A Hunger Artist

Winning the battle against anorexia.

Anorexia and the Diet Delusion: Healthy Eating After Recovery

What does it mean to eat healthily (after anorexia)?

For some time now, I’ve felt as though I have been eating healthily. When I have this thought, I do so of course in the context of my history of anorexia. By this I don’t mean, however, that the statement is merely relativised: I eat as healthily as can be expected for someone who used to have anorexia. Rather, a history of clinically disordered eating perhaps entails qualitatively different parameters for its opposite, healthy eating, than apply to the wider population. However, there are many similarities too; it’s by no means the case, I think, that sufferers from eating disorders are destined always to eat differently from others. It would be hard to maintain this whilst also believing (and presenting evidence for the fact that) full recovery from eating disorders is possible. Clinical surveys vary in their assessment of the long-term prognosis for anorexia—and indeed defining recovery is problematic in itself—but a review of relevant studies ten years ago suggested that more than 50 percent of sufferers fail to recover fully. Nonetheless, that means that nearly 50 percent (46.9 percent) do recover fully. We might argue about definitions, but I suppose people know when they are fully recovered, if not exactly when they make the transition—certainly I’m quite sure.

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Perhaps in fact there’s only really one different parameter when it comes to healthy eating specifically for former anorexics, and this can be summed up as: everything in moderation. I’ll try to expand on this as I go along. (I apologise in advance for the length of this post; it just ended up needing this much space.)

A word first about why I’m writing this post. I was about to say that in some ways it goes a little beyond the remit of the blog, since it’ll include elements of nutritional science and will focus more on life post-recovery than on anorexia itself—but then I realised that this isn’t atypical of my posts more generally, and can hardly be thought of as way off-topic. So I’ll dispense with such caveats—although I’ll talk a little more about my hesitation later on.

In any case, one recent prompt to write about this was a message from a reader who is trying to resist comparing her food intake with that of various female members of her family, who practise various diet-related habits in the interests of eating ‘healthily’. This of course raises the question as to what assumptions her family are making about what eating healthily means. It also ties in with anorexia’s origins, which often lie in teenage dieting (i.e. eating ‘more healthily’ in order to lose weight), often through emulation of older women, often relatives, with the same aims. In what follows, I’ll explore what healthy eating may or may not mean for the general population, and how these broad considerations yield a particular conclusion as regards anorexia and hunger.

Every recovering anorexic has to come to terms with the fact that the world of ‘normal eating’ which he or she is at last regaining entry to is full of people who eat unhealthily, whether primarily in physical or mental terms, whether to extremes or barely perceptibly. Some people are addicted to junk food, others are addicted to ‘healthy eating’ regimes (sometimes referred to as orthorexia); people order their lives around their diets and measure their self-esteem with their waist sizes; a great many people in the industrialised world live with low-level longings to be thinner and therefore, they believe, happier, and live more or less permanently with the calorie-restricted diets they believe will achieve this for them – because they assume everyone else does too, and that this is normal and as good as things can be.

This is all a shock to the person who has invested enormous effort in reaching a healthy weight again, and who has been assured by her therapist or any number of self-help books that a healthy body weight is the way to a healthy mind. It is, of course, the only way (for someone with anorexia), but it also isn’t a guarantee—it is necessary but not sufficient. A great deal of hard work is necessary to translate a healthy body into a fully healthy mind. But as I’ve described, all the effort of recovery can ultimately mean that the formerly sick person has more and better psychological and behavioural resources to combat the innumerable dietary delusions out there than people with no history of eating disorders have. The key is to keep these in practice as recovery recedes further into the past—in the sense of automatically helpful reflexes against encroaching immovable food rules, say, or missed meals.

This well trained healthy attitude is constantly confronted, though, with its opposite in other people—even, or especially, people who claim they are living the epitome of healthily. Perhaps the primary problem here is the pervasive equation of healthiness with thinness, or with the loss of weight. (And note that this is usually talked of in terms of undifferentiated loss of ‘weight’, rather than as targeted fat loss. Even if the latter is what people mean, the methods they use to achieve it often result primarily in fluid and muscle loss.) There are many reasons why thin doesn’t necessarily equal healthy, including the location of fat deposits and amount of muscle, as well as cardiac fitness. And of course, anorexia is an excellent example of what happens when we take this received wisdom to its illogical extreme—the problem being that no one ever tells you where thin stops being good and starts being deadly.

