This is a question that has always made me wonder: when is it an eating disorder? And when is it an extreme diet? Or a lot of comfort eating?

Is it the person's ability to stop? An article from Australia details the unhealthy lengths women go to in order to lose weight. Diet pills, fasting, vomiting: unhealthy, no doubt. But what makes something an eating disorder? Self-induced vomiting for weight loss seems to be a clear-cut thing. Yet if it's only once--what about then?

A famous Italian chef admits to binge eating disorder. He is quoted in the article as follows:

"I binge-eat like I used to binge drink," Zilli told The Daily Telegraph. "When I'm not in a good place, when I'm a bit stressed and depressed, I eat chocolate and desserts. Everything sweet. We are weird us chefs. That sends me to the unhappy place where the alcohol took me."

But how often does he do this? Is it the equivalent of a post-breakup sob fest on the couch with a few pints of Ben and Jerry's? Or is it something more regular? And how much of a problem, really, is emotional eating?

Do we say it's when the person realizes there's a problem? Because there's such a thing as both denial (when you know you're sick but don't want to admit it) and anosgosnia, which means you literally do not know that you are sick.

Do we say when there are physical complications? Or is that too late? Too broad? Not definitive enough?

I do understand that eating issues can exist on a continuum, but where do we reach the point between "not the greatest habits" and "Houston, we have a problem"?

Can we draw the line? Should we? And if so, where?

Here's a slightly old paper I found on PubMed that really captures some of my thoughts on the usefulness of amenorrhea as a criterion for anorexia.

Towards a physiologically based diagnosis of anorexia nervosa and bulimia nervosa.

Here is the abstract from the article:

Diagnosis of anorexia nervosa (AN) and bulimia nervosa (BN), while including such physiological data as weight and the reproductive status of the individual, are primarily based on questionnaires and interviews that rely on self-report of both body-related concerns and eating-related behaviors. While some key components of eating disorders are psychological and thus introspective in nature, reliance on self-report for the assessment of eating-related behaviors and nutritional status lacks the objectivity that a physiologically based measure could provide. The development of a more physiologically informed diagnosis for AN and BN would provide a more objective means of diagnosing these disorders, provide a sound physiological basis for diagnosing subclinical disorders and could also aid in monitoring the effectiveness of treatments for these disorders. Empirically supported, physiologically based methods for diagnosing AN and BN are reviewed herein as well as promising physiological measures that may potentially be used in the diagnosis of AN and BN.

I don't think any decent physician will discount a person's personal experiences; those do have meaning in treatment. But when you're confused or unaware of what's really going on, it helps to have some objectivity.

This would also show things like the level of starvation and malnutrition, which, to me, play just as much a role in eating disorders as weight and the presence of menses.

About half of the articles I see on eating disorders are titled "Dying to be Thin." This always irked me, and I started thinking about exactly why.

From the outside, it does seem like sufferers are dying to be thin."I'm not thin enough yet," they say. Or, "I'm not that thin." And perhaps that is what our minds make of the eating disordered experience. Dieting and thinness and virtue are all ideals in Western culture. And we all need to narrate our own experiences. Make it cohere somehow.

As someone who is about a religious as a gnat, framing my eating disorder in spiritual terms is not something that I would ever do. God is not punishing me. He is not trying to make me choose between him and Satan. Praying will not cure me. And I am not starving to get closer to god. I'm just not. I wouldn't say it if I had cancer, and I'm not saying it because I have anorexia.

Yet in the Middle Ages, the "fasting saints" did indeed starve as a means to get closer to god. It was seen as an act of purity and devotion.

Come to think of it, dieting and anorexia are seen like that now. If we stick to our diets, we are being "good." If we eating something we "shouldn't," we have been "bad." And just look at some of the pro-anorexia jargon out there. Purity is a HUGE theme. They have "Prayers to Ana*." Yet fasting is much less a part of organized religion (specifically Christianity) today than it was 500 years ago. The purity is still in a moral and cultural sense, but not as much a religious one.

So thinness is very much about our making sense of the illness. But is it really about the illness?

The more I look at it, the more I'm not so sure. I don't think the "drive for thinness" associated with anorexia is so much an actual drive for thinness. I think it's an intense fear of fatness. If you're scared of being fat, then the obvious solution is to try and be really thin. It's not entirely rational, of course, but there is a kind of screwed-up logic about it. And the terror is intense. I couldn't explain why. I didn't even really get all upset about other people's weights. I judged myself. Period.

Then there's my personal pet peeve about eating disorders being about "control." And like thinness, it sure does seem like it from the outside. Also like thinness, it is more about fear than control. In a way, it's a basic fear of food. If you think food is going to make you fat, and you are deathly scared of fatness, then it makes sense to be scared of food. Many run of the mill dieters are also afraid of being fat (hell, our whole culture is), but people with eating disorders often have a deep underlying anxiety about pretty much everything. I think the fears are stronger, more intense in people with eating disorders. But it's just a theory.

You aren't "dying to be thin." You're afraid of fatness, of your own weight. You aren't "controlling" your food. You're desperately searching for that control, and trying to control your fear of food. You aren't refusing to maintain a normal weight, you are unable to maintain a normal weight.

It's semantics, but it matters.

