By: Lauren Goette
Lauren Goette received her B.S. in Psychology from Cal Poly, San Luis Obispo June 2017, and plans to become a licensed professional counselor in the future. Having personally struggled with anorexia, Lauren has become an advocate for mental health, working as a Peer Health Educator at Cal Poly and speaking out against the stigma surrounding mental illness. This was a paper she wrote her senior year (published with permission).
The deadliest mental disorder in existence, Anorexia Nervosa (AN) threatens the lives of millions of US citizens each year. According to Arcelus, Mitchell, Wales, and Nielsen (2011), anorexia has the highest mortality rate of any mental disorder. In fact, it has been estimated that anywhere from five to twenty percent of individuals with AN will die from the disorder (“Anorexia Nervosa,” n.d.). This exceptionally high mortality rate is largely the result of anorexics’ self-induced starvation, which can be achieved through methods such as calorie restriction and excessive exercise (“Feeding and Eating Disorders,” 2013). As a result of these behaviors, anorexia can lead to serious physical problems, such as slow heart rate, low blood pressure, reduced bone density, severe dehydration, fatigue, hair loss, and a plethora of other physiological issues (“Health Consequences of Eating Disorders,” n.d.). And while there are numerous physical complications that result from this disorder, a significant amount of damage is also inflicted on the cognitive level. A variety of studies conducted in the past two decades have shed light on the devastating cognitive impacts of anorexia, as well as the promising positive effects of refeeding. Current evidence shows, as a result of semi starvation, individuals struggling with anorexia can experience drastic structural brain changes, inhibited cognitive abilities, and memory impairments, which may be improved with weight restoration.
Structural Brain Changes
One of the most severe physical and psychological costs of anorexia is structural brain changes, which can cause significant harm to the cognitive functioning and overall mental health of anorexia sufferers. In the short term, a diet deficient in calories and nutrients, often coupled with excessive exercising, can lead to loss of both white and gray matter (Sidiropoulos, 2007). Prolonged caloric restriction promotes “abnormal reward responses to food and a deviation from a healthy feeling/perception of the body when eating.” These structural changes may, in part, explain why anorexics continually avoid food consumption, as the act itself appears to elicit a negative perception and/or sensation of the body. Additionally, this reduction of gray matter in may also contribute to the disturbance of the brain’s typical reward responses which encourage food consumption.
Often the direct result of structural brain changes, AN sufferers can experience a wide range of cognitive difficulties. Higgs (2009) explored the impact of interference from diet-related thoughts on anorexics’ cognitive abilities. On a cognitive task, restrained eaters’ reaction times when imagining eating cake were significantly slower compared to when they imagined drinking water. On the other hand, unrestrained eaters' reaction times did not significantly differ between the cake or the water conditions. Higgs maintained that the cognitive impairments displayed by restrained eaters were the direct result of a “reduction in processing capacity due to interference from diet-related thoughts.” With this reduction in processing capacity, dieters’ ability to perform basic cognitive tasks was drastically diminished, highlighting how impactful caloric restriction can be on AN individual's thoughts and on their execution of simple cognitive tasks.
In addition to these milder cognitive issues, AN sufferers can also develop chronic cognitive deficits. Specifically, Gillberg et al. (2010) found, eighteen years after AN onset, anorexics had more attention, executive function, and mentalizing problems. Anorexia was found to be associated with “a range of neuropsychological problems that are present long after the eating disorder… is no longer an important feature.” Even after starvation has ceased, weight-restored anorexia survivors can experience lingering cognitive issues. Gillberg et al. suggested that this is the result of severe structural damage which can leave important cognitive facilities critically damaged. Moreover, Fowler et al. (2006) found that even “relatively severe” neurocognitive impairments have the potential to adversely affect AN sufferers’ daily social and occupational functioning in the long term. These impairments can have a substantially negative effect on recovered individuals’ quality of life, making typically simple cognitive tasks exceptionally difficult to accomplish.
