Food and Eating... the Extremes

[Connie Stapleton PhD 342]

I got a text this week from a former client who moved out of the state a while back. This woman, who I will call Mattie, had weight loss surgery four years ago. She lost the majority of her excess weight and has maintained that weight loss. She’s even had a baby and continues to maintain her weight loss!

Mattie asked me a few questions. We exchanged a few texts before I told her I would send her an email with some thoughts. I was actually on the treadmill at the time and haven’t quite mastered accurate texting while hustling on the treadmill (and watching my guilty pleasure, The Young and The Restless) while I walk!

Here’s how our messages went...

I got a text this week from a former client who moved out of the state a while back. This woman, who I will call Mattie, had weight loss surgery four years ago. She lost the majority of her excess weight and has maintained that weight loss. She’s even had a baby and continues to maintain her weight loss!

Mattie asked me a few questions. We exchanged a few texts before I told her I would send her an email with some thoughts. I was actually on the treadmill at the time and haven’t quite mastered accurate texting while hustling on the treadmill (and watching my guilty pleasure, The Young and The Restless) while I walk!

Here’s how our messages went:

Mattie: “I want your professional opinion… Orthorexia nervosa and body dysmorphia… real or not real?”

I honestly had never heard of orthorexia nervosa, so, while contemplating whether or not I like the new actor playing Billy Abbot, I looked up orthorexia nervosa. Here’s the definition from the National Eating Disorders Association (https://www.nationaleatingdisorders.org/orthorexia-nervosa):

“Those who have an “unhealthy obsession” with otherwise healthy eating may be suffering from “orthorexia nervosa,” a term which literally means “fixation on righteous eating.” Orthorexia starts out as an innocent attempt to eat more healthfully, but orthorexics become fixated on food quality and purity. They become consumed with what and how much to eat, and how to deal with “slip-ups.” An iron-clad will is needed to maintain this rigid eating style. Every day is a chance to eat right, be “good,” rise above others in dietary prowess, and self-punish if temptation wins (usually through stricter eating, fasts and exercise). Self-esteem becomes wrapped up in the purity of orthorexics’ diet and they sometimes feel superior to others, especially in regard to food intake.

Body dysmorphia, just to get the formal definitions over with, is a clinical diagnosis in the Diagnostic and Statistical Manual (DSM V), the guidebook used by psychiatrists, psychologists, and other health care professionals. People who have Body Dysmorphic Disorder are:

“preoccupied with one or more nonexistent or slight defects or flaws in their physical appearance.” Keep in mind that the emphasis is on nonexistent or slight defects, not something that is clearly visible. “‘Preoccupation’ is usually operationalized as thinking about the perceived defects for at least an hour a day… The preoccupation must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.”

“At some point, the individual must perform repetitive, compulsive behaviors in response to the appearance concerns. These compulsions can be behavioral and thus observed by others – for example, mirror checking, excessive grooming, skin picking, reassurance seeking, or clothes changing. Other BDD compulsions are mental acts – such as comparing one’s appearance with that of other people.”

Now that you know what we’re talking about, I’ll continue with our text conversation. In response to Mattie’s question about whether or not orthorexia nervosa and body dysmorphia are real, I responded: “Yes, real.”

Mattie: “Thank you.”

Me: J J J J

Mattie: “I’ve been doing a lot of research on eating disorders and the psychological issues that come with them when I came across these.

Me: Do you think you have those issues?

Mattie: I don’t know. I think I may but I feel crazy saying that. I need to do some

more research to know for sure but from everything I’m reading it describes me pretty well. I seem to have gone to the opposite extreme from where I was three years ago.

Me: That means you haven’t dealt with the issues but are acting them out on the

other end of the spectrum.

Mattie: That’s what I’m scared of.

Me: Yeah, but you would not be exploring it if you weren’t willing to work on things.

Mattie: Very true. I just feel like it’s all in my head but then again, not. It’s deeper

than just my thoughts. It’s almost like these other little voices outside of myself telling me what to think and how to act.

Me: What are the voices saying and whose voices are you hearing?

