WHEN FOOD HURTS

I’d like to discuss a topic that nearly everyone has experienced at some point in their lives, but that many others live with chronically: Negative physical reactions to consuming food, even very nourishing food. So often we talk about hunger and we might assume that the natural anecdote to hunger is, ultimately, to eat. But what happens when eating regularly leads to symptoms like reflux, gastric and abdominal pain, bloating, distention, gas, constipation, diarrhea - the list goes on.  Despite these being very common occurrences for a large number of people, it can take months, years, sometimes decades to address the underlying causes - of which there can be many - and receive appropriate treatment and relief. Hunger can be painful, but so can nourishment. And determining the right way to balance hunger and nourishment has physiological repercussions but also psychological underpinnings, often from our earliest feeding experiences.

For conditions like Irritable Bowel Syndrome or IBS, for instance, a cluster of symptoms affecting up to 15% of the US population, it wasn’t until the last few decades that many clinicians began to recognize it as something clinically valid and not all in patients’ heads, given that the effects don’t show up on any diagnostic test or exploratory procedure. Diagnosis is instead a process of elimination and treatment is based on careful monitoring and evaluation of a patient’s individual triggers. For some, triggers might be alcohol or caffeine. For others, fried/fatty foods or even food volume can have a tremendous impact. And for many others, stressful situations can induce a flare of symptoms, seemingly out the blue. What’s even more challenging, however, is that the root cause of IBS is still being researched. We know that people with IBS have an inherent disconnect between the Central Nervous System, or the brain, and the Enteric Nervous System, or the nerves that weave throughout the gastrointestinal tract. We also know that, as a result, the gastrocolic reflex in people with IBS is dysfunctional, meaning that when food enters the stomach, the colon contracts in spastic ways that are not seen in typical digestion. 

The gut nerves of people with IBS are more sensitive to the presence of food, or liquid, or gas, and so normal digestion and colonic contractions often feel particularly painful. There is also ongoing research suggesting that the gut microbiome, or the population of bacteria that lives in the digestive tract, is notably different in people who suffer from IBS. Whether this is causal or an effect of IBS remains to be seen. But what I see over and over are eating disorder clients who also suffer from very real, very painful gastrointestinal conditions like IBS and slip through the cracks because many of these symptoms mirror those symptoms inherent in eating disorder behaviors and recovery. So it follows that re-introducing food in someone who has a condition like IBS might be more viscerally painful, and this requires tremendous sensitivity and attention. There may be foods that an IBS-sufferer genuinely cannot eat without experiencing exceptional flares, and this is not because it is a so-called “fear food” as a part of the client’s eating disorder. It’s incredibly important to listen to the client and believe the client when they report that eating certain foods causes intolerable pain, and to help discern which symptoms might be driven by an underlying condition and which might resolve with eating disorder recovery.

Another condition I see more and more frequently in my practice is Mast Cell Activation Syndrome, or MCAS, which research shows likely impacts 20-25% of the eating disorder population. This is an immune condition where immune cells called “mast cells” over-react to environmental triggers, including food, can manifest in nearly every organ system in the body, including the gastrointestinal tract. It can be brought on by trauma or stress, like that of starvation in an eating disorder, or by infections like mold toxicity, Lymes Disease, and even COVID. Because MCAS is still in its infancy as far as research goes, it is often overlooked or even dismissed by clinicians, and remains an undiagnosed factor impacting how clients are or are not able to eat. For this reason, MCAS can both precipitate eating disorders or manifest as a result of them.

So if conditions like these are overlooked, not only do we run the risk of a missed diagnosis, but we allow our clients to needlessly suffer, sometimes for years, while they shuffle in and out of eating disorder treatment. And while neither IBS nor MCAS is 100% curable as of this publishing, there are very well-studied, viable ways to manage and treat these syndromes and significantly improve the ability to eat for many who suffer. Working with an eating disorder team that is trained in recognizing and treating these conditions is vital to make sure the entire person is being considered.

A final word about conditions like these that impact the digestive tract: Many people have suffered from these conditions since their earliest years, sometimes since infancy, and their experiences, whether conscious or unconscious, have had a tremendous impact on every aspect of their lives, including how they formed their earliest relationships and how they continue to move in the world as adults. It is said that the way we do one this is the way we do everything, so it becomes quite crucial to look at our patients through this lens, in order to understand how we can best assist and how we can use the clinical relationship to heal, too. 