Along with cognitive difficulties, AN can also cause notable memory impairment. Kemps, Tiggeman, Wade, Ben-Tovim, and Breyer (2006) found that anorexic individuals’ frequent obsessive eating-disordered thoughts actively prevent their working memory from operating effectively, which can lead to various issues with basic memory functions such as recall. Chan et al. (2013) also found anorexic’s impairment in memory functions to be positively correlated with BMI. In other words, the lower an AN sufferer’s BMI, the worse their memory functions were, and vice versa. Kingston, Szmukler, Andrewes, Tress, and Desmond (1996) also discovered an association between anorexics’ lower weight and poorer performance on memory tasks. Kingston et al. maintained that this poor performance was directly related to anorexics’ degree of weight loss, concluding that anorexics’ memory performance declines with their decrease in weight. Chan et al. proposed that this correlation between BMI and memory impairment indicates that anorexics’ memory deficits may, in part, be associated with malnutrition, however current research remains inconclusive.
Having focused largely on the starvation-induced structural, cognitive, and memory impairments of AN, it is also imperative to recognize the simplest yet most effective treatment for such damage: weight restoration. Though not a “cure-all,” weight restoration, accomplished through the refeeding of the anorexic patient, has the potential to reverse much of the structural and cognitive damage caused by the disorder. In terms of brain matter recovery, Sidiropoulos (2007) demonstrated how weight restoration resulted in the return of white matter to premorbid levels. Simply by increasing caloric intake, anorexic patients were able to recover all of the white matter they had lost throughout the course of their disorder. Similarly, Wagner et al. (2006) found that weight restoration in long-term recovered anorexic individuals resulted in the reversal of structural brain abnormalities. These results imply that weight restoration has the power to reverse structural brain damage, and restore any and all white matter lost to anorexia.
Focusing on the psychological implications of structural brain recovery, Bernardoni et al. (2016) found a strong association between partial weight restoration and improvements in affect and eating disorder symptoms. With even minor increases in weight, recovering anorexics experienced significant improvements to their psychological wellbeing. On the cognitive side, Hatch et al. (2009) discovered that weight-restored individuals were notably faster on cognitive tasks, and exhibited superior verbal fluency and working memory. Hatch et al. concluded that, with refeeding and weight gain, cognitive impairments in weight-restored AN sufferers appeared to normalize.
Despite the existing support for weight restoration, it has noteworthy limitations. First and foremost, complete structural brain repair is not entirely possible through weight restoration While Sidiropoulos (2007) did find significant improvements in the quantity of white matter recovered in weight-restored individuals, in truth, some gray matter loss persisted. In spite of the recovery of white matter to premorbid levels, previously anorexic individuals sustained irreversible gray matter loss, which remained unaffected by their increased weight. Secondly, weight restoration fails to improve distorted cognitions about body image. Even after weight restoration, Bernardoni et al. (2016) revealed that patients remained dissatisfied with their bodies. Lastly, weight restoration fails to recover weight-restored individuals’ memory abilities. Nikendei et al. (2010), discovered that deficits in immediate and delayed story recall in currently ill AN patients persisted even after these patients were weight-restored. Nikendei et al. suggested that this was the result of a so-called “scar effect” on the brain caused by chronic starvation. They maintained that this scar effect may play an important role in the etiology and/or persistence of AN, and might also explain why memory impairments sustained during AN are seemingly irreparable.
The vast body of anorexia research available today highlights both the extensive damage AN can cause to anorexics’ brain structure, cognitive abilities, and memory, in addition to the reparative power of weight restoration. Tragically, for individuals struggling with AN, the damage sustained throughout the course of the disorder can inhibit their brains’ basic cognitive functions. The structural brain changes caused by AN can lead to an irreversible loss of brain matter, as well as serious complications with cognitive and memory functioning. Anorexia nervosa can make simple cognitive and memory tasks, such as attention and recall, exceedingly difficult to accomplish. These cognitive and memory impairments, which can be caused by both structural brain damage and cognitive interference, can make everyday functioning a challenge. Not to mention, the irreversible nature of some of this damage can cause long-term impairment, even in weight-restored individuals. Despite the seemingly endless list of structural, cognitive, and memory complications caused by AN, weight restoration may hold the key to the recovery of both brain matter and cognitive abilities. In spite of its shortcomings, weight restoration has the ability to effectively repair the structural brain damage and cognitive impairment caused by anorexia nervosa.