*I hate hate HATE the word "ana" for anorexia and "mia" for bulimia. It's trivializing. Use the full name or abbreviations like AN or BN. Ana is not a person. It's a brain disease.

One of the big debates for the next edition of the Diagnostic and Statistical Manual (DSM) is the use of amenorrhea as a criterion for anorexia. Some of the issues raised include:

--Girls who haven't reached puberty
--Women in menopause
--Women on oral contraceptives
--Men

Furthermore, even women who meet the weight criteria for anorexia might not lose their periods. This is especially true as women get older. My very well researched slightly random opinion is that menstruation is better established once women hit 20 and older. Which means that it takes more damage to the body before menstruation ceases. There are also plenty of teens who don't lose their periods, and there are plenty of older women who do.

So what are we to make of this? Can amenorrhea be a clinical criterion for anorexia? If it can, should it be?

Researchers at the New York State Psychiatric Institute looked at this issue in recent research published in the International Journal of Eating Disorders. From a clinical standpoint, does amenorrhea really make a difference? They found that women who had lost their periods had a lower lifetime BMI and a lower BMI when admitted to the inpatient unit. However, no other significant differences were found. The researchers concluded:

"These results indicate that amenorrhea does not distinguish between groups on a number of important measures of clinical severity. It may be that amenorrhea reflects weight and nutritional status, rather than providing useful diagnostic information. Future studies are needed to examine the potential prognostic value of menstrual status."
(Emphasis mine)

The bolded sentence leads me to a second study in the Journal of Adolescent Health titled "Irregular menses linked to vomiting in a nonclinical sample." The title basically reflects what they saw: girls who vomited even one to three times per month were 1.5 times more likely to have irregular periods. And this is far from the clinical criteria for bulimia. The risk for irregular menses was 3 times higher for girls who vomited once a week. These findings held true even when underweight and overweight girls were excluded from the sample. The researchers also controlled for "other eating disorder symptoms, weight status, age, race/ethnicity, and school clusters."

Remember: these are not girls with clinical eating disorders. Certainly vomiting for weight control is a HUGE sign for disordered eating. But amenorrhea may be a sign that something is going wrong with your endocrine system.

So perhaps maybe amenorrhea isn't useful as a diagnostic criterion. But it can (and perhaps should) be used as an indicator of issues with physical and mental health.

A short story:

I'm walking down the hall in my office*, and I pass one of my co-workers. A young, female co-worker, to be exact.

She is unwrapping a Snickers bar.

I smile at her as I walk by. She moves her hand to cover the "Snickers" name.

She is ashamed.

How sad. I wish she could enjoy her food without shame. I with we all could.

*Yes! I work in a real office! With real people! Who aren't competing to lose weight! How lovely!

I've seen a number of news articles on a phenomenon charmingly named "drunkorexia." (See here and here). It's the latest in a series of -orexias, such as bigorexia, manorexia, and orthorexia. And while they certainly are related to eating disorders (and in the case of "manorexia," it IS anorexia nervosa, period), I tend to think they overlap with other brain diseases.

It makes me wonder: how well do we, as a culture, really understand eating disorders?

I've read reports of bigorexia. Sounds a lot like Body Dysmorphic Disorder to me. It's also true that eating disorders and BDD overlap, quite frequently. And considering the range of overlap between Obsessive Compulsive Disorder and both eating disorders and BDD, well you have quite a nice constellation of symptoms.

Orthorexia sounds to me like OCD as well. It's OCD about food. You have obsessions about not eating "good enough" food. Or "healthy enough." Or "pure enough." The compulsions? Don't eat it. It's anxiety. I don't know whether people with orthorexia have the same body distortions as those with anorexia and bulimia. They are almost certainly malnourished. So the lack of the body distortions and drive for thinness (or fear of fatness) might be a way to distinguish the two. But we don't know enough about eating disorders, let alone a new syndrome like orthorexia, to even begin to compare.

Yet so many people have a fear of fat and don't see their bodies accurately. So where do we draw the line? There are clinical criteria, and that's important if for no other reason than we can't measure what's out there if we don't know what we're counting.

This brings us back to "drunkorexia." The situation appears to be approximately as follows (forgive the broad generalizations): Girl goes off to college. Girl hears about Freshman 15 to the nth degree. Girl feels anxious about fitting in and being away from home. Girl feels pressure to fit in and relieve some of the anxiety about being alone and friendless. Girl knows the way to fit in is to party and drink. Girl drinks. Girl gains weight. Girl freaks out. Girl makes up for it by eating less. Girl keeps drinking. Girl keeps starving.

Frankly, this is alcoholism and anorexia wrapped into one. Alcohol quells anxiety (temporarily). Starving, bingeing, and purging quell anxiety (temporarily). A woman suffering from both disorders who was interviewed in a New York Times article titled "Starving Themselves, Cocktail in Hand," said this:

“Drinking helped me be less anxious,” she said. “It helped me be more of Trish. The two go together: If I drink more, I’m more into my eating disorder and vice versa.”

So why this epidemic of -orexias? Has anorexia become kind of chic? Or are people ashamed of admitting they have an eating disorder--an actual, true-to-life eating disorder--that they disguise it with cute names to make it (haha) easier to swallow?

What do you think?

