Diet pills, we don’t talk about this in ED recovery enough

Diet pills/ appetite suppressants… another side of eating disorders we don’t readily talk about. We should.

Over the years I have used many forms of products that were labeled as either “diet pills”, appetite suppressants, detoxing or laxatives .

I probably started using them well before I developed a full blown eating disorder. Raising the question for me, are they a gate way drugs to eating disorders?

Taking diet pills is disordered in itself. I trialed all sorts , I bought them without really knowing what the active ingredients were. Which for me, is completely against my personal values. I’m a scientist and to be so driven to take something purely for the goal of weight loss is baffling. I’m the kinda gal that has to know the how, why and the risk/ benefit of anything. However diet pills were different.

I remember buying my first diet pills in secondary school. I thought it would be a “quick fix”. They are addictive.

Soon diet pills became a part of my ever expanding routine and rituals.

I would hide this behaviour from others, which means I knew what I was doing wasn’t normal. I was incredibly secretive about this behaviour. It eventually expanded to other drugs including laxative abuse.

Neither diet pills or laxatives result in weight loss. The weight loss associated with laxatives is water weight. It’s purging and extremely dangerous.

I felt cleanest when I was emptiest and high from ignoring hunger pangs, and even more euphoric if the hunger was suppressed. Sometimes I felt superhuman. But I wasn’t. Looking back now, I only felt happy if I was empty. I wasn’t happy outside of this. I was numb.

I’m fortunate I don’t have lasting effects from the laxative abuse. Many are not so lucky. Laxative abuse is not something to be scoffed at or ignored people can be rendered incontinent or dependent on laxatives for life in order to be able to poop.

Diet pills are also dangerous. Not only do I believe they encourage disordered eating and other behaviors they can be harmful in themselves. Many of the diet pills or appetite suppressants are widely available without prescription or worse over the internet without any safety regulation. That means many of the products have not been approved for use in humans let alone approved as safe. You do not know what is in many of them. The drugs that are rigorously tested and checked require approval from the Food and Drug Agency (FDA). Anything without out this approval stepping into completely uncharted waters and potentially very dangerous. I had signs of liver inflammation when I started recovery and signs my liver was struggling. When we don’t know what we are putting into our body we really are playing with fire. Thankfully my liver recovered.

Social media is rife with adverts selling these hazardous products. Companies that sell them are also cunning and as soon as a drug is labeled as dangerous, they rebrand the same product. I bet you have seen celebrity’s used as promotions for such pills, claiming celeb X had a miraculous result to their product without any ill affects. When in reality I am willing to bet, the celebrity NEVER takes them. But people who engage in disordered eating or want to fit into the societal norms are easy targets. I was. You name it I tried it. I have intentionally omitted the product names of anything I took, as I do not wish to trigger or promote disordered actions. Frankly I know that when I was in the depths of my eating disorder if I heard about a new product, I was onto it as soon as I read about it, and so I know what goes through some of our eating disorder brains.

I want you to see that it’s something we don’t talk about enough in the eating disorder community. However, I am confident it’s a hell of a lot more common than we think.

I’m not going to pretend stopping this behavior wasn’t difficult. It was but it is completely possible. I can’t imagine putting something I had no idea the content or safety of into my mouth now (unless it is food).

I went cold turkey- I flushed my pills and binned all the detox teas. It was one of the first behaviors I tackled in recovery ( that and the Fitbit, which is a post enough in itself) Fitbit aka handcuff.

Now when the adverts appear on my social media I either report them or remove them.

Diet pills are an odd one, but if you want to recover they have to go. They don’t work and who know’s what damage they’ll do.

Let’s make this discussion part of eating disorder recovery and bring it out in the open.

There are somethings in life we are never meant to control. Nor should we..

Some things are not supposed to be controlled. They are not our personal responsibility. Weight is one of them. I repeat, your weight is not your personal responsibility or choice.

This may sound controversial because we have been taught that our weight is inversely correlated with health. But this is oversimplified and largely untrue.

We cannot “healthily” manipulate what’s not supposed to be manipulated.

Your weight, much like your height or eye color is predetermined, by genetics. But it’s influenced by environment, your health, your diet history, & both diet and exercise. The latter two are only small contributors. With all the other factors that you have no influence over, it’s futile trying to micromanage. If you go too far in one direction, your body will fight it to live in homeostasis.
If you are genetically built to live in a larger body you will never have a “healthy” smaller body regardless of all the exercise or dieting you do. It just won’t work, the body will fight it and you will see all of the negative effects of this.
The larger body you were born into was healthy.

