Kartini Clinic for Children and Families

Pediatric Eating Disorder Treatment Program

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Food and Love

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I was so struck by the discussion I heard on the radio that I had to pull over to write the words down: “someone who loves you is at home cooking for you.”

In the social avalanche of discussions online, on-air, on-screen about fat/weight/fitness (largely misplaced and often futile) I frequently hear blame placed for our increasing girth on families and individuals being very “food focused”. We are admonished not to equate food with love.

What? Food, its procurement, its preparation and the sharing of it are love…in the deepest, most tribal, most biological sense.

Across the animal kingdom and certainly with humans, adults work all day to bring food home to their young. Somewhere in prehistory humans learned to cook their food, increasing its nutritional availability, storage potential and safety. And the smell of cooking, especially over a fire, as in grilling outdoors, is profoundly attractive to us. If you have been raised principally on rice, the smell of rice cooking is deeply familiar and elicits hunger and pleasure cues, especially when the aroma of garlic and ginger as they hit hot oil is added to it. In other households, the smell of bread baking, of meat or vegetables coated with olive oil roasting in a hot oven is similar.  Ever come home to the smell of chocolate cake baking?

A lovely young woman with a demanding professional job told me the other day how gratifying, how comforting it was to come home knowing that her husband would have been making dinner for her, to enter a house that smelled not of air freshener or aroma sticks, but of food being made for the love of her, for the love of family. It doesn’t matter if the person cooking for you is your husband or your wife, your friend, your mother, your father or a grandparent. What matters is that it is done for the love of you.

At Kartini Clinic we have spent years trying to convince busy modern families of the power of food cooked at home, the power of sharing the effort and the gift. Not only are family meals less expensive and more healthful, they promote togetherness and offer an opportunity to just talk to each other, free of distractions.

For many people today the Holidays are some kind of a mine field where they see themselves picking their way through “temptations”: cookies, candy, sauces and pies. For a moment they throw caution to the wind and suspend their obsession with weight (falsely disguised as concern for ‘health’) and then experience a guilt they cannot keep from talking about.  

It’s time, I think, to refuse to engage in this way.  Enjoy those cookies, that glazed ham, the deep yellow mashed potatoes dripping with gravy! Be grateful that you can. Be proud of what you have made possible for yourself and for others. Rather than feel guilty about partaking of the abundance of our lives, resolve instead to try and share that abundance next year with those who have less.

Take a deep breath near the kitchen, put the kettle on to boil, stick your finger in the cookie batter and lick it off; close your eyes to experience food and home. For if there is one powerful thing we can be grateful for, it is that someone who loves you is at home cooking for you.

Finding Your Sass

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When I first thought about writing this blog I had patients with anorexia nervosa in mind. Patients with AN often struggle to find their voice, regardless of how smart, competent and encouraged they may be by others. On the other hand, our patients of high body weight for whom metabolic problems have lead to obesity, can have the same problem: shame and self-loathing has made them reluctant to use their voice, to fight back.

Unfortunately, “finding their voice”, a commonly stated treatment objective, may not be enough, both groups of kids actually have to find their sass.

Why? Because for both diagnoses there is abundant negative feedback and shaming coming from the environment, to say nothing of the negative voices coming from within.

Kids with anorexia nervosa hear that they are “superficial” “attention seeking” “and just want to look like a model” and that they are “ruining their parents’ lives”.

Kids of high body weight are told they are “lazy” “gluttonous” and “obviously don’t care about their health”. They are shamed in every way imaginable and just about everywhere they go.

But not at Kartini Clinic.

We treat kids with all conditions of disordered eating, just as another clinic might treat all conditions of disordered metabolism (endocrinology) or all conditions of childhood cancers (oncology) with no effort made to segregate these kids from each other. They are all just kids, and have a remarkable ability to find resonance with and compassion for other kids who have eating issues, even when those issues appear to be very different than their own. We adults could learn from them.

But back to finding their sass:

It is not enough to recognize how people and institutions shame you for your condition, one you did not ask to have and did not choose and one your parents did not cause, either. It is also important to learn to fight back. “Finding your voice” may be a polite way to respond to misguided comments from others, but you will discover soon enough that people fight back when their cherished beliefs about body weight, eating disorders and mental health are challenged. Why, if they are to believe that it happened to you — and that you didn’t choose it — then it could happen to them too or to someone they love, and that is scary. In the great game of “46 card draw” (aka your genome), we all get genes for complex illnesses… or not. Virtue is rarely the determining factor.

So when an adult, say a teacher, promotes messages that imply that eating disorders are a result of poor parenting or a “choice to get too thin” or that severe high body weight is caused by “poor food choices” and being “too lazy to move around”, you are going to have to call them out. How polite you are about doing this depends on who is it and where you are. You may need to be downright sassy to be heard. You may need reinforcements (parents), but you should not go quietly! I write this blog to be useful, for example, not only to help Kartini families, but also to have something concrete to give to people who need educating or at least to hear a voice with a different, informed, point of view.

To fight back you will need not only your voice, but your sass. Find it!