As a RD, I have gotten so many questions about the fad diet du jour: the "Keto" or "Ketogenic" diet. I finally decided to just write down the research in a reader-friendly version. Here you go-
The ketogenic (or “keto”) diet is just another fad diet.
The Keto diet is an amped-up Atkin’s diet (that we all know now was/is terrible for your cardiovascular system, and not a sustainable way to keep weight off) where the majority of what you eat comes from fat, and carbohydrates are extremely limited (In contrast, a healthy diet should be a much more balanced macronutrient distribution of 20-35% protein, 45-65% carbohydrate, and only 10-35% fat). This skewed macronutrient distribution is actually very dangerous for the human body for several reasons -
#1, We use carbohydrate as fuel for our brain. Glucose is needed for cognitive function, and many people on the Ketogenic diet experience brain fog and difficulty focusing. Ketone bodies, which are created when carbohydrates are not present, are not as effective (or healthy) for our brain. This may also cause metabolic acidosis which is characterized by a reduced pCO2 and/or lower pH (we need to stay in balance!).
#2, On a ketogenic diet, your intake of fruits and vegetables is extremely limited (if eaten at all) and we all know how important the fiber, vitamins, minerals, and other compounds in fruits/veggies are. On that note…
#3, The keto diet is extremely low in fiber! Fiber is not only protective against many gastrointestinal cancers, it is also a big factor in fullness and weight loss. Furthermore, constipation is very common on low-fiber diets like the Keto diet.
#4, Ketosis/ketoacidosis is what is happening in the body/brain on a chemical level – this is the body making fat into something the brain can use when carbohydrates are not available. It is hard on the body to produce, not as efficient as carbohydrate, and is incredibly dangerous for diabetics.
#5, “Keto breath.” Halitosis (bad breath) from ketone bodies makes for an acetone-like smell on your breath that no amount of brushing/mouthwash can fix. Medical professionals look for (smell for?) this in malnourished patients.
#6, High blood lipids/cholesterol/blood pressure. It’s a high fat diet- you didn’t see this coming? The body can only break nutrients down at a certain rate, and high levels of fat in the diet lead to high levels of blood lipids are responsible for blockages (atherosclerosis), and other cardiovascular complications up to death. While you can reverse the numbers, the plaque buildup in arteries is almost impossible to reverse. Not worth it!
#7, Following this diet is often a form of disordered eating or may lead to an eating disorder (just as with any restrictive diet). Cutting out whole food groups is not healthy. We need all 3 macronutrients in appropriate proportions (majority coming from carbohydrates) to have a healthy body. Our body needs a variety of foods for best health. The reason this diet “works” for weight loss is that it restricts the types of foods that people tend to over-do-it-on like chips, candy, pastries, etc. Any diet that cuts out your favorite foods will cause weight loss, but at what cost (physically and mentally?)
#8, Not all fats are created equal. Most people starting a Keto diet are not differentiating between saturated (solid at room temp, and not something we want in large quantities) and unsaturated fats (liquid at room temp, and “healthier”). Getting this wrong also increases complications from the diet.
#9, It may mess with your thyroid and other hormones – lowering your metabolism (isn’t the point of this diet weight loss? That’s counter-intuitive…), energy, and fertility. Every time we lower our metabolism through dieting it lowers the “set-point” of our metabolism, making it harder and harder to lose weight. This is an adaptive response for mammals in famine, but not what the average person wants nowadays.
Who it the Keto diet appropriate for?
The only population that the ketogenic diet is scientifically proven to be beneficial (and safe) for is a select group of people with epilepsy (seizure disorders). This is the position of the Academy of Nutrition and Dietetics.
The Keto diet especially sucks for athletes (and people working out to lose weight)
Since our preferred fuel source is glucose (carbohydrate) from either blood glucose or glycogen (fancy term for carbohydrate stores in the liver and muscle cells), running exclusively on fat slows athletic performance as the body works much harder to break down fat (dietary and adipose storage).
Additionally, the lower protein intake and change in hormones in the body with a keto diet lower the ability to build and maintain muscle mass. If “mirror muscles” like biceps are not motivating enough to keep you off it- remember that our organs like the heart are also muscle tissue that would be broken down by this diet, causing organ damage or failure.