The diet industry, in all its manifestations from diet books to diet foods to dieters’ fitness programmes, feeds and feeds off this indiscriminate desire to be thinner—and it also feeds off the fact that the vast majority of the diets it peddles, and their many accoutrements, don’t work, so people keep coming back for more. I’ve done quite a bit of reading on the subject of nutrition over the years, and the most persuasive writing I’ve come across on why conventional calorie-restricted diets don’t work—persuasive because, in the main, engaging carefully and thoroughly with the scientific literature – is by the science journalist Gary Taubes, notably his 2010 book Good Calories, Bad Calories. (This book was published as The Diet Delusion in the UK and Australia, and I’ll refer to it by this title, because I prefer it for its richer associations: the pun on ‘diet’ prefigures the book’s debunking of the myth that ‘diets’ in the conventional sense are our only weight-loss option, and hints at the delusions we may be subject to as regards diet more generally.) Taubes covers a great deal of ground here (there’s a digested version for those without time for the full account, called Why We Get Fat and What to Do About It), but his conclusions are set out concisely in the epilogue (p. 454—also reproduced here).

Most importantly for our current purposes, calories aren’t key to weight loss and gain, carbohydrates are: ‘Insulin is the primary regulator of fat storage. When insulin levels are elevated – either chronically or after a meal – we accumulate fat in our fat tissue. When insulin levels fall, we release fat from our fat tissue and use it for fuel. […] By driving fat accumulation, carbohydrates also increase hunger and decrease the amount of energy we expend in metabolism and physical activity.’ These conclusions challenge the received wisdom that consuming excess calories is what makes us fat; that dietary fat is what makes us fat; and that insufficient exercise is what makes us fat. The standard way of thinking about body fat and food is that we become fat because we eat too much. Taubes argues that, on the contrary, we eat too much because of hormonal and other biological mechanisms that drive us to become fat (depositing and not burning fat). Other examples of these mechanisms include the glycerol phosphate molecule produced from glucose, which plays an important role in binding fatty acids together into triglycerides: ‘a product of carbohydrate metabolism—i.e., burning glucose for fuel – is an essential component in the regulation of fat metabolism: storing fat in the fat tissue’ (p. 388).

To me, these arguments and their supporting evidence are relevant to the once-anorexic in one key area: hunger. Taubes presents evidence to suggest that carbohydrates in the diet create hunger by promoting fat storage (making fatty acids unavailable as fuel), and that undereating—that is, eating in order to create an energy deficit, in conventional diets by reducing fat and therefore increasing carbs—causes hunger, and is therefore ineffective as a dieting strategy in the long term. Sooner or later, the dieter will get sick of being hungry, and will abandon the diet. A slowed metabolism and likely muscle loss will then make it all the easier to regain the lost fat.

What about anorexia, then? Why doesn’t this logic apply to anorexics who very successfully lose weight and keep it off? Taubes, unfortunately, isn’t good on anorexia. He discusses it only once at any length in The Diet Delusion. I quote the passage in full:

One of the most radical implications of this hypothesis [that both hunger and satiety are compensatory responses to the insulin-driven cycles of fat storage and fat mobilisation] is that even such an intractable condition as anorexia nervosa—which, like obesity, is now universally considered a behavioral and psychological disorder—may be caused fundamentally by a physiological defect of fat metabolism and insulin. The behavior of undereating may be a compensatory response to a physiological condition, just as the behavior of overeating can. Any hormonal abnormality that makes it difficult to store calories as fat—the fat cells, for example, becoming prematurely or abnormally resistant to insulin—could conceivably induce a compensatory inhibition of eating behavior and/or an increase in energy expended. What appears to be purely a behavioural phenomenon, the anorexia itself (and perhaps even bulimia nervosa), would be the compensatory response to a physiological problem, the inability to store calories after a meal in the energy buffer of the fat tissue. Correctly identifying cause and effect in these conditions would be difficult, if not impossible, without the understanding that there is an alternative hypothesis to explain the observations. (p. 440)