It’s Enough to Make You Crazy

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Let’s start with the impetus for my morning study focus: requirements by the American Board of Pediatrics (ABP) for what they call “Maintenance of Certification”.  Those of you reading this who are American physicians know what I mean: we are required to take Board Examinations every ten years, something I have just finished doing (again).  Some of you reading this may be lawyers or therapists—imagine if you had to retake your professional exams every ten years.  I am not talking about CME’s/CEUs or CLEs;  this is in addition to those.  I am talking about the full Board examination, just as you did when you were a newly minted graduate.

Ok, so that’s irritating, expensive and time consuming enough, but the real torture comes with the additional requirements for participation in courses and written “mini exams” required to fulfill “maintenance” in between the main exam every ten years.  

I am a natural student. I like to study. I like to read. I don’t even really mind endless multiple-choice tests. But what I really, really hate is group think.

I just finished a course in genetics for fun, offered for free, through Coursera (in contrast to the terribly expensive Board exams — a racket, in my humble opinion).  It was wonderful and inspiring.  I learned a great deal about things I had no concept of before I took the course.  That’s my idea of intellectual heaven, and I strongly recommend it to anyone who wants such a thrill.  But the course on “Obesity Management” I have had to endure for the ABP is the very opposite: a lengthy, pompous, confusing exhortation of pediatricians in the assessment of “fat” kids.

Published in the American Academy of Pediatrics (AAP) 2007 Journal as “Assessment of Child and Adolescent Overweight and Obesity” by highly educated and well-meaning colleagues of mine, this required reading seeks to make recommendations to pediatricians across the country and becomes immortalized in Board questions, which you have to get “right” (i.e. consistent with its conclusions).  And the main article itself — 32 pages long and listing 366 citations with a six page list of “articles citing this article” (the newest thing) — is a poster child for everything that can be problematical with “evidence-based medicine”. Despite inadequate and frankly contradictory studies cited for their positions and recommendations throughout, the authors nonetheless make all the recommendations you would expect from those who do not dare to challenge conventional thinking on the subject.

The first six pages are arguments and justifications for using BMI to accurately assess “fatness” in children and adolescents.  Then they move on to “implications” with, among other things, this statement: “Overweight and obesity in childhood and adolescence have been associated with adverse socioeconomic outcomes, increased health risks and morbidities and increased mortality rates in adulthood.”  

Those of you who have become astute readers of scientific literature for kids with eating disorders may rightly home in on the words “associated with”.  You know that to say A is associated with B does not prove that A causes B.  They may both be caused by C, for example. But to expose the real problem (beyond the correlation/causation issue) try substituting the concept “being Black” for being overweight and obese and you get an equally true statement: “Being Black in America has been associated with adverse socioeconomic outcomes, increased health risks and morbidities and increased mortality rates in adulthood”.  But what? Stop being black?  Just because something is associated with with adverse outcomes does not mean it is possible –or desirable– to change it.  Group think glosses over these simple points of reflection in favor of simplistic popular conclusions.

As my car’s navigation system says:  “recalculating….”

The contribution of genetics and environmental obesogens, other than food and exercise, are systematically ignored throughout this article.  The recommendations were based on conclusions the authors had apparently come to before they examined the evidence.  For example, they spend a great deal of time recommending that pediatricians assess the overweight child’s “readiness to change”  (in a ten year old!?) as part of collaborative interventions, and yet they note that “several studies that applied these methods to nutrition and physical activity showed successful short-term results but less convincing long-term results.”

Could it be because we are not asking the right questions, and/or refusing to change our assumptions even when contradicted by evidence?  Maybe it just plain doesn’t work and all the wishful thinking in the world — not to mention the pressure placed on overweight children — doesn’t change outcome in a meaningful way.  Dressing the Emperor up in politically correct clothes such as “motivational interviewing” doesn’t change the fact of his nakedness.

In this field (obesity) I frequently see authors cite evidence that contradicts their personal, deeply held positions, and they basically deal with this by insisting that “larger studies” will no doubt justify what they think and assume to be true.

Obesity is a symptom, not a health outcome.  Some obese people — maybe even most — also have symptoms/conditions thought to lead to bad health outcomes, such as high LDL, low HDL, high insulin levels, high blood sugar levels and high blood pressure, but many do not.  Even where obesity can be shown to be associated with these things, it still does not mean that obesity causes them.

Another example: one of the recommendations made in this gigantic article is for a reduction in “meals eaten out of the home”.  OK, I like the sound of that.  But largely because it conforms with my own built-in social and generational prejudices and marginally because I think it may improve nutrient quality. But their own data report conflicting results, including one by French et al. which found that although it was associated with eating larger portions and more fat as well as fewer vegetables,  “the frequency of fast food consumption by adolescents was not associated with overweight status”.  Yet the article confidently recommends that pediatricians target changes in behaviors including “eating outside the home”.  The evidence base is weak, but the recommendation is unabashedly strong.

This is what I call group think.  The underlying, socially popular assumptions are not challenged, and the system is setup to perpetuate whatever “consensus” an official body has arrived at by inserting them into professional examinations and “standards of care” for “excellence” in practice.

