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In the upside-down world of anorexia nervosa, fear of starvation can cause starvation

Something I wrote for AnorexiaMyths.com after a conversation with its proprietor. I’ve tried to convey the bizarre logic of anorexia in this piece.

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Something that comes up a lot in discussions of anorexia recovery is “energy balance.” This topic is often misunderstood, so I’d like to an

The short version:

Negative energy balance means expending more calories than you consume over some time interval.

We know that persistent energy deficits are harmful for people with anorexia, because they lead to weight loss.

However, there is some reason to believe that short term energy deficits may be worth avoiding too.

I hope researchers will take note; figuring out how energy balance affects recovery seems like low-hanging fruit.

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(This post was sparked by reading the excellent post at AnorexiaMyths.com on calorie labeling in the UK)

Calories on menus. Underweight models on magazine covers. Ubiquitous “keto-friendly” food marketing. Zealous CrossFit advocates. Given this trigger-rich environment, It’s no wonder that those of us with anorexia have such a hard time recovering fully. Right?

I’m not so sure. It’s true that it’s hard to recover from anorexia. Indeed, it was hard for me. But I question whether these external factors are the reason. Yes, they can trigger intrusive thoughts when you're recovering. But even if you manage to avoid diet culture entirely, you’re still going to have plenty of intrusive thoughts. And most of those thoughts are going to come from inside your own head.

Learning to manage (and ignore) your intrusive thoughts is one of the goals of recovery. They come up when you notice clothes fitting differently. Or when you're feeling uncomfortably full most of the time. Or when you feel incredibly lazy for not moving constantly. There will be a voice in your head alternately hectoring with you for ignoring it and pleading with you to pay attention to it again. This usually gets better after a few weeks, but for most people the early days are tough.

Anorexia robs us of our agency while making us think we’re in control. It tells us that we’re weak-willed and fragile even though we’re capable of performing incredible feats of discipline every day. And it makes us think that we can only get better if conditions are perfect.

The illness taunts people who are trying to recover. “Your mother-in-law commented on your weight — looks like you’ll have to go back to restricting.” “Your doctor noted that your BMI has increased — guess it’s time to go back to the gym.” “That actress is skinnier than you were when you were sick — there’s no way you can justify milk in your coffee now.”

Aren’t these taunts kind of lame? “Well, I was going to get better, but then an ignorant person said something to me. I guess I’ll have to keep harming myself.” How could the existence of ignorant people justify self-harm? Anorexia impairs our ability to see through such silly reasoning.

Anorexia will latch onto any available reason to perpetuate itself. In modern Western cultures it usually picks “social pressure to be thin.” But in non-Western cultures it often appeals to “digestive discomfort”. And in the old days it used “religious purity.” The illness doesn’t care what the justification is, only whether it works to convince people to starve themselves.

I worry that every time we say “calorie labels harm people with anorexia” we make it a little more true. Anorexia can weaponize anything. “Look!” it will say, “that menu lists calories. Didn’t you hear that this was a good reason to relapse? It was all over the news. Nobody will blame you!” Don’t get me wrong: I don’t think we should blame people with anorexia for struggling to recover. The illness is at fault, not the person. But we should try to make sure our compassion doesn't give ammunition to the illness.

It would be great if we could rearrange society to accommodate those of us in recovery. But the hopeful message that I want to convey is that we don’t have to. Determined adults can still get better even in an imperfect world. The existence of supermodels doesn’t mean we have to keep suffering. If we have the strength to run ourselves ragged every day, we have the strength to overcome these obstacles.

For what it’s worth, I oppose mandatory calorie labeling because it’s a costly measure that probably won’t reduce obesity. I’d rather not see underfed models on billboards because I don’t find them particularly attractive. And I don’t want to hear about “keto” or CrossFit because they’re boring. It’s good to oppose worthless and annoying things because they’re worthless and annoying; we don’t have to oppose them because we think they make life hard for people with eating disorders. Eating disorders make life hard for people with eating disorders.

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Bella Reed’s Anorexia Myths blog continues to really get it.

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My third piece for AnorexiaMyths.com.

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My second piece for AnorexiaMyths.com.

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Thinking about food all the time but don’t feel hungry? Your brain is trying to tell you something.

I wrote this guest post for the excellent Anorexia Myths website.

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Q&A with a researcher who studies the genetic basis for anorexia nervosa

The excellent Anorexia Myths site has posted in interview with Cynthia Bulik, one of the top AN researchers in the world. I wrote about a study Bulik co-led in 2019. This interview features one question I submitted about follow-ups to that research.

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Is anorexia nervosa a choice? Does everyone with Anorexia have a low BMI? Is anorexia a modern malaise? Is anorexia all about control?

An anonymous mother of twin daughters who have struggled (or are struggling) with anorexia is learning everything she can about the illness and writing about it.

I have to say that she really gets it, and not just because she says nice things about me on her resources page.

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I spoke to Stephanie Dulawa, professor at University of California San Diego, about two articles she co-authored on the subject of Activity Based Anorexia (ABA). The first came out in 2012, and was co-written with Stephanie Klenotich. The second came out in 2021, and was co-written by with Jie

Here is an interview I did with Stephanie Dulawa, who co-authored a paper on animal models of anorexia that I wrote about previously.

If you’re somebody who can run a study on whether mice have body image issues, please get in touch... (I’m not joking; I want to know if this result can be replicated in animals)

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I happened to read Ethan Watters’s 2010 book Crazy Like Us, and was struck by the section about a doctor inducing anorexia in himself in order to better understand his patients.