Mattie: They are mine and the voices of lots of other people I have known throughout my whole life. Most of the time they are just telling me whatever I do isn’t good enough and that I have to do more. No matter what, don’t mess up because it’s impossible to undo. All my flaws are being pointed out along with the mistakes I make and how much I still need to do. Last week I had a full-blown panic attack because I ate some rice with my meal and felt like I could feel it going through my system and turning into fatter things and a big old stomach. After I finally calmed down I ended up at the gym doing cardio for 2 ½ hours. Stuff like that happens more than I care to admit. Sometimes when I think about it I freak out so much I actually get sick. All of this makes me wonder if the surgery wasn’t the result of my brain saying ‘you should do this because it will make you prettier and healthier.’”

Me: I’ll email you… too much to say and I’m on the treadmill.

I also didn’t want to miss finding out if Billy was in cahoots with Phyllis or if he was backing out of their deal…

The more I thought about all I wanted to say to Mattie, the more I decided others would benefit from the information. I’m certain she’s not the only one struggling with many of the issues she brought up.

To begin with, a great many people who have weight loss surgery find themselves engaging in behaviors that are unhealthy two to three years later. I’ve worked with patients who start drinking excessively, shopping themselves into financial distress, sleeping with people they don’t even want to be sleeping with, abusing/becoming dependent on pain medication, returning to unhealthy eating behaviors and starting to regain weight, spending too many hours exercising, behaving in other forms of bulimic behavior, engaging in anorexic behavior, and, I now learn from Mattie, orthorexia nervosa.

It’s fairly predictable. For the first year to 18 months, people are thrilled because they are losing the weight they struggled to shed for so long. It’s exhilarating to see the results they so longed for. It is an exciting time and the body is doing what it is supposed to do following the surgery. As the body heals and weight stabilizes, sometimes people begin to engage in behaviors they may not even understand themselves.

So what is the explanation for a return to eating unhealthy food in spite of knowing the misery of having been morbidly obese and experiencing significant health issues as a result? What sense does it make to become anorexic or orthorexic or alcoholic or a shopaholic or to engage in any sort of behavior to the point it creates problems in your life?

To mental health professionals, it makes perfect sense. We understand that for many people who struggle with weight issues, there is emotional baggage beneath the surface. Weight loss surgery doesn’t treat “head issues.” When people have weight loss surgery, they lose the option (at least for a time) to use food as a coping mechanism, an attempt to avoid dealing with things that are under the surface.

Mattie was quick to point out what is at the heart of the real problems, the issues underlying one’s weight and focus on food… it’s the voices of various people from your past who have told you things similar to what Mattie continues to hear in her head:

• You could have done better.
  
• You could have done more.
  
• You got all A’s but one B… why wasn’t that an A?
  
• Why can’t you be more like your sister?
  
• If you keep gaining weight, no one will marry you.
  
• You’ll never amount to anything.
  
• It’ll just never be ‘good enough.’
  

Mattie made it clear that it’s not just the voices of others she hears, but also her own. There’s a simple reason for this: Children learn what they live…and then they live what they learned. The negative messages you heard about yourself from others as you were growing up are what you learned as you grew up. Every time you repeat those messages to yourself in the present, you are living what you learned. As an adult, you’re reinforcing to yourself the negative things you initially heard from others about you.

The solution? Simple – yet very difficult! You have to make a commitment to yourself to no longer talk to yourself about yourself in negative terms. Even if you don’t believe yourself at first. And you have to put a lot of effort into changing and restating the negative messages you repeat about yourself so they are at least neutral:

· You could have done better.

o When you hear this message, change it to, “Maybe I could have done better, and yet I can’t change the outcome of this situation. I’ll think about what more I might be able to do the next time this situation arises.”

· You could have done more.

o When you hear this message, change it to, “There’s probably always more that could be done in a given situation. That’s as much effort as I was willing to put into this situation at this time.”

· You got all A’s but one B… why wasn’t that an A?

o When you hear this message, change it to, “Perfection doesn’t exist, nor did I want to put forth the effort for that particular endeavor. I’m pleased with the results.”