Eighteen pages into the article the authors made three sweeping statements which for me epitomize preconceived notions carried into analysis (aka confirmation bias) and unaffected by conflicting evidence:  “Diet and activity are inextricably linked” they say, (no citations). “Overweight and obesity result when daily energy intake is greater than daily expenditure over time”, completely ignoring the role of genetics on metabolism. And finally: “This concept of energy balance is crucial for successful assessment, prevention and management of overweight and obesity in childhood and adolescence”  But then why do weight loss strategies utilizing dieting and exercise fail so spectacularly over time?

The many examples of weak evidence and unequivocal recommendations in this lengthy paper are too numerous to cite here, and would doubtless exceed the patience of most readers to hear about.  It certainly exceeded mine.

I think I’ll go out in the garden.

Can Measuring Leptin Lead to Happiness?

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In our clinic we spend a lot of time thinking and talking to our patients about the hormone leptin.

In another instance of the concordance of important findings to obesity science and eating disorder science, the study of leptin and body weight, leptin and menstrual function and now leptin and mood, has revealed relevance to both of these groups.   According to an article titled Leptin Predicts Decreased Depressive Symptoms, from the Neuroendocrine Unit of the Department of Psychiatry of Mass General, Lawson E, Miller K et al., leptin levels also affect depression and anxiety levels.

Leptin was discovered by animal lab researchers working in the field of obesity.  Leptin is a hormone secreted by fat cells which has receptor sites throughout the body and brain, in areas relevant to the regulation of appetite and, interestingly, also in brain areas thought to regulate the emotions (e.g. limbic system).  It appears to have been one of several critical hormones evolutionarily important in protecting us during times of famine.

For most of mankind’s history famines have been more common than times of plenty, and the brain is built to try and withstand this assault on our survival.  As our body fat stores diminish, so does leptin.  This signals the brain to turn on other hormones responsible for increasing our appetite and food foraging behaviors.  We are forced to seek food by the brain.  Leptin also has a dampening effect on some of the hormones of reproduction, such as LH (luteinizing hormone), and through them suppresses menstruation.  In other words, the brain judges times of famine to be poor times to reproduce.

As part of Kartini Clinic’s Weight Restoration 2.0, we routinely measure leptin levels of our patients.  At the start of re-feeding these levels will be very suppressed.  As body weight goes up, leptin levels begin to rise and other hormones normalize, eventually resulting in a balancing of those hormones which drive us to eat and those which tell us we have eaten enough.  At least that’s how it’s supposed to work.  In some patients, for reasons too complex to go into here, leptin remains suppressed.  It can be suppressed by aerobic exercise and by dieting (restricting), even for short periods of time.  For these patients with prolonged suppression of leptin menstruation does not return.

But that’s only part of the story.  Back to the article.  There investigators looked at the relationship between anxiety, depression and leptin levels and they found that low leptin levels correlated with depression and anxiety, independent of body weight, in four groups: those with anorexia nervosa, those with lack of menstruation for other reasons,(“hypothalamic amenorrhea”), those who were overweight/obese and a control group with none of these conditions.

The fact that mood is adversely affected by low leptin levels is important to full restoration of health in our patients. Many of our patients with AN are focused on normalization of their leptin levels as their ticket to being allowed to return to exercise.  But it may turn out to be more important that normalizing leptin levels (through adequate fueling and rest) has a potential to improve mood and sense of well-being.  After all, it’s about happiness, right?

The Suffering of Others

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“With what incredible courage we are able to endure the suffering of others” — My favorite quote from English garden writer Christopher Lloyd.  And nowhere does it apply more than in medicine.  And within the world of medicine, nowhere more than in the world of mental health.

When my neighbor is poor, he deserves it for his sloth and lack of thrift.  When I am poor, I am the victim of unfairness and persecution.  When a young man medicates his abdominal pain with narcotics, he just wants to get high, when I have severe pain and use whichever drug works for me, it is justified by my suffering.  When my neighbor has lost her hair and can’t work because of fatigue and joint pain, it is because she is neurotic and avoidant, when it happens to me, it is an undeserved tragedy.

Doctors are often unsympathetic with patients who complain of medication side-effects.  Rather than assume that such side effects are the result of genetic differences in the metabolism (as is the case with  almost all drugs), we tend to believe the patient is vested in “complaining” — and since we have little better to offer, it seems natural to place the blame on the patient rather than recognize the limitations of our profession.  This, by the way, is why we have begun genetic testing at Kartini Clinic to better understand individual biology as it pertains to psychotropic medication.  And what an eye-opener it has been.

The whole world is unsympathetic to those whose weight is higher—sometimes much higher—than it “should be”.  And this judgmentalism can be so severe that there have been publicly uttered proposals that fat children be removed from their parents’ care.  The ultimate in parent blaming!

For those of us who are professional “listeners”: doctors, nurse practitioners, nurses, therapists, psychiatrists and even neighbors, we need to learn to ask ourselves “how would I think about this condition they are describing if it were happening to me or to my own child? How can I make their suffering meaningful to me without having to walk a mile in their shoes?”

People face suffering every day, our challenge is to recognize them for it.