These suggestions (and of course he does only present them as tentative suggestions) ignore—or reveal ignorance of—several key facts about anorexia. For example, people recover from anorexia, and it is unlikely that recovery (which usually occurs through a combination of psychological therapy and increased calorific intake, in a wide variety of proportions of carbohydrate to fat and protein) always just happens to coincide with the end of the fat cells’ resistance to insulin or similar. Secondly, as I’ve discussed before, the boundaries between anorexia and other eating disorders, notably binge-eating disorder and bulimia, are so fluid, and the clinical trajectory from one to another so common, that many practitioners find their categorisation as separate conditions unhelpful. It isn’t clear how Taubes’s hypothesis would account for the fact that the transition from anorexia to binge eating occurs more often than not. Thirdly, mere forced undereating (as in the Minnesota Starvation Study) effectively induces anorexia, while refeeding can then cure it. Fourthly, the implication here is that anorexics don’t feel hunger—which is one of the myths I’ve tried to counter, and is clearly not true for all (probably not for the majority) of sufferers: denying hunger is not at all the same as not feeling it in the first place. Fifth, this argument implies that anorexics eat and eat and nonetheless fail to put on weight, which is a bizarre misunderstanding of a condition that is well known to consist in eating too little. It is true that in some cases, as with me, a stable diet is established that seems relatively generous in calorific terms—certainly more so than many conventional weight-loss diets—but not to the extent that a genetic insulin resistance need be posited to account for the absence of weight gain. A calorie-restricted diet that is followed rigorously and permanently does result in continuing weight loss to a point beyond which the body can no longer function; this is why people can starve to death. (Conversely, a relatively high-calorie diet that is followed rigorously and permanently from an underweight starting point does result in continuing weight gain; this is why, as I've described, weight gain in recovery from anorexia can proceed with relatively predictable ratios of calories consumed to kilos regained.)

The two crucial facts that Taubes neglects, and which could in fact end up supporting his overall argument about hunger—are, firstly, that anorexics grow addicted to the sensation of hunger itself, and secondly, as I mentioned just now, that anorexia often culminates in binge eating or another eating disorder. The hunger addiction of anorexics may well have hormonal elements (as in the endorphin-fuelled ‘hunger high’), and these contribute to buttressing its central position in the value system that is built up around it (hunger = self-denial, strength, power, purity, specialness, etc.), and thence to strengthening the behavioural web of habits that preserve it. This addiction is why anorexic ‘diets’ succeed where others’ fail (where the goal is significant weight loss). The reasons why this addiction develops in some people and not others need to be better understood, but the fact is that some anorexics go on undereating year after year, sometimes decade after decade, living with hunger in a permanence that others are unable or unwilling to accept. As for my second point, the reality is that in the majority of cases (where neither recovery nor death occurs first), anorexia mutates into another eating disorder, in which eating consistently too little gives way to alternating between too little and too much, or vomiting to reduce calorie absorption. This brings anorexia back into the realm of the ordinary, flawed diet, and supports Taubes’s claims as to why such diets ultimately fail.

For those who do not make this transition to another form of eating disorder, recovering from anorexia involves learning to cope without hunger in the sense that other people have to learn to cope with it when they embark on conventional semi-starvation diets. Some people never manage this, and never get fully better. Others (like me) do manage it, retraining their appetites as their body weight increases, relearning how to listen to their hunger, and creating lives in which they don’t feel hungry for extended periods, and in which hunger is a signal to eat rather than a signal to be ignored. I am simply no longer willing to put up with the tedious pain of prolonged hunger, and don’t need to any more. And this is as it should be. This kind of relationship with hunger, I think, is a key element of what it means to eat healthily.

The trouble is that this balance can easily be upset, as Taubes describes, by an excess of dietary carbohydrate. And the greater trouble in the context of anorexia is that a small slip—a slight movement towards relapse, in a time of stress, say, when the old coping mechanisms of dietary restriction and resulting weight loss fall imperceptibly back into place—can easily be magnified if, as is likely, the dietary restriction takes the form it takes in all the diets we’re familiar with. The way we’ve all been taught that weight loss happens is through restriction of fats and concomitant increase in (‘good’) carbs, but the trouble with this route for the former anorexic is that hunger increases because insulin secretion increases, the old hunger addiction is reawakened, and a full-blown relapse is then more likely to occur.

This is why I think it worth writing about The Diet Delusion in this blog: it offers a different perspective on weight loss. The common low-fat, (low-protein,) calorie-restricted diet is unlikely to be a healthy way for anyone to eat for long periods, and it is certainly the way in which failure to recover fully from anorexia is most often manifested, as people ostensibly recovered insist on maintaining their body weight at a pre-determined level through dietary restriction. This kind of semi-starvation diet usually results in muscle depletion, a slowing of the metabolic rate, and constant hunger and often preoccupation with food.

Taubes is writing for and about a Western population for whom semi-starvation diets are dangerously ineffective; former anorexics are a sub-section of that population for whom such diets can be dangerously effective. But an understanding of the biology is equally important to both groups, I think. In the latter case, I wonder whether understanding hunger and its causes better, rather than allowing us to lose or rigidly maintain body weight more effectively, might let us know that an inclination to lose fat can be acted upon without inducing hunger, and without triggering all those old destructive associations. This applies whether the inclination is what we might call either ‘unhealthy’ or ‘healthy’: prompted by some unrelated life event that increases stress or reduces self-esteem, or prompted by a sensible, measured desire to make oneself healthier in relation to, say, the heart or one’s joints.