What’s prompted this post is following announcements from the UK governement they may financially reward weight loss in a campaign to “fight obesity”. They talk about providing incentives with subscriptions to restrictive diets such as weight watchers and slimmers world. This is such a harmful campaign. Further more, this announcement was released in the middle of national eating disorder awareness week, the theme of this was Binge Eating Disorder (BED) (1). Binge eating disorder sufferers are already statistically less likely to seek help than any other eating disorder, despite it being the most prevalent eating disorder. 1 in 50 people in the UK are expected to be affected by BED. A staggering 40% of people in the US following weight loss programmes meet the criteria for BED (2). BED is a serious mental disorder with physical side effects. People with BED, consume large quantities of food quickly without feeling in control, it is NOT the same as “over indulging”. Patients often restrict heavily between binges which fuels the cycle. Often patients with BED do live in larger bodies, they are “obese” by societies definition. The UK government’s message is damaging and harmful to those with BED. Weight stigma is a huge problem in society and in healthcare. Patients with BED are stigmatised, invalidated and often do not seek help. They are too commonly prescribed restrictive diets as an answer. However evidence has proven time after time, binges follow restriction.

Campaigns like this, will have a ripple effect, making access to treatment all the more difficult. More patients are likely to develop eating disorders such as BED, following restrictive diets will not end well.

I anticipate- the “obesity crisis” will increase after everyone regains the weight they lose and more, furthermore it is encouraging disordered eating, which will raise the incidences of eating disorders. Without tackling the core issue of weight stigma, many of those eating disorders will go undetected. “Atypical anorexia” is another diagnosis used by the DSM-V ( diagnostic, statistic manual psychiatric disorders) to diagnose patients with anorexia but are not underweight according to BMI. However Anorexia can manifest in any body shape or size. The difference is the weight stigma those suffering with anorexia in a larger body experience. They are often congratulated for their disordered behaviours, not taken seriously making access to help more difficult.

Let’s discuss BMI. The BMI was invented by a Belgian mathematician in the early 19th century. Lambert Adolfe Quetelet was a mathematician, statistician, sociologist with an interest in anthropometric sciences (3). Anthropometric study is essentially is body measurement study. He had no medical training. He has since been heavily criticised for his population studies of BIPOC and labelling people of colour as “separate species”. One of Quetelet’s areas of interest was in the “average man”, he used data including height and weights to help him determine this.
His studies were largely population based, cohort studies, mostly including white European males. He developed a formula to calculate a ratio of body weight to height squared, after an observation that there were weight and height variations within populations. More specifically that weight did not appear to be directly proportional to height, he discovered weight varied in proportion to height squared. This became known as the Quetelet index, before Ancel Keys renamed it the BMI in 1972. Ancel keys a famous physiologist, attempted to prove correlation with obesity, BMI and poor health. He did not succeed.
The BMI was not used to determine health it was to show “population averages”. It was designed to track population’s weights. It did not measure adipose tissue, or account for muscle. Once again it primarily referenced white European men.

It can therefore not be used as a predictor of individual health status, at best it’s a population screening tool, particularly if that population is white, male and European.
It identifies potential “population risk” of certain diseases such as diabetes, coronary artery disease. However an individual’s BMI, in isolation is not helpful, as a person can have a high BMI but very little visceral fat which has been associated as a greater risk factor. Muscle mass contributes significantly to weight and therefore BMI.

Interestingly, the optimal BMI for mortality is actually within the “overweight” category on the BMI scale. The most optimal BMI statistically from latest studies is actually 27 (4). Yet the BMI scale has not been updated to reflect the definition or risk stratification. Go figure.

The more I learn the less I know, but the more I want to know. Nutritional science is an incredibly complex field of science. It’s also a very difficult area to interpret. I am relatively confident in my ability of interpreting scientific papers coming from an oncology background, but I do not feel equipped to interpret and advise patients on nutritional science. The studies I tend to go to as my default for information and decision making in my career comes form the “gold standard” of evidence, which is data from meta-analysis of randomised control trials.

Meta-analysis analyses data from big randomised trials. (For anyone non medical or non scientific, randomised control trials (RCT) are the holy grail of investigating an intervention. It involves studying two groups, randomised to receive the intervention or a placebo. The difference in the two groups is studied. For example a group of patients with diabetes are randomised to receive a new blood sugar lowering drug. One group gets the drug, the other does not. The changes in their blood sugars are observed. You can control for variables because people are selected based upon specific characteristics, such as age, starting blood sugar levels for example.