It’ll get you, mentally and emotionally
Ketogenic diets cause headaches, brain fog, and often irritability and obsession with food. This type of diet will very likely make you think about food an unnecessarily large amount of time, and make it difficult to be social (not being able to eat at the same places as your friends; oh, and that bad breath!).
You may feel more depressed (especially if you are already prone to depression and/or taking antidepressants) as serotonin (the “happy” neurochemical) is produced from carbohydrates. If you take an SSRI know that this class of medications work directly on serotonin that is present, and the diet requires a minimum about of carbohydrate (as we learned from the works of Ancel Keys in his starvation study) to allow the SSRI medication to work.
So, what’s the verdict?
In case you didn’t get it from the above – the Keto diet sucks. Not only is it a fad-diet (aka – not suitable for long-term weight loss/lifestyle), it can be very dangerous.
If you need help figuring out what to eat, contact a Registered Dietitian. In the meantime, if you do need some structure, balanced eating like the Mediterranean diet or DASH diet is a better way to go.
Don’t give up the foods you love. There is room for all foods in a healthy diet. We just need to keep proportions and variety in mind to fuel our body optimally.
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I am so excited, because an idea I have had rolling around in my brain for months has finally come to fruition!
Yesterday, January 8th, I opened for enrollment my course for performers,
"Whole Health for Performers!" This course is "A scientifically-based mind-body approach to get the most out of yourself, so you can focus on creating the performance of a lifetime."
This class is aimed at non-pro level actors, dancers, singers, musicians, directors, drama teachers, and techies who get their heart rate up on (or back) stage.
We cover: Physical fitness, Eating healthy, even when you are busy, Avoiding digestive issues on stage, Hydration, Vocal health, Mental health in the theatre, Better coping skills, and more, with step-by-step "homework" with each module so you actually TAKE ACTION on your goals!
It is being offered at a low cost of $97 for beta testing. This means you get to be a voice in the creation of this course! I will be tweaking the course based on your suggestions, and will be offering free live Q & A sessions to overcome personal barriers in a private facebook group for those who sign up. I normally charge $125/hour for individual counseling, so this is a steal!
Keep your eyes peeled for more educational courses coming later this year! I have some free education available on the online education page under "services" - check them out too
(I admit they are my first online creation, and not the prettiest!).
If you are in the performing arts, and want to take better care of your body on and off stage, what are you waiting for? Go to the course now!
Don't just take my word for it, a wonderful article about this course was written by the creator of OnStage Blog. Here it is for more info:
(A lot of people ask me how I started my business, and why I got into the field of eating disorders. While I do usually tell whomever asks, I have put-off writing this for a while. Maybe because I haven't felt that I have really "made-it" yet, maybe because I don't want to get that personal. Anyway, here's how I came to be "Not Your Average Nutritionist."
When I first passed my Registered Dietitian exam, I was about to get married, and was looking for a local job in my field.
That was going to be a lot harder than I first realized.
I spent about a year and a half (!!!) applying for, interviewing (several rounds), and networking for various jobs in any position as a dietitian. Unfortunately, there was always someone with 10 years of experience, or bilingual speaking, that would swoop in and get the job. (Eventually I did end up with a temp job with County Public Health after that year and a half).
While I was looking for my first "real job," an email had come through our local dietetic association from a young woman who was starting college locally, and was relapsing into anorexia nervosa (for which she had previously had some outpatient treatment). She was looking for a female, Christian, dietitian to work with her. I sent an email back asking if she wanted to give me a try (being new and all).
Now to give a little more background on the eating disorder part of this, in school/internship we spend very little time on eating disorders as undergraduate nutrition majors. Of course we had to learn some about it, but it just does not go very deep at that level of education (which is also why I went back for my Master's). So why did I think I could do it?
#1, I was desperate; and #2, I had struggled with restrictive eating during my early college years, and understood her mindset. She agreed, and I met with her and her mom to see if we would be a good fit. This was the start of my entrepreneurial journey.
Fast forward a few months and I had read countless books on eating disorders and sought out a mentor in (who I didn't realize at the time was a founding expert in the field, and whom many others call "a rock-star!") a local RD, Francie White, who allowed me to come watch her work, and help with the IOP/PHP treatment center in Santa Barbara, CA. Since I (still) didn't have another job (other than teaching some group fitness classes), I set my mind towards making a legal business.