A lot of people with anorexia (it's estimated to be about 80%) have issues with exercise and hyperactivity. Some of it is a psychological need to burn calories and lose weight; other parts of this hyperactivity are biologically driven. When rats are deprived of food, they run incessantly on their wheels. I highly doubt the rats are worried if their tails make their butts look fat.

This kind of excessive, compulsive exercise has HUGE damage on the body. It can cause the Female Athlete Triad, characterized by eating disorders, amenorrhea, and osteoporosis. But those are signs and symptoms, not causes. And by the time you see many of these signs, there can already be irreversible damage. I lost my period for only about 9 months, and still developed osteoporosis (which was diagnosed at only 5 months without a period).

Recent research has looked at the role of leptin* in not only appetite, but also in activity-based anorexia. What researchers found was that the lower the leptin levels, the greater the hyperactivity. And since hyperactivity is associated with a poorer outcome in anorexia, finding ways to treat this symptom could help improve the typically dismal recovery rates for chronic patients.

One obvious solution is to treat hyperactivity with leptin. In an animal model of activity-based anorexia, leptin treatments did decrease hyperactivity. Except low levels of leptin are correlated with decreased appetite. Ultimately, the rats still had a negative energy balance Translation: they burned more calories than they ate.

Whoops...

On a more uplifting note, other research has shown that leptin levels normalize with the restoration of a "normal" body weight. Where "normal" here equals the body weight determined by your DNA, and not some formula**. The use of olanzapine (brand name Zyprexa in the US) has been shown to decrease hyperactivity and hence improve the ability to reach a normal body weight. It did help calm the obsessive thoughts in me, only it helped trigger my seizures. Alas.

All of these experiments and discoveries are interesting and crucial (at least to me) in teasing out the causes and effects of anorexia and the malnutrition it causes. However, the most promising treatments are olanzapine, eating a proper level of calories whether you feel hungry or not (when underweight, low levels of leptin mean you feel much less hungry), and prevention of hyperactivity. Some level of activity can help with anxiety. I took brief walks with my mom every day, which was both nice to get outside and relax, as well as have some uninterrupted Mommy-Daughter time. But I also had to make up for the calories I was burning, and as long as my weight remained stable, I was approved for walking.

Because hyperactivity is so biologically driven, so much support is needed to overcome these urges. They're not your fault. And you can overcome them, but you need lots of support.

*Fun factoid: leptin is secreted by adipocytes, a fancy name for fat cells. So as body fat percentage decreases, so does leptin production and secretion. Which enables the sufferer to lose even more weight, and a vicious cycle ensues.
**The formula of 100 lbs for a woman 5 feet tall, and adding 5 pounds for each inch over 5 feet would leave me underweight and batty.

I was looking at Barnes and Noble this afternoon and came across a book of poetry by Louise Gluck (who has become one of my favorites). One of her poems from her chapbook "The Wild Iris" really resonated with me.

Snowdrops

Do you know what I was, how I lived? You know
what despair is; then
winter should have meaning for you.

I did not expect to survive,
earth suppressing me. I didn't expect
to waken again, to feel
in damp earth my body
able to respond again, remembering
after so long how to open again
in the cold light
of earliest spring--

afraid yes, but among you again
crying yes risk joy

in the raw wind of the new world.

We hear a lot about intuitive eating. The premise is one of those "simple but not easy" things.

Eat what you really want.
Eat when you're hungry.
Stop when you're full.
Move your body for fun.

And I do think it's a wonderful goal for recovery. Your ability to do these things (without guilt) is a fine indicator of recovery. See also the pizza test.

However.

However, those of us with histories of eating disorders have a neurochemical difference that makes true intuitive eating kind of dicey at times. There are times when I might not be hungry, when I don't "feel" like eating. True intuitive eating would say to honor your body's signals. But for those of us who find starvation soothing, this might not be the best option.

Enter responsible eating.

My psychiatrist in my last round of residential treatment used an intuitive eating approach. We all had a required amount of calories to eat each day. Unlike many places, we didn't have exchanges, and we didn't even know the range.* This was to help the transition to intuitive eating.

But she also said something to me during one of our sessions (when I had a cold and was griping about having to eat when I wasn't hungry) that really stuck with me. "You might not have the luxury of practicing true intuitive eating all the time. You need to be responsible."

When I had the flu earlier this year, I flat-out didn't want to eat. And even when I did, I was often to tired and achy and ick to actually prepare something. With a horrific sore throat, I ended up eating a lot of these high calorie ice cream sandwiches sold in the party store down the street (they had a chocolate chip cookie on each end- yum!). I knew I needed to eat, swallowing was a bugger, but I couldn't make something myself. Without this insight, I probably would have gone right back to bed and to hell with eating. Yet because of my history, I knew this was the fast track to relapse.

Responsible eating.

Then there are times when looks a little different. I visited the zoo in Chicago with a good friend of mine, and we had decided to eat lunch there. Which was fine. The place we found had some yummy looking curly fries and that was really what I felt like having. With a late breakfast, I wasn't profoundly hungry and guessed the fries would have been more than enough, especially given the huge portion. But I also knew that I needed protein to hold me over until dinner. I know I could have ordered the fries as a side, but I'm not going to pay $5 for something and throw half of it out. Nuh-uh. So I searched the menu for the protein-containing item that sounded the best.