“ONCE I START, I CAN’T STOP”

When it comes to food restriction - through dieting or in some more clinical eating disorders - clients often express a sense of fear: They limit themselves because once they start eating, they won’t be able to stop. And then when they do allow themselves access to food more freely, their worse fears are confirmed! The entire package of cookies or box of crackers or bag of chips disappears, despite their best efforts to “eat just one serving”. So what is going on here? It can be maddening because, to the client, it feels like they are failing miserably at something that should very much be under their control and that if they’re just more disciplined, just have just a *little* more willpower, or distract themselves, they can resist the temptation to eat the entire box.

One of the things I can say with near certainty is that when I see this pattern, I look for the other side of the coin: Where is the restriction? Restriction and then subsequently eating more than feels comfortable in one sitting (sometimes called ‘bingeing’) go hand in hand and here’s why: Our bodies require pretty specific amounts of energy (or calories) to function from day to day. This is not just for the visible activities we take part in, like planned exercise or movement in our daily lives, but also for the invisible processes that we might not even think of, like brain energy, cellular repair, organ functioning, and a whole host of other micro-level activities that take up the bulk of our energy. And through evolution, the body is primed to seek enough energy everyday to meet these needs.

So I think of our bodies’ energy intake like a pendulum: Eat less than our body optimally requires to survive and the body will literally drive an increase in energy intake, not just “sufficient” to meet needs, but often more than what the body needs because it is making up for a deficit. The body does not care if this is an intentional deficit, as through dieting and restriction. It just knows, “Ah, we did not meet our needs today so we will try to get as much as possible to compensate and even excess, to serve as an insurance policy, should this deficit continue to happen.” This is the swinging pendulum of restriction and then feeling unable to stop at 9pm at night when the body has taken in only a fraction of its energy needs. And because the body has evolved with this safety mechanism in place for millions of years, it is always going to win over our so-called “willpower” - what we “think” is best for us. 

You can think of it this way: Imagine you’re trekking through the desert and have run out of water. The sun is burning down, your throat is parched, you’re dehydrated and exhausted. When you finally reach an oasis, you throw yourself down in front of it and take huge gulps of the fresh, cool water; not polite little sips. And you don’t think, “How silly - I don’t usually need this much water.” Instead, you know require more because you’ve been in a deficit all day and you’re compensating for this. The same is true for food energy. But instead of feeling dehydrated, you might be tired, irritable, brain foggy, or generally unhappy. Or perhaps you feel euphoric! You’ve survived on so little! You must be superhuman! And then you watch, almost in a trance, as your body walks to the cupboard and pulls out the snack foods and begins to devour them greedily, like slurping water from the oasis. This is what we could call your “Starvation Brain” or as Dr. Jennifer Gaudiani coined, your “Cave Person Brain” kicking in to gear. It is our most primitive survival brain, evolved to keep us alive. Again, Starvation Brain does not care that we are on a diet. It does not care that we are perfectly content to eat less than our body needs to function optimally. All that brain knows is survival. And it will win out every single time.

So what’s the solution? How do we interrupt the cycle of not being able to stop eating something one we start? Let’s return to the image of the pendulum. A pendulum swings because at one point, it was held to one side (or restricted) and then released so that it swings with equal and opposite force to the other side of its arc. But what happens when we stop interfering with the pendulum? Eventually and inevitably, it always settles in the middle because that is science, a law of physics (don’t ask me which one!). The exact same thing is true of our bodies. When we stop interfering with the ability of our energy expenditure and intake to roughly match one another, we allow our hunger and fullness drives to settle too. And this does not necessarily happen each and every day. There is a wonderful study from the 1980s that charts the milk intake of an infant over the course of several weeks and of note, the intake is wildly different from day to day: 20 oz one day, 15 the next, 28 the next and so forth. But what is remarkable is that the *average* was essentially the same from week to week, allowing for very normal and predictable growth on the infant’s growth chart. The same is true for adults: We might eat more one day at a party because the food is different, tastier, more exciting than what we typically have access to. And then the body will ON ITS OWN compensate over the course of days or a week by eating a little less. We don’t need to DO anything - we just need to keep allowing access to a variety of food throughout the day and let the body’s hunger and fullness cues take over.

