.  It is also within this area that tragedy lies.  The tragedy is that we so completely clueless about how to deal with such a major threat to the health of our country. 

All three authors use perjorative or dismissive language when describing obesity.  This includes Bruni, who defends and sympathizes with what he calls Christie’s “evident gluttony”.  Gluttony?  Isn’t that one of the seven deadlies?  Having Christie sit in the middle seat on a crowded airplane, says Bruni, “would be cruel to the people on the window and aisle” and “many voters aren’t going to want to look at him as often as they must look at a President.”  After recounting his own torturous experiences with weight control, Bruni concludes that the whole weight control thing is just too shallow and he’d rather have “a big, fat President”.   He mentions the possibility that morbid obesity could impact Presidential health only as an afterthought. I suspect that Bruni is like so many of my patients.  He understands the extreme difficulties of dealing with weight and hates people who are prejudiced against  the obese.  A guilty part of him, though, harbors the same feelings.  This uncomfortable truth is the topic of many of the discussions that take place in the group I run for weight maintainers.  They felt awful about being heavy and after losing the weight they often feel even worse when they find themselves judging people who are still obese.

All three authors believe that obesity is caused by a weakness.  In the case of Robinson and Kinsley, it’s a weakness of will; the inability to “just say no”.  In Bruni’s case, it’s a weakness caused by addiction and compulsion.  Whatever way you look at it, the obese are somehow flawed. 

All three authors buy the usual nonsense about obesity.  “Take a walk and eat a salad” is just another way of saying that anyone can control weight by eating less and exercising more or that moderate changes to lifestyle work.   According to Robinson: 

…. the science of weight control now takes into account the role that genetics might play, along with psychological factors that lie outside our conscious control. There are new options, including gastric surgery, beyond the dieting roller coaster — lose 40 pounds, gain it all back — that Christie says he has been riding for years.

What science is that?  The obesity epidemic is only about 30 years old, no where near long enough for 70% of America to undergo a genetic change!  And to which new options is he referring?  Could he be talking about the 3 or 4 new medications which the FDA declined to approve for physician use?  Or to the gastric bypass surgery which often fails to provide a permanent solution while exposing patients to significant operative and post-operative risk?

On the other side of the fence, Bruni is no better.  Remember his gluttony comment?  Here is his amplification:

Let’s talk as well about that gluttony. It may say much more about his (Christie’s) allotment or early rearing than his resolve. Over recent years, there has been more and more scientific consideration of obesity as an expression largely of hereditary and environmental factors beyond a person’s ready control, and there has been evidence that one person’s fatness versus another’s thinness may to a significant extent be foreordained.

I guess Bruni is reading the same science journals as Robinson.  I wonder what the Pima Indians would think of this.  Completely lean and without modern disease until they began eating sugar and flour and living on the reservation, the Pimas now have one of the worst health profiles of any ethnic group.  Were they genetically pre-ordained for obesity or did their perfectly functional genes run afoul of a sick and clueless food world?

Our 24-hour-a-day news cycle and our tabloid approach to politicians  is perfectly designed to make Christie’s corpulence the target of gossip, character assassination and schadenfreude.  But what if we lived in a  more perfect world? What if Christie turned his blunt, honest-to-a-fault style on his own weight problem?  What if this became the opportunity to discuss new and more effective solutions for our growing problem with fat and fat-created illness?

Here’s what I would tell Christie..or any politician (or columnist) who is willing to listen. 

We need to stop repeating the same old nonsense.  We won’t lose weight or become healthy again until we return to something close to our original eating patterns.  This will take a national effort that includes incentives and disincentives to major food producers and a simple and oft-repeated message.  In particular, we have to vastly decrease the amount of sugar and starch in our diet.  Apart from their extremely deleterious affect on fat storage, these foods are addictive. If we worked relentlessly on this message alone we would do more good than the past twenty years of telling people to eat less and exercise more.

We also need to educate our kids and ourselves about how our own bodies work.  We need to show people the graphic details.  How does sugar tear up our blood vessels?  How does the food we eat wind up as a gummy clot inside a major artery and cause a piece of our brain to die in a stroke?  What exactly is diabetes and why is it that we really, really don't want to get it? We can’t know this unless we know ourselves and right now, we understand our cars better than our own bodies.  Basic physiology and pathophysiology (the study of disease) should be a mandatory part of the curriculum of every grade school and high school in America.   

The obesity problem is not easy to solve but no one benefits from the advice to just be more disciplined.  If we all understood what is at stake---from a disabled and depleted population to the bankrupting effects on our medical budget---perhaps we could get serious.  Lest we forget, Chris Christie is us.  

 

A Calorie Just a Calorie? No Way

by Barbara Berkeley, MD

 A calorie is a calorie.

This is my least-favorite dietary mantra.  Why?  Because in the real world of real people and real weight loss, it isn’t true.

In scientific terms, a calorie is a specific measure that refers to the amount of heat needed to raise the termperature of 1 gram of water 1 degree centigrade. We can measure the amount of heat contained in any substance by burning it in a machine called a calorimeter.  Using this narrow definition, there is no question that calories are all the same.  One calorie of lettuce will raise 1 gram of water by one degree.  So will one calorie of M&Ms.