It's a dance, learning how to eat again. I'm a terrible dancer. My sense of rhythm is minimal at best. And this kind of dance isn't any easier, but I'm learning.

*Unless you're a veteran calorie counter, through which you have a pretty good idea. But it's the thought that counts.

I think I've expressed my opinions frequently about the role of food in eating disorder recovery. You need to eat first. Before anything else. Before everything else. Because life isn't all that fun when you're starving. You can't solve problems very well with a malnourished brain.

Food is medicine.

One of my classmates had strep throat a month or two ago, did her week-long course of antibiotics, and recovered just fine. Penicillin was her medicine. But her immune system also had a role in this- gobbling up the dead bacteria, modulating all of the chemical signals that might otherwise have sent her into shock, keeping her cells in balance.

Penicillin was her medicine. Food was mine. But penicillin wasn't enough for her. And food wasn't enough for me.

Yet another tale. I met a woman (S) shortly after I was first diagnosed with anorexia back in 2001. We were in the same support group and quickly became good friends. Although she was in her mid-30s at the time, this wasn't her first bout with an eating disorder. When she was in high school, she also suffered from AN, somewhat briefly. Long enough and bad enough to meet the official diagnosis, but eating disorders weren't on people's radar screens back in the mid-80s the way they are now. She had siblings with mental health issues of their own, as well. But soon she was home sick from school for an extended period of time, and her mom, she said, made her eat.

And her eating disorder did go away. For a time. Yet 15 years later, the old behaviors came creeping back.

Some who criticize the Maudsley Approach, which treats food as medicine, might say that this means eating disorders really aren't about food. If they were, my friend S should have been cured.

Right?

My guess is this (I haven't asked S about it, so I can't say for sure): S quelled the AN voice by promising that this eating, this indulgence, this gluttony, was only temporary. Soon enough, she might have said, I will be back with you.

It's what I said every time I was in treatment. Obviously, I knew I had to eat in the hospital. I didn't like it (especially because the food sucked), but I did it. Part of it was the grim inevitability of it all: eat or be tubed. Yet it was easier than doing it at home, and not just because of the support. It was easier because I knew it was temporary. I'll use the damn butter, drink the whole milk, eat the pizza but only while I'm here. When I got home, I knew I would go back to my old habits.

When I began eating at home, it was harder mentally because I knew there was no getting out of it. I would have to start making peace with butter, because it wasn't going anywhere.

Part of the difference between S and I was that I had a diagnosis. I had support. She did not. S didn't know the cruel voice was anorexia, and she didn't know how to fight it. She didn't learn how to nourish her body properly, even when her brain was telling her to starve. And she didn't have to face the inevitability of butter.

That might be, in part, why bringing my recovery home was so important: I learned to survive the peaks of anxiety. I rode the waves and survived. The butter itself was more important than just a source of much needed fat. It was the knowledge that I could eat it and life would go on.

I hear a lot about self-esteem in therapy. "Work on your self-esteem," they say. Do affirmations. Give yourself a manicure/pedicure. Take a bubble bath.

Um, okay.

Not that these things are bad at all. But they're not me.

I saw this article awhile ago, then, and was intrigued. "Be kind to yourself and cure your eating disorder." I have no illusions (never did) that being nice to myself would magically cure me of anorexia. If only!* However, ED professionals in the UK are pioneering a new therapy called Compassionate Mind Therapy (CMT) to help people "develop strategies to treat themselves in a compassionate way." CMT seems essentially a form of cognitive behavioral therapy; here, instead, you replace ineffective/harmful behaviors with ones that are more compassionate.

One of the psychologists using CMT with his patients had this to say:

[He] thought that this would be a good focus for the work he was doing with patients with eating disorders: “They experience high levels of shame and self-criticism, and CMT helps people to develop the ability to soothe themselves at times of emotional distress. For example, bingeing is often used as a way of promoting a positive or neutral emotional state to avoid anxiety, anger or shame. If people can activate the self-soothing system they won’t need to engage in bingeing to manage difficult feelings.”

Gilbert explains that it is a case of replacing one set of emotions with another. “So instead of self-anger or contempt, there is self-kindness and warmth. This is
the same as in therapy for anxiety in which people are taught relaxation
exercises because they can’t feel anxious and relaxed at the same
time.”

Interestingly, part of dialectical behavioral therapy (DBT**) involves emotion regulation and self-soothing. And researchers at Duke found that self-compassion worked better at helping people deal with negative events.

Many people with eating disorders are perfectionists, people who tend to criticize themselves relentlessly. So even if therapies like CMT don't help you recover, per se, it can help you stay in recovery and learn better life skills to prevent relapse.

*I have major problems with this headline. When will they say "Food cures anorexia"?
**Don't you just love acronyms?

Spammers:

I would say "please stop" but I don't know how many manners you have in the first place.

Let me make one thing straight: this is an eating disorder recovery blog. Diet and fitness solicitations are NOT WELCOME. EVER. Period. You wouldn't post booze ads (I hope) on a blog for recovering alcoholics. Don't post that shit here. It's the same thing.

As soon as I see the comments, I will delete them.