One important note, if you have been controlling your food intake, rather than letting your body do its job, it can be challenging to get back into the swing of trusting your body to settle where its supposed to. This is where enlisting a trained Dietitian can become helpful - to relearn what its like to allow the body’s energy pendulum to swing freely, and to get in touch with how that feels. It’s sort of like re-training, getting back into the body of that infant who knew when to start and stop drinking milk, even without a blueprint. 

WHAT ARE WE REALLY WEIGHING?

This past week I’ve had a lot of clients bring up their scales. And it made me wonder, with household scales, whether for body weight or for weighing food, what are we really weighing? And how do the numbers on a scale potentially serve as fillers for something deeper that perhaps cannot be measured so easily?

When we’re out of touch with what we’re feeling, sometimes we unconsciously seek ways to express those feelings. And the scale could be one such way. Because a scale is concrete science, right? I had to look up the actual definition of weight, which reads: Weight is the measure of a body's relative mass or the quantity of matter contained by it, giving rise to a downward force; the heaviness of a person or thing. So we’re essentially measuring our own heaviness and what we contain.

I don’t know about you, but I use the word heavy to describe a mood sometimes, or even to describe the state of the world, or to express the impact of some piece of unsettling or unpleasant information - that’s really heavy, I might say. Could we be using the scale to measure how heavy we feel in relation to something, perhaps even something intangible or so far, unknowable? And if the number on the scale goes down, it often lightens our mood too, right? We’re both objectively and subjectively “lighter”.

What about measuring what we contain? What if we could measure or quantify our emotions: Our anger, our sadness, our pain, our loneliness, on a scale, making it visible, and tangible? Could that be partially what we’re attempting when we weight ourselves? It can be terribly disappointing to see what we contain - all of our doubts and fears and aggression and destructiveness and narcissism - all normal human traits that tend to bring us shame and guilt, that we are generally pretty careful to keep at bay and hidden from public view, sometimes hidden from our own view. And sometimes we say, “the scale doesn’t lie” and maybe that’s the inherent dilemma of the scale: It captures our “heaviness” even when we try to hide it from view.

On a practical level, the scale is also measuring what we’ve taken in - food scales can capture and regulate how much we take in to ourselves. And the body weight scale captures the aftermath: What we’ve allowed in or haven’t allowed it. And if we’re trying to keep something, or someone, out, out of fear of being hurt, being vulnerable, being overwhelmed, being intruded upon - then it makes good, logical sense we might attempt to regulate that and then try to see how well we’ve done. This is one reason why I do not necessarily encourage clients to get rid of their scales right away - they are often serving a psychically important purpose, serving as a reliable safety mechanism of sorts. And ripping off a bandaid is good way to leave a gaping wound before it has had sufficient time to heal and time to explore alternative ways to protect oneself.

When we are looking at a body weight scale, I sometimes wonder if it matters what the client is actually measuring. For instance, if we cut our hair or even use the restroom before weighing, that number would go down. So it’s not necessarily always about measuring fat loss - which is what clients typically report wanting to lose in the name of health and wellbeing. Gaining or losing fat weight cannot happen in a matter of hours or days. So any number that changes on a scale that quickly is not measuring fat. More frequently the scale is measuring water fluctuations. And the water content of our bodies is constantly shifting - relative to how hydrated we are, relative to how much water we’re storing in our cells and in our muscles at any given moment, relative to how our bodies respond to being awake or asleep for extended periods of time - but the number is not reflecting fat gain or loss.

Water is stored in the muscles and in the liver alongside something called glycogen, which is the storage molecule for glucose, or energy. So when we have glycogen on hand for quick energy needs - which is a good thing from a biological perspective - we automatically store more water too. So relying on the number on the scale to indicate fat can actually backfire and make people think they need to restrict more, which can cause that number to fluctuate even more with increased dehydration and lack of glycogen stores, perpetuating the myth that fat is being lost. A good dietitian can help discern the difference and explain what is actually happening in the body when we see numbers shifting on a scale. Trying to interpret this alone can be a recipe for a going down a rabbit hole that can be difficult to climb out of solo.

Essentially what I am suggesting is that the pursuit of weight loss according to a scale is the surface layer of a much more complex, emotional pursuit. When clients come with the wish for weight loss, often we will address the short- and long-term risks, rewards, and consequences of these pursuits  We all know weight can be lost through a variety of avenues these days - that is generally not in question. But what can also be examined are the longings, wishes and desires behind this pursuit, as well as some basic biologic education that can ultimately help us understand how we might be helping or hurting ourselves in the name of health.