With the help of a local non-profit organization, SCORE, I figured out what I needed to do to get a business license, and set up bank accounts. My first business name was "Libby's Fit Nutrition." I thought I would focus more on helping stay-at-home moms with weight loss and fitness. I did have a handful of those clients (whom I met in their homes), but pretty quickly I was finding that a lot of people who desired "weight loss" really had disordered eating or bad dieting practices, and I found myself doing more education around that. The more I worked with these clients and learned about EDs, the more passionate I became. I took some more psychology classes through community college, and contemplated what to get a Master's degree in.
Fast forward another 2 years or so, I was working as a teacher (Allan Hancock College) and in Corporate Wellness (Provant/PG&E). My online presence had generated a lot of interest from college students who were having issues with disordered eating. I was seeing so many students from Cal Poly (the local college), that I was talking on the phone almost every week with one of the school's nurse practitioners (the amazing, June Stanley) about shared clients. One night as we were talking about how many students she was seeing with eating disorders, she (I thought, jokingly) said "we should just have you on campus." Little did I know that conversation would lead to BIG things for me.
A few months later, I turned on my phone to see a voice mail from Dr. David Harris, Cal Poly's Executive Director of Campus Health and Well-Being. His message asked me to call back and set up a time to meet. He heard I was THE person to go to for eating disorders, and wanted to hire me to be on campus to work with the students at no cost to them. (Fun fact: when I walked into that first meeting after saying hello, his first words were, "when can you start?")
I started working at Cal Poly in Spring of 2016, as the first Registered Dietitian (as far as we know) to be specifically hired at a CSU to work with students with eating disorders!
I love my job! It is so nice to have co-workers who respect me and my opinion, since starting we have developed a multi-disciplinary treatment team, getting involved with athletic trainers and coaches for more open communication about the college athletes health and eating disorders, and I have been able to provide some in-service trainings to the medical staff.
This past year I changed my business name to "Not Your Average Nutritionist," to better represent what I was doing (not many RDs are competent in the area of eating disorders, and even less seem to focus more on the person and coping skills than the food piece), and I was no longer focusing on the fitness aspect. I also changed the legal structure from a sole-proprietorship to a LLC, for more legal support and the ability to hire staff in the future. I have a lot of lofty goals for my business in the next 10 years or so, but for right now I want to slow-down and savor the process.
So, where am I with my business now?
- Still working part-time at Cal Poly (over-booked, but feeling competent)
- Seeing some private clients.
- Almost done with my M.S. in Nutrition Science (emphasis in EDs).
- Working with a supervisor (Cynthia Saffell, MS, RD, LCSW, CEDS) for an advanced credential in EDs (IAEDP - CEDRD).
- Teaching at Allan Hancock
- Feeling better about my own body image than ever.
- ...and getting ready to launch a new phase of my business in 2018! Stay tuned for online nutrition courses!
Moral of the story:
Do great work.
The rest will fall into place.
You got this!
(originally posted 1/7/2014. libbsfitnutrition.com)
1. Food Journal. Research has shown, even without "dieting" more people maintain weight loss by writing down everything they eat, every day. No calorie counting required. It can be as simple as a list of what you ate, or as complex as a chart of times, who you were with, level of hunger before and after, emotions, measurements of food, etc.
2. Make one meal automatic. For most people this is breakfast, because it is the least likely to be changed by other people. Take the thought process out of it, and create one, healthy, breakfast that you like and stock up on ingredients. If you want to save time in the morning, prep it the day before (as much as you can). We make a lot of decisions throughout the day, and the more decisions we have to make, the harder it gets to make good ones.
3. Schedule exercise like an appointment. Pull out your phone, planner, google calendar- whatever you use, and plan when you can take time to move. Scheduing it makes it more likely to happen, let's you plan uninterupted time to do it, and makes your day more efficent, so you are not thinking, "I guess I could go to the gym...maybe in a hour. Ooh, Netflix!" Bonus points by having a buddy to meet you and hold each other accountable.
Libby is a Registered Dietitian focusing on eating disorder treatment and prevention. She is working on the central coast to create wellness in individuals and the community
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