Always staying slightly below weight—who cares?
I am a pediatric eating disorder doctor and try my best to see people only until age 21. Why is this hard? Because I have a great treatment team and good treatment is hard to come by, so we sometimes run into deserving and desperate adult patients, whom we simply must refer to adult providers. I say this so that the readers of this blog may put my recommendations into the context of the age group with which I am most familiar, although it is my opinion that this topic is relevant to the adult patient as well.
Starvation affects the brain. Period. These effects are likely to be more damaging the younger the patient, since in childhood and youth the brain is developing, neurons are being pruned, channeled, connected and disconnected, and the effects of the environment are profound during this period of plasticity (for our purposes, remember: food is the environment). An example of this—an extreme example—would be reports of a very few children who were raised until adolescence almost accidentally without access to human speech, and who then were unable to acquire it. There are developmental windows of opportunity, apparently, that when missed, lead to permanent disability.
The effects of starvation on the brain have been well documented, from Ancel Keys in the 1940’s to Debra Katzman (Toronto Children’s) in the present. It is politically incorrect to discuss possible permanent lower levels of mental functioning caused by under-nutrition and frank starvation in children in the third world and impoverished places in the first world. Politically incorrect and terrifying. It is clear that under-nutrition cannot be good—yet as practitioners, many of us contribute unintentionally to this mistake every day.
How? By allowing patients to remain slightly below a weight that represents real physiologic restoration. For fear that they will not be able to tolerate the anxiety of returning to a non-skinny weight/BMI, many practitioners allow adult women, for example, to remain at a BMI of 18.5 (the so-called cut-off for so-called ‘underweight’). Most women will not menstruate at this BMI, at least, they will not have the ovulatory periods necessary for full hormonal restoration. And it is frankly incredible that there are licensed practitioners in this day and age who believe that if you take the oral contraceptive hormone pill and therefore experience regular bleeding, you are “having a period”. This is a delusion, and one with far reaching consequences. Women of all ages need endogenous estrogen to function normally cognitively. That means: if you don’t eat, you can’t think. Please google Dr Katzman’s work if you would like the citations for this. Furthermore, you need true hormonal restoration for normal libido and eventually normal reproductive capacity.
At Kartini Clinic, because we are physicians, we have the advantage of something we call “weight restoration 2.0” : we are able to do fairly extensive hormonal and metabolic testing that supports calculating a weight appropriate to an individual patient’s own biology. A therapist or dietician may not have this access to detailed metabolic studies, but they can support the kind of eating that underlies it (sufficient fat!) and help the patient deal with the anxiety that they are sure to feel as they cross that “phobic weight” threshold of about 90%. Don’t stop there! There’s a lot at stake.
Notoriously, some eating disordered patients (of all ages) will reject some of our best efforts to help them. Some will be satisfied with a less than ideal weight result because they cannot bear to go farther. Well, that’s one thing. It’s quite another for professionals themselves to stop short of the goal. The patient needs to trust us to push them when needed and praise them along the way. But this requires an update of our own databases periodically, since such a strong emphasis on weight restoration flies in the face of what has been taught in the past. But “updating our data base” is what lifelong learning is all about, and these days it is mandatory for professionals everywhere.
If you would like to read more about this issue here are some people to google: Dr Debra Katzman, Dr Emily Cooper, Dr Olga E Titova, Dr. Olof C Hjorth, and you can always follow my own blog at www.kartiniclinic.com where comments, arguments and challenges are welcome.