[Dr. Sing Lee] began to severely cut back on his food intake and skip lunch entirely. He also began an intense exercise routine. Like all dieters, at first he felt the normal drop in energy and mood as his body struggled to make it through the day with a depleted supply of calories. After a few weeks he had lost five pounds, but he still felt like he was dragging himself through his daily routine. After a month and a half of restricting food, he was another five pounds lighter but felt no better. His stomach ached and growled for food.

It was around the three-month mark that some gear shifted in his physiology. His energy began to return and his mood improved—more than improved, actually: he felt great. He was going to bed later and waking up earlier. He performed behaviors that he would have identified in a patient as potentially pathological. As he rode the elevator up to his office every morning, for instance, he did arm exercises on the handrails. He began to feel a hyperalertness and sense of mastery over his body and his life. For much of the day he was on the sort of pleasant runner’s high that one feels in the middle of a good workout. His hunger, which for months had been sounding a deafening alarm, had become a background whisper that he could easily ignore.

He found himself feeling somewhat superior to other people, who seemed to be ruled by their incessant need for food. He couldn’t understand why so many people who tried to diet lacked the willpower to do so. He found that he was inordinately pleased that he had the strength of will to see his project through. The next ten pounds came off with little effort and his friends and family began to comment on how thin he was.

This resonates for me: the same gear shifted in my physiology, and it took many years for it to shift back. I couldn’t break out of the self-starvation cycle until I stopped reinforcing it by restricting and over-exercising.

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Two years

12 months of real time later (39 months of subjective 2020 time) and it’s time for another anniversary.

More than once during this year I've thought "if all this happened two years ago, the only thing I would have cared about was whether I could find a way to exercise with gyms and park trails closed."

That narrow focus seems so tempting when the world is falling apart. When the only thing on your mind is scheduling workouts, you don't worry about people getting sick, losing jobs, and all the other outrages.

So why not go back to that? Nothing is stopping me. I could resume starving myself and working out obsessively. It would be even easier to sneak out of work to go for a run now. Easier to dodge meals when no friends are coming over for dinner.

I don't want to go back because I remember: being anorexic is torturous. I thought I was being high functioning and managing my illness. I had no real sense that I could do better.

But right now I am doing better! Even though everything sucks I'm still happy to celebrate this anniversary. December 2018 was a major turning point in my life, and I'm glad it happened the way it did.

And you! I assume you'll read this at some point. It would be weird to thank you every day, but privately I do. Cryptically in public sometimes too.

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リカバリー

The Japanese language version of my “no-nonsense guide for people who think they might have an eating disorder” site is now available. Many thanks to xiao9259 for doing the translation!

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Translating NoNonsenseGuide.net

If all goes well, the first translation of The no-nonsense guide for people who think they might have an eating disorder into another language will be available soon.

If you’re interested in translating it into your language, send me a note!

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Justification reversal

One thing that those of us with restrictive/hyperactive eating disorders seem to have in common is this deeply ingrained belief that “exercise justifies food.” That is, for whatever reason, we feel like we have to do some unreasonable amount of exercise in order to eat.

For me this took the form of rules that I would follow: Walk x miles before eating breakfast, run y miles before eating lunch, work out z minutes before eating dinner...

It wasn’t so much that I felt like exercise morally justified consumption. It was that I had to obey a bunch of eating disorder demands before I could eat something without going crazy. If I didn’t or couldn’t follow the rules, I’d be agitated for days (and have to make up for any lapse).

This is all much better now after a year+ of recovery. However, the slips and regressions I’ve had in that time all seem to be from reversing my old pattern: letting “food justify exercise.” That is, I feel like because I’m eating regularly, it’s OK to exercise a lot.

Maybe that’s fine for a normal person, but for me it’s a road back to illness. The fact that I’m not skipping meals anymore doesn’t mean I can spend hours each day exercising. The goal is to break the food/exercise link, not just flip it around.

It shouldn’t be a surprise that decades of eating disorder patterns take time and effort to break, but I keep having to remind myself. I’m working through one of these “over exercising” regressions now, and identifying the fact that “I’m using food to justify extra running” has helped.

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Hey, Musing Archimedes! Keep it up!

Yes, you! Good luck with your unrestricting project; I am rooting for you.

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One year later

Anniversaries don’t usually mean much to me. But I’ve been counting the days and months for this one: it’s been a year since I began my “recover from anorexia” project.

Since I don’t really remember a time before the illness, the recovery process has been a major life change. It feels more transformational than becoming an adult did, more than getting married did, and almost (but not quite) more than becoming a parent did.

I think the main reason for this is that having an eating disorder steals so much focus. What should have been notable life events were hard to fully notice - the illness never shut up and let me pay attention to what was important.

In getting better, I realized been living with a form of anhedonia. Recovery has allowed me to actually feel things fully. I’ve experienced a pure sort of joy when playing with my son as he’s learned to walk and talk. And I’ve felt a strange mix of full-scale emotions that I last remember from being a love-struck teenager (this is better than it sounds).

Being properly-fed and properly-rested has had positive consequences - this seems obvious, but anorexia makes you kind of dumb. I’m largely free from the torment of mental hunger, and don’t feel the need to do weird movement rituals anymore. But I’ve also been able to improve my friendships and relationships. And my career lurched forward in a way I didn’t expect. Both of these things I attribute to being better.

I’m not “fully recovered” by any stretch. I can still be tempted into over-exercising. And being sufficiently bored or stressed can send me back into disordered thought patterns. But things are so much better - if you’re someone reading this and wondering if the difficulties of recovery are worth it: yes, they are!