But the colloquial usage of “a calorie is a calorie” (let’s call this C=C) bears no relation to the scientific definition.  What's usually meant is this: diets that contain the same number of calories will have the same effect on your weight loss.  It doesn’t matter if those calories come from chicken breast or chocolate cake. 

Those who claim that any calorie we eat is equal to any other calorie,  routinely invoke the First Law of Thermodynamics as evidence.  This argument is a real show-stopper.  It’s hard to argue with the basic laws of universe!

But a deeper look at the thermodynamic argument reveals many holes. The First Law says that energy cannot be created or lost, only transformed.  C=C  proponents interpret this to mean that any calorie that goes in has to be balanced by a calorie that goes out.  If the balance is tipped one way or the other, you will either lose or gain weight.   But  the equation for the First Law was designed to represent energy in a closed system, not in a biological system that exchanges energy with the outside world. It would be much more true if the body acted like a perfectly consistent machine and burned all calories with equal efficiency.  While all calories may be the same, the way in which the body burns calories is not.  This variation depends on the package which surrounds those calories.

The calories in food don’t stand alone.  They are intertwined with the other properties of foods… their protein, fat and carbohydrate contents for example. These properties have absolutely no effect on a calorimeter, but they have profound effects on the human body. 

This leads to an important omission in the thermodynamic argument.  While those who believe in C=C support their contention with the First Law of Thermodynamics, they never mention The Second Law.  (There are four, but only two apply to the physics of food). This Law states that when energy goes through a transformation, there is always some loss of energy as heat.  This dissipation of calories is a function of the efficiency with which the calories are burned.

In a 2004 paper on this topic Dr. Richard Feinman offered this useful analogy (the italics are mine):

 The efficiency of a machine is dependent on how the machine works and, for a biochemical machine, the nature of the fuel and the processes enlisted by the organism. A simple example is the inefficiency of low-test gasoline in high compression gasoline engines. If a "calorie is a calorie" were true, nobody would pay extra for high test gasoline. (The calorimeter values of a gasoline will be the same whether or not it contains an antiknock compound).    

This dovetails nicely with what I have observed clinically for many years;  that our body loses fat, works better and is less hungry when we feed it “primary” or ancestral foods.  I believe that these foods are our biological “high-test”.  As I often say to first-time patients, “Your body is a Ferrari but for years you’ve been putting kerosene in the gas tank”.  

Feinman’s article posits a “metabolic advantage” to low carbohydrate foods.  There are many studies that show that at equal calorie levels low carbohydrate foods promote greater weight loss than high carbohydrate foods.  While a single calorie of each of these foods will look exactly the same to a calorimeter, it doesn’t look the same to the body.  One possible reason for the difference in weight loss? The brain needs a certain amount of glucose, or blood sugar, to run.  On a low carbohydrate diet, the food we eat may not provide enough.  The body has to manufacture its own sugar via a process called gluconeogenesis.  This process uses energy and therefore burns calories.  Thus, the net available energy from a low carb calorie is lowered simply by the fact that it provokes another, heat-generating, bodily process.

A low carb calorie may be very different from a higher carb calorie in other ways.   It appears to suppress appetite better. A 2011 study in the journal Obesity reported that dieters who were fed a low carb diet for two years had significantly less hunger and a statistically significant decrease in cravings for sweets and starches when compared to those on a low fat diet. 

A diet that is higher in protein may have the same calories as another diet, but the protein content may cause increased thermogenesis…the loss of calories that occurs through digestion. This effect and others are laid out in a paper in the Journal of the International Society of Sports Nutrition http://www.jissn.com/content/1/2/21.

And then there is this important consideration: many of us who eat the SAD (standard American diet) have developed insulin resistance.  This is a condition in which insulin is produced in response to elevated blood sugar, but fails to work properly.  The muscles, which normally would burn off some of this sugar, have stopped responding to insulin.  Instead, there is diversion of calories into fat.  For people with insulin resistance, calories from sugar and starch provoke a very different bodily response than do protein or fat calories.  They should be avoided.

Perhaps the issue is not whether a calorie is a calorie.  It is the understanding that a calorie is not ONLY a calorie.  When it comes to food, the body reacts to myriad elements of the food package and calories may be only a minor part of that.  Even for those who already believe that calories are just a single aspect of food, the answer to the question of perfect diet remains elusive.  Much of the literature refuting the C=C position comes from scientists who support low carbohydrate diets. When designing studies that pit low carb against low fat diets, they tend to use the Atkins diet as the low carb choice. While I am firmly in the low carb camp I believe in low carb in the context of Primarian (or ancient-style) diet.   In our clinic, we see all of the benefits of very-low carb diets like the Atkins induction (brisk weight loss, decreased hunger, correction of metabolic abnormalities).  We achieve this, however, with Primarian plans which are less restrictive and easier to follow.  Unfortunately, there are few studies that have looked at the effectiveness of ancient-style eating for weight and health.  

The moral is this: calories are not the be-all and end-all we’ve been led to believe.  While lowering calories is key to weight loss, the type of calorie you’re consuming is equally—if not more—important.