Obviously, if you have an ED recovery blog yourself and would like me to look at your site, don't be discouraged. By all means, let me know.

But if you're shamlessly hawking your wares, don't bother. I'm not interested. Go bug somebody else.

The Nintendo Wii-Fit is (apparently) all the rage right now. I've see the ads on the tops of the taxis that drive by in my city. I've heard a bit of the hype in passing. Otherwise? I couldn't be bothered.

Then again, I grew up on Atari and Frogger, so go figure.*

The idea of Wii-Fit is clever and interesting, and it's not something I would flat-out refuse to consider buying. Until I read this: the machine measures your BMI. And then tells you whether or not you are fat.

I guess that throws the whole fit-and-or-fat debate right out the window, huh?

You tell the little Wii-fit machine your age** and your height, and the platform you exercise on weighs you, spitting out your BMI. A number, of course, is not enough. You see, to the people at Nintendo, BMI isn't arbitrary enough. No. The Wii-fit has to then tell you whether your are "underweight," "normal," or "fat."

That's right. Not "overweight." Not "obese." Fat.

Now I am all for making fat a less loaded term. It's an adjective, that means the opposite of "thin." But that's not how most people use that word anymore, nor is BMI a rock-solid indicator for the amount of fat you have. And the Wii-fit measures your BMI each time you play. A person's weight can fluctuate up to five pounds each day. So a machine that tells you fat/normal/fat/normal/normal/normal/fat/fat is just a super-quick way to become utterly paranoid about your weight. As if we weren't before.

With any sort of fitness equipment, there's a bit of a caveat emptor. But the Wii-fit is also marketed at children, specifically those children who are taking our country to hell (hell, I tell you!) because they have velcroed their fat asses to the sofa to do nothing more than stuff potato chips in their faces and suck down gallons of Coke. Because we all know that's just what kids do these days.

Never mind that more children than ever are involved in athletics. But that's beside the point.

The issue was raised when a man's healthy, active, fit ten year old daughter (weighing 84 pounds) was told she was fat after playing Wii Fit. Thankfully, for all of the other families out there, he cried foul, bringing the issue to media attention.

BMI for kids is random and arbitrary at best. Tam Fry, of the National Obesity Forum in the UK, had this to say about the Wii Fit:

"I'm absolutely aghast that children are being told they are fat," he said. "BMI is far from perfect but with children it simply should not be used. A child's BMI can change every month and it is perfectly possible for a child to be stocky, yet still very fit.

"I would be very concerned if children were using this game and I believe it should carry a warning for parents."

Wii-fit doesn't need to measure your BMI to work properly. I'm no super-geek (at least not in the tech sense), but I can't see why the machine would need to know your BMI and then rate you accordingly in order to work. Rather than a warning, parents should be allowed to disable the feature. I don't think this will give anyone an eating disorder. But it can be one more step on the way to anorexia or bulimia. And I do see MUCH potential for it to be abused by a young person with an eating disorder.

So unless Nintendo starts sending the Wii-Fit to medical school (and it can start writing refills for some of my meds, which would be mighty convenient), it shouldn't tell me whether I'm fit or fat. That's just Wii-diculous.

*Yes, this dates me. Horribly. But, damn- wasn't Frogger great?
**Isn't that silly thing supposed to know you aren't supposed to ask a lady her age? Methinks Nintendo doth protest too much...

No seriously, admit it: this little guy just made your day.



And get some more Joe-Joe action here:





(h/t to Emmy for the first Joe Joe video)

Recovery is...

• Visiting a friend for the weekend without bringing a list of what you will and won't eat.
• Buying a muff-cake (muffin-cupcake) at the store because it looked yummy, eating 3/4 of it, and finishing the rest later. With a cup of milk.
• Looking at your butt in the mirror and freaking out and thinking ewwwww. And then getting the hell on with your day.
• Finding recipes to cook and then eat, rather than cook and drool over or cook for someone else.
• Deciding you would rather snuggle with your cat on the couch than workout. You feel guilty and then? Get the hell on with your day.
• Drinking copious amounts of coffee WITH breakfast rather than FOR breakfast.
• Letting yourself take Advil when you need it, rather than waiting for meals/snacks because you need to eat food so the pills don't dissolve your stomach.
• Evaluating your health in terms of what you can do and how you feel rather than what you weigh or what you eat.
• Messing up, freaking out, feeling guilty, and getting the hell on with your day.
• Staying up late and reading, just because.
• Going to bed early, just because.
• Never perfect, but better than the eating disorder.

I was out of internet contact for the last few days and didn't get to wish everyone a Happy Mother's Day.

First of is my mom, who literally kept me alive the past 8+ years of the anorexia insanity. She never gave up, even when I had, and so did many treatment professionals. "Carrie is chronic," they said. To them, chronic anorexia means hopeless. Not to my mom. She didn't think it was weird to have her 26-year-old daughter move back home (with her kittycat!) into her childhood bedroom and be totally dependent on her parents once again. And then to take all of the late night hysterical sobbing phone calls from the now 27-year-old daughter after she moves out.

Mom, seriously- you saved my life. "Thanks" is so hollow compared to what I really mean, but "thanks" will have to do.