· Why can’t you be more like your sister?

o When you hear this message, change it to, “I can’t be more like her because we are different people and I’m learning to like myself just fine.”

· If you keep gaining weight, no one will marry you.

o When you hear this message, change it to, “I’m learning to accept myself the way I am and I don’t want to marry or have close relationships with anyone who doesn’t accept me as I am.”

· You’ll never amount to anything.

o When you hear this message, change it to, “Never amount to anything according to whom? I’m becoming more and more comfortable with who I am and what I want in life. That’s what matters.”

· It’ll just never be ‘good enough.’

o When you hear this message, change it to, “I’ve come to terms that I am, indeed, ‘good enough,’ and I like myself this way.”

What makes this different is that people say, “I tried, but it doesn’t work.” Well, keep trying. The reality is you are battling years of negative messages and your brain has literally developed neural pathways so you slip back into those well-worn paths quite easily. In order to develop new neural pathways that are more optimistic toward self, it will also take thousands of repetitions. If you were learning to speak a completely foreign language, it would take days and weeks and months of repetition before the new language would come easily. It’s the same thing with positive self-talk. The good news is, you can benefit from positive changes as soon as you start talking better about yourself. Remember, no one is putting you down at this point in your life except you. (If there are others degrading you, then you need to learn healthy boundaries and tell those people to stop and/or get them out of your life.)

The negative self-talk is part of the deal and changing that is a huge part of the solution. But, WAIT – there’s MORE! Of course there is! There’s actually a lot more, but this is supposed to be a short article, which it already isn’t. Therefore, I will only address one more essential issue related to weight regain and/or the transfer to another unhealthy behavior after weight loss surgery. In Mattie’s case, the transfer has been to a rigid attitude about eating healthy foods, feeling tremendously guilty if she eats anything but healthy foods, followed up by a form of bulimia known as exercise bulimia, as evidenced by her working out for 2 ½ hours after eating some rice.

Regardless of what unhealthy behavior a person switches to following weight loss surgery, what needs to be addressed is the purpose the behavior serves. This points, also, to looking at what purpose food and/or obesity served prior to weight loss surgery. Simply stated, an almost obsessive focus on food, whether that is thinking about what one is going to eat next, pouring over recipes, relentless counting of calories and grams, watching every show on the Food Network, exercising excessively, obsessing about healthy foods, is a coping skill. In the adult world, people are capable of learning and understanding that these eating and food-related behaviors are unhealthy in that they negatively affect health and relationships. The reasons people remain engaged in these negative behaviors, in spite of knowing they are detrimental to their physical, emotional and relational health include the possibilities that: 1) they have addictions (to food, or other substances/behaviors), and weight loss surgery does NOT treat food addiction, 2) they are tremendously afraid of feeling their own feelings and are terrified of dealing with past emotional issues; what’s more, people often deny having any past issues they need to deal with in the first place. Trust me… we all do. Every human being has had some painful experiences in their lives. People are terrified of what I call cleaning out their emotional closets because they literally fear experiencing feelings. Here’s why: when people experience feelings from past losses and hurts, they feel it with the same intensity at which they felt it at the age they were when it happened. That frightens adults and they avoid dealing with their past at all costs. And these costs can be high; anyone who has had weight loss surgery understands the physical and emotional costs that being obese bears.

Here’s the deal: if people don’t dig into whatever they are avoiding emotionally, or address any addictions head on, and if they don’t learn healthy adult coping skills, communication skills, and how to set healthy boundaries, then they WILL switch to another unhealthy behavior to use a coping skill (another name for avoiding reality and feelings).

In Mattie’s case, she swung to the opposite end of the eating continuum. Either end of an issue often means the person is just acting out the same unhealthy coping skill in the opposite way. You often hear of people who are not at all religious becoming overly immersed in a religion. Same problems… just acting them out in opposite ways. Hence, my response to Mattie as she described “having gone to the opposite extreme” with her eating behavior, when I said, “That means you haven’t dealt with the issues but are acting them out on the other end of the spectrum.”