I appreciate that this weapon could be a double-edged sword. Adopting any nutritional perspective that presents one food group as problematic may be dangerous for someone who has had anorexia. On the low-carb account, the demonisation of dietary fat is undone, but sugars become the enemy of (physical) health. For the former anorexic, though, the specific associations between body weight and psychology mean that the physical benefits of a certain dietary strategy have to be weighed against the possible psychological costs of consistently pursuing any ‘abnormal’ strategy.

As I mentioned at the beginning, comparison and competition with others in the food context—primarily trying to make sure one eats less than everyone else—is a very prevalent characteristic of anorexia, and coping with other people’s diets can be difficult during illness, recovery, and to a lesser extent even afterwards. But perhaps a different perspective on the whole concept of dieting—an understanding, for example, that a reduction in ‘calories in’ (or energy intake) will always result in a reduction in ‘calories out’ (energy expenditure), through mechanisms like a change in metabolic rate; or that eating less fat in practice usually means eating more carbs—can help us change the parameters of the comparisons and stop fixating on sheer quantity, or on probably misguided notions of healthiness. This is not to advocate that the former anorexic adopt a holier-than-thou attitude to other people’s dietary decisions, nor that a gulf be opened up between her and those around her. Anorexia itself does both these things beautifully.

As I write this post I keep hesitating as to the wisdom of bringing low-carb ‘diets’ into a blog about anorexia at all, and I am aware that for some recovered anorexics ignorance may be bliss (or mental health) when it comes to the ongoing debates on nutrition: given that there is no single right answer, and given that immersing oneself in evidence and counter-evidence can easily increase one’s obsessiveness to no very salient purpose, it may be better just to eat what one likes, or what makes one feel good, or what people around one eat, and go no further. I certainly did this myself for some time after recovery, and was happy that way. But I guess that, like me, lots of people in my situation don’t remain happy that way. It’s also simply unrealistic to maintain that no recovered anorexic will ever want to actively modulate his/her own body shape or weight, and it seems to me that being informed is better than being uninformed.

Ultimately, the philosophy of ‘everything in moderation’—so counter to the essence of anorexia—must be key here. In everything food-related, the former anorexic has to be on guard against fanaticism. (This wouldn’t be a bad philosophy for everyone else, either, since dietary fanaticism itself often leads to eating disorders.) The possible gains in cardiac health or hormonal balance of, say, never eating pudding again, are countered by the risks to mental health and the possibility of relapse when any single rule about food becomes uncontravenable.

I like living with an informed perspective on these issues, but I’m careful not to live solely according to the nutritional theory. Taubes argues persuasively, in The Diet Delusion and elsewhere, that human beings (and all animals) aren’t ‘thermodynamic black boxes’ subject to the laws of energy in versus energy out. But we also need to remember that the ‘evolved complex systems of hormones and enzymes and proteins’ that constitute our bodies also bring with them psychological causes and effects, and these may mean having a dessert in a given instance is healthier for the organism as a whole than not having it. The balance is here slightly differently weighted, I think, for those who have had eating disorders in the past than for those who haven’t. Thus I generally eat a diet high in fat and protein and a moderate amount of carbs (my enthusiasm for strength training means I eat more carbs as a convenient fuel than I otherwise would), but there are plenty of exceptions to this general rule, and I cherish the exceptions (the pasta, the chocolate, the alcohol, etc.) as contributing to rather than diminishing the healthiness of the way I eat, seen holistically.

Seen holistically, the functions of food ought also, I think, to be balanced against one another: food is, primarily, a fuel for everyday activities; it can also be a fuel for extraordinary ones; food is a means of moulding one’s body to one’s physical ideals; it is a socially cohesive force and an identity-shaping one; it can alter moods and promote physical health in various related senses; it can be a simple source of pleasure. Perhaps never letting any one of these functions or roles eclipse all the others is the best recipe for healthy eating for those who once had anorexia.

For the anorexic, food is freighted, far more than for most other people, with a great number of value judgements, and its selection, preparation, and consumption are distorted into spectacularly odd forms, from minuscule weighing and measuring and sub-dividing to elaborate accompanying rituals to simple deferral, all supporting the valuation of food as danger or threat to be resisted, or, conversely, ultimate delight to be worshipped. After recovery, food can be released from these shackles of immovable routine, and can be the fuel for happier things—all those listed above, and more. But I think that for anyone who has suffered from anorexia, it’s important to bear in mind that food is none of these things exclusively, or even predominantly, in a healthy body and mind.

Emily Troscianko is completing a doctorate in German at Oxford University, England.

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