Next up are all of the other moms in my life. The phrase "It takes a village" has become kind of ridiculously cliche, but it's SO TRUE. You have all taught me so much about how to be a person, not just an anorexic. So a little shout-out to:

Laura
Harriet
Jane
Mary
Marcella
Irishup
Tracey
Stephanie

I am honored to know you all.

One of the most common features of anorexia is an inability to see that you are sick. I don't have a problem, no, no. You're the one with the problem. Worrying too much. Freaking out over nothing. Oh, I know. You're jealous. Right? Aren't you jealous?

Losing weight was NOT my problem. Was not a problem, in my mind. I set out to lose weight, and damn did I succeed. So how could this be a problem? I still have trouble seeing the huge fuss. I wasn't that sick. Was I?

(My mom is nodding her head yes. Yes, Carrie, you were. I can just see it.)

And yet. Yet I did understand several things. I was lonely and miserable. My hair was falling out. My skin was a pale yellowish-gray color. I was always cold. I had no energy.

But I was losing weight! I was losing weight, dammit.

This is known as "illness intrusiveness," a measure of how much you believe your illness (anorexia, depression, cancer, etc) is impacting your life. They can measure this via questionnaire, and a group at the University of Toronto indeed did just that. They compared illness intrusiveness in people with anorexia to intrusiveness in people with other psychiatric and medical conditions.

Lo and behold, they found that people with anorexia found their illness to be much more intrusive than other patients also hospitalized with other conditions. So even if they weren't able to say, "Gee, I think I'm losing too much weight. Better go have a sandwich!" there was a tacit understanding that the eating disordered behaviors were problematic.

I don't know if this was a universal feature of people in this study, and it likely wasn't. And therapy should not be hinged on this recognition. It often isn't enough to let individuals "choose" to recover. But it can help.

A group at the Maudsley Hospital in London is looking at a technique called motivational interviewing. My first thought was of Stewart Smalley on Saturday Night Live (you know, back when it was still funny), staring in the mirror with his little cardigan, saying, "I'm good enough, I'm smart enough, and doggone it, people like me."

Not quite.

Rather, this technique can help people make positive changes as they move forward with eating disorder recovery. When used properly, it can help provide perspective on what patients might be missing by continuing with the eating disorder--much like it might be used with substance abusers.

But trying to show a heroin addict what he's missing when he's high as a kite isn't going to do you any good. He needs to detox. For a person with an eating disorder, they need to be eating regularly, not engaging in other ED behaviors and at a healthy weight (that is, detoxed) before this really reaches its full potential. I see it being really useful in adults with eating disorders, people who might not otherwise be willing to embrace recovery or have someone to give them that shove forward. Something to keep you afloat in those waves of anxiety can be priceless.

Many of the neurochemical differences in people with anorexia seem to be related to changes in the brain circuitry that moderate hunger and satiety. It's more complex than that, but there's little doubt that this changes are hugely important in anorexia and ANY eating disorder.

Researchers at Duke University recently released a study about the relationship of a brain enzyme to appetite. This particular enzyme helped to make ghrelin, a hormone that signals fullness. When a mutation caused this pathway to be blocked, no ghrelin was produced and the mice at significantly less and, shocker of shockers, they lost weight.

The study was, of course, framed in the context of weight loss. To some extent, this makes sense; after all, weight loss was one of the primary results in the mice. But this is being touted as a new finding to "combat obesity." Indeed, the first sentence of the press release was:

Imagine being able to tone down appetite and promote weight loss, while improving the body's ability to handle blood sugar levels.

But appetite and weight regulation are likely more complex than this. I would ask several major questions should research be done in humans: is maintaining a lower weight than appropriate any better than being at a higher weight that has been determined by your genes? And what happens when you stop taking the pill that blocks the ghrelin pathway? I would think you would gain the weight back, but I'm sure the pharmaceutical industry would just love this fact.

One should also note the links to Duke's well-known weight loss center on the page with the press release.

What struck me, however, was the possible relationship with this gene mutation and anorexia. Abnormalities in levels of ghrelin and leptin (which functions as the opposite of ghrelin and stimulates fullness) have been found in people with anorexia. I've been asked a lot (usually with a tone of wonderment): how can you eat so little for such a long period?

Hell if I know. But maybe my brain does.

Certainly, people with eating disorders still feel hunger and fullness. Yet they might feel hunger less often and fullness faster once the chain of events gets started. Before my eating disorder started, I think I ate pretty normally. I had my quirks--one of my favorite snack was pretzels mixed with mini marshmallows--but I think I felt hunger and fullness just fine, thank you very much. But then the weight loss started. Just a little bit. And all of those abilities went a-flyin' out the window.

Of course, eating disorders are likely far too complicated for one gene or one enzyme. There's almost certainly much more going on than that. But finding these genetic differences may help determine who is at risk, and better ways to treat the illness.

Today was International No Diet Day, a day when you should honor your body, eat what you want, stop when you are full, and move your body with joy.

I had a therapy appointment today, and part of what came up was the continuing anorexic thoughts that I have. I've been at a healthy weight for a little over a year, I'm eating a wide variety of foods, most of the time I eat enough fat, I exercise moderately--in a nutshell, all of the things that I am "supposed" to be doing in recovery.