My suggestion to Mattie and to anyone else who is engaging in any disordered eating behaviors, anyone who has regained weight, and anyone who has begun engaging in other addictive or unhealthy behaviors following weight loss surgery: Get into individual and/or group therapy with a therapist who understands “family systems” counseling and/or addiction counseling. Talk about issues underlying your addiction to food (your emotional dependency on food), any losses you experienced throughout your life that you haven’t dealt with, and any trauma/abuse you have experienced at any time in your life. Work with a therapist to learn and develop healthy coping skills to implement into your adult life, how to implement healthy boundaries in your adult life, with yourself and with others, and learn healthy communication skills. Read about these same topics, and add to the reading list the topic of “re-parenting the self.”

Orthorexia nervosa and body dysmorphia are real, as are bulimia and food addiction and transfer addiction. Weight loss surgery can inadvertently open the door for these problematic behaviors. Do what I always tell people to do: Get Help and Get Happier!

Thank you, Mattie for bringing these topics up to me. I hope this has helped you and many others! Oh – and by the way, I’ve decided I like the new Billy Abbot… so far!

Connie Stapleton, Ph.D.

www.connie@conniestapletonphd.com

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[Cervidae 2,389]

I'm in the process of getting therapy for these very issues! It's not easy to learn to be objective and realistic about yourself when you have an eating disorder because your reasoning is flawed, and thoughts that you feel are valid and logical are often completely skewed by the disorder.

If anyone reading this has noticed these problems... get help! We didn't go through a life-threatening, life-altering surgery only to keep treating our bodies poorly. You deserve to take fantastic care of yourself, and if you need help to do that, there's no shame in it.

Thanks for the post. It was a good read and a reminder that this is always going to be a journey of health, not a destination.

[Babbs 14,681]

Wow, what a great article! Thanks for bringing Orthorexia Nervosa to people's attention. I've seen the behavior in people before, but never knew it as an actual disorder.

[Inner Surfer Girl 12,015]

Thank you so much for such an educational, enlightening, and useful article.

By the way, several years ago, before I started even considering Weight Loss Surgery, my eating disorder therapist at the time recommended your book Eat it Up! I read some of it back then. But, not until I was in the process of having surgery did I read it carefully, cover to cover.

Now, it is one of the books I recommend on a regular basis to people who are going through this process.

Thank you.

[CowgirlJane 14,259]

What made this interesting to me, was the specificity. Like, actual examples of the experience. I have issues, but not these, which I find oddly reassuring.

Really, i don't feel guilt or even really worry about what I have eaten. I am diligent in the sense that I keep a close eye, but I don't feel the desire to punish myself with excessive exercise, for example, if I eat more than planned. In fact, I view exercise as a tool to keep my body ready to do the stuff I WANT to do like hiking, horseback riding, snowshoing, cross country skiing etc. Exercise in and of itself is not really a big focus for me anymore, it is kind of like basic hygenie I guess.

I had about a 10# regain this last summer and in the past I would have faced that with one of two approaches, both essentially panic responses:

- what the heck, give up, stop weighing, buy bigger pants

-panic, try some program lose 30# and regain 50

Instead, I stayed calm and decided first to focus on stopping gaining. I made small changes and stabilized. Then I thought, hmmm, what do I need to do to lose a few. I made some more small changes - going back to basics of course. I am back under goal again but it took several months. This was a low stress way to address it. what I also noticed was those 10# felt horrible because my snugger jeans wouldn't zip anymore, but nobody around me even noticed. It is not like the Earth stops rotating because Jane put on 10#... there is something to be said for putting these things into perspective.

[Alex Brecher 10,513]

Connie,

Thanks so much for this article! These are some really good tips for accepting yourself if you realize you’re always putting yourself down or feeling inadequate. You have great ideas for being realistic about what you want from life and what you can demand and expect from yourself without asking for so much that you’re setting yourself up for failure.

In addition, this whole issue and article provide a good reminder that the eating issues we have dealt with for years before surgery and since aren’t always just about the weight. If we don’t get to the heart of the matter, they will show up somewhere else, either on the other end of the disorder spectrum as you talk about here, or in something like a mental disorder (say, depression) or replacement addiction.

Thanks for the great insights!