So what gives? Why, after all this time, do I still instinctively want to restrict? Why, in times of stress, do I want to exercise like a madwoman? Some of it, I know, is how my brain is wired. But I had hoped that after a year of all of this turmoil, it would get a lot better.

And it has gotten somewhat better. Somewhat. But I still have to talk myself through a lot of things. I still have to remind myself that butter is not something that exists for the sole purpose of decorating my fridge. That I can cook with it. Put it on my bread, or baked potato. I have to remind myself that exercise feels good, but only as long as I don't overdo it. Sometimes I still get horrifically anxious if I can't exercise as I had planned. So I sit myself down and have a long pep talk with myself and try to get through it.

No wonder my roommates all used to think I was whacked. Luckily Aria doesn't seem to mind.

Yet all of these thoughts are a several-times-a-day thing. I had hoped they would be more fleeting. Can I manage them? I suppose- I've been doing it for a year now. But it's exhausting, and I'm tired of it. Not tired enough to give up recovery, however. Just tired in the sense that I have this plaintive question that remains: when will it get easier?

My therapist reminded me that, considering I've been sick for almost 8 years now, it's going to take more than just a year of a healthy weight and eating properly for the thoughts to go away. Which, okay. I do logically get that. I'm just frustrated with it all. I had hoped I would bounce back more quickly. I guess, ultimately, I'm having a hard time accepting how ingrained the AN thoughts were/are. I don't like to think about that.

I can function on the outside, and that's something. That's an achievement. I can go out with friends, even if that going out involves dinner. But it's still just so damn hard. And I almost wish that the inner turmoil was more visible, that yes, I look and act moderately normal, but my head is still a little screwed up.

I was also reminded that the thoughts may never fade entirely, but I will instinctively replace them with positive reminders of why I need to eat. That it won't be such an effort. I'm not entirely thrilled with that thought, but if it does become my reality, I can at least figure out ways to deal with it.

I used to be told that the eating disorder would end when I chose to end it. Obviously, I have several problems with this. First of all, someone with an eating disorder can't just randomly "choose" to start eating again. Believe me, if we could, we would. But secondly, I can't totally control how long these thoughts will stay with me. I am ultimately in charge of managing my recovery. I am ultimately responsible for feeding myself properly, for ensuring I don't start exercising compulsively. These behaviors will have a HUGE impact on whether the AN thoughts go away. But I can't control how long the thoughts will stick around.

All I can do is remind myself that if I want to get well, I need to stay at a healthy weight. And I can certainly start losing again, but that will just mean I'll have to gain weight again. The relief of restricting is NOT equivalent to the torture of weight restoration. So I'll have to sit it out, and get the hell on with my life.

I was reading the book "The Ancestor's Tale" by Richard Dawkins (an impressive tome in which the reader goes on a virtual time-travel back through evolution), and I stumbled across this little gem in the section known as "The Salamander's Tale," the excerpt of which has nothing to do with salamanders.*

"Many Western countries at present are suffering what is described as an epidemic of obesity. I seem to see evidence of this all around me, but I am not impressed by the preferred way of turning it into numbers. A percentage of the population is described as 'clinically obese.' Once again, the discontinuous mind insists on separating people out into the obese on one side of a line, the non-obese on the other. That is not the way real life works. Obesity is continuously distributed. You can measure how obese each individual is, and you can compute group statistics from such measurements. Counts of numbers of people who lie above some arbitrarily defined threshold of obesity are not illuminating, if only because they immediately prompt a demand for the threshold to be specified and maybe redefined...Nevertheless...our brains evolved in a world where most things do fall into discrete categories."

Dawkins' stance on size acceptance is really not the point here. Rather, it is the almost innate habit of humans to put essentially anything and everything into one of two categories.

Fat or thin.
Healthy or not.
Tall or short.
Dead or alive.
Rich or poor.
And so on.

Companies and advertising take advantage of this. One of the banner ads at the top of my emails sometimes read: Are you fat or healthy? As if you can't be both. Or neither. The irony is that most of us fall into some middle ground, neither rich nor poor, short nor tall, healthy nor unhealthy.

And not only do we want to categorize other people, we also want to categorize ourselves. We ask: am I normal weight, overweight, or obese?** I saw a book when I was browsing at Barnes and Noble yesterday that was titled, "Eat This, Not That." Very dichotomous. But frankly, I don't like either Big Macs or a Baconator, the two choices of burgers on the cover. I didn't look further in the book, but I got the basic premise.

Even more, one of the two categories is always more highly desired by society. It is also harder to achieve, which is perhaps why it is so highly valued. The harder it is to place yourself in a category, the more a company can sell you products to move yourself into said category. If you're not beautiful, you're ugly. It's very hard to be considered beautiful in our society. Your eyebrows must be perfectly plucked, no wrinkles on your skin, always wear makeup, style your hair, etc.

And how much money is made by selling products to de-wrinkle your skin, find the perfect foundation/mascara/eye shadow, hair dye, hair gel, curling irons?

A lot. A whole freaking lot.

Especially when we're younger, our brains are very black and white. We haven't yet mastered complexities and nuances of such things. Because this drivel is continuously driven into our heads by companies and culture, it gets harder and harder to break free.

This is where teaching kids about "healthy eating" and "healthy body weight" gets dangerous. A 5-year-old is not equipped to know that eating a slice of cake--even on a regular basis--is fine, but a steady diet of buttercream frosting isn't. Cake is bad. Cake is unhealthy. These two things are now considered exactly the same.

If you are either fat or thin, healthy or unhealthy, and thin=healthy and thin=desired, then you will want to be thin. Above all else. Kids aren't stupid. The pecking order on the playground is brutal. Fat is not looked upon favorably.

We could tell our children to eat a wide variety of foods, and to enjoy them. We could tell them that human beings come in an array of shapes and sizes. We could. But we also feel the need to pare information down to the most basic level, at the expense of the message itself. Healthy or not. Fat or thin. If teachers are always talking about dieting and weight loss, kids begin to think it's normal. And if "everyone is doing it," what's wrong with my thinking that?

The issue is first that this is taught at all. Good food/bad food is totally arbitrary. Margarine used to be thought of as "better" than butter because it had less saturated fat. Now "butter is better" because margarine has trans fats. In the 1980s and 90s, fat in general was the culprit of all of society's ills. In the 2000s, it's carbs. The second issue is that it is taught too soon, where your brain can't yet sort out all of the information properly (or that it's so diluted that you don't get all of the proper information). And the earlier kids are brainwashed into thinking this way, the more it is reinforced, and the harder it is to break free.

Even we as adults have a hard time breaking out of this mentality. It has been so reinforced that it seems almost instinctual. And because this dichotomous thinking has been honed by millions of years of evolution, the either/or concepts are quite natural. But if we have evolved speech and calculus, I think our brains are up to the challenge.

*The structure of the book is based on Chaucer's Canterbury Tales- an interesting choice for a hard-core atheist. But I digress...

**These online tests might tell you, after you plug in the numbers, that you are, in fact, underweight, but it never asks you that outright. Just the three choices above.

There has been quite a hullabaloo in the size acceptance world about a study that was released earlier this week in the Archives of Internal Medicine. The study, titled "The Joint Effects of Physical Activity and Body Mass Index on Coronary Heart Disease Risk in Women," spawned dozens of news headlines, like "Study Gives the Skinny on 'Fit but Fat'," and "Exercise-heart study casts doubt on 'fit but fat' theory."

Which basically did nothing but add fuel to the fire of the diet hysteria that is engulfing the nation. Granted, the fire is burning sufficiently hot that it's kind of like adding kindling to a kiln, but we don't need any more, either. Much of the response to the study and the articles have been of the moralizing-from-the-high-horse philosophy. We TOLD you that you needed to get off your fat butt and lose some weight. NOW look at the pickle you're in.

Many people--even those in the health profession--look at the idea of "fit and fat" as kind of a cop out by fat people. It might not be what they directly say, but much of the thinking on the subject tends in that direction. It's an excuse, they think, by fat people who just have no willpower and can't lose weight. Except that dieting isn't about willpower and desire; millions of years of evolution can trump willpower and Jenny Craig in a heartbeat. Your brain doesn't want you to starve* and will take every effort to make sure that you eat.

And yes, dieting is a form of starving. Maybe not the Ethiopian kwashiorkor kind, but if you're not eating enough, even a little less than enough, your body and brain go into starvation mode.

So whatever the response to this study is, there remains the simple fact that DIETS DON'T WORK and there is no proven method to make large groups of people lose weight and keep it off long term.

Where are we left, then?

The study itself has some serious flaws, and I will leave it to other people with more time to deconstruct it. But even if the results of this study are true, even if they are, what then?

It might just be an inherent genetic risk factor. You can't do anything about the weight your genes want you to be at. I think of it this way. I have very fair skin- to the point where I tend to glow in photos. I have to look for cover-up in things like "ghost" shades. I got fair skin because my family ultimately hails from northeastern Europe. It means that my risk of skin cancer is higher than those who have darker skin tones.

There's not a damn thing I can do about this. I wear sunblock religiously to reduce my risk. I stay out of the sun the best I can during the most intense hours. But it's part of the genetic draw. I likely have other traits that might reduce my risk for other diseases. Again, I have no control over this.

So if your weight is meant to be at the upper end of the spectrum (or even higher than our society deems "healthy" or "acceptable," which is, you know, practically everyone), it might raise your risk of heart disease. There's no evidence concluding this for sure, but for the sake of argument, let's say there was this evidence. Just like my fair skin/skin cancer combo, it might just be something you have to accept. Not in a oh-crap-I'm-doomed-forever kind of way, but in a proactive way. Enjoyable physical activity is an important part of health. So is sunblock. It can reduce your risk of disease for which your genes might otherwise put you at higher risk.

This study, true or not, doesn't mean that you need to go out a diet. It would be like me using that spray-on tanning stuff (and orange you glad I did!). My skin color might be darker, but it would do precisely nothing to reduce my risk of skin cancer. Dieting won't help reduce your risk. At best it will make you batty and cranky. At worst, it will put you at risk for developing an eating disorder and ruin your physical and mental health.

The take home message remains the same: accept your weight, regardless of your size. Take care of yourself. It's the best thing you can do for your health- and your sanity.

*Unless you have the peculiar neurochemistry that makes starving, I don't know, preferable to eating.