Nutritional science is difficult to interpret, because, the studies are largely cohort studies (population based), i.e. you cannot ethically conduct randomised control trials in this field (i.e. you couldn’t restrict a particular nutrient from a group). You cannot control the variables that vary like you can in an RCT (you have no idea how much carbohydrate someone eats compared to the next or how their body actually uses it). Interpreting them is difficult. Therefore I feel uncomfortable ever promoting something I have little or no understanding in. Examples that have come from nutritional science are: the “carbs are bad”, high fibre diet and colorectal cancer risk reduction, ketogenic diet, vitamin E and reduced risk of developing alzheimers. But, unlike medical studies, we cannot control variables in the studies and then apply them to individuals or draw cause and effect. Vitamin E, has been shown to reduce the risk of Alzheimers, but when you look at how, it is not actually understood. Therefore taking a supplement that is not that same as the vitamin E absorbed from a persons diet is just not generalisable.

At medical school we get minimal training on nutrition, yet we are asked important questions that I feel we are ill equipped to provide. I find it concerning when people advocate things such as low carb diets as a one size fits all, pun intended. It’s an issue, there are so many shades of grey. However I am confident in my knowledge and the evidence surrounding BMI, and weight bias. Weight bias is dangerous and our lack of understanding or inappropriate use of nutritional science is concerning. Nutrition is also a luxury and we do not acknowledge this. I am a white middle class female, I acknowledge my privilege, what this means is I am fortunate to be able to choose what I eat. Many people are not as fortunate and they eat what they can, therefore prescriptive diets by nature are also not available to a large population, and yet they are stigmatised for choices that are actually not really a choice.

The BMI was never intended to be used as the measure of individual health, that is is used for today. It is also not applicable to a wider population as it included a narrow cohort. Yet we base such importance on a number that never had any intention for medical use.

For anyone who has received weight stigma or bias, please understand you are not alone. Binge eating disorder is serious and everyone should be able to access help. We can be healthy at any size.

References:
  1. BEAT Eating disorder Awareness Week: https://www.beateatingdisorders.org.uk/edaw
  2. BEAT information page BED: https://www.beateatingdisorders.org.uk/types/binge-eating-disorder
  3. Quetelet index: https://pubmed.ncbi.nlm.nih.gov/17890752/
  4. BMI associations and mortality: Change in Body Mass Index Associated With Lowest Mortality in Denmark, 1976-2013 Afzal, S., Tybjærg-Hansen, A., Jensen, G. and Nordestgaard, B., 2021. Change in Body Mass Index Associated With Lowest Mortality in Denmark, 1976-2013. https://jamanetwork.com/journals/jama/fullarticle/2520627?resultClick=1

Recovery isn’t about never making mistakes

Setbacks will happen, because life happens.

Whether you are just starting recovery or have been on the the path for some time setbacks are inevitable.

It’s okay. It doesn’t mean you can’t recover, I absolutely believe recovery is possible.

But not preparing for setbacks is setting yourself up to fall. After all perfectionism is part of the issue right?!

I am happy that I will one day consider “succeeding at anorexia” as my biggest failure. A setback or relapse does not mean you have failed at recovery.

Setbacks teach you things and pave the way for what might be ahead. They prepare you for a fulfilled life without your eating disorder.

I’m hoping my latest setback will help you.

I’m not ashamed I momentarily took my foot off the recovery pedal. It happened, I’m back in control and wiser for it.

Why did it happen?

Well if you’ve read any of my previous posts you will know I am a firm believer that eating disorders have a strong neurobiological component fueled by energy deficit. Energy deficit being the match to the flame if you like. The physical and psychological symptoms that follow being the fire that is contributed by everything else such as environment, stress etc. The important thing is the match in the genetically vulnerable.

I have just finished a set of night shifts. Night shifts to the average person without a history of an eating disorder can reap havoc on health, both physically and mentally. They disrupt your natural circadian rhythms, they can be socially isolating and routine can become difficult.

I’ve worked shifts for years. I know it’s a time where previously I have allowed my eating disorder to thrive. Therefore, armed with this knowledge I planned to avoid falling into the trap of my eating disorder.

Knowing I cannot allow myself to slip into energy deficit I made preparations to attempt to combat this. I ate more before work and before I slept, I planned out snacks to take with me.

But life happened. I missed some breaks and a few snacks. I was lacking sleep and so my appetite was lacking, I hadn’t made self care and routine a priority.

I didn’t think much of it in the craziness of the shifts, but when I found myself unable to eat 3 meals a day when I came off my shifts I knew I had slipped.

I haven’t had “fear foods” for sometime.

I haven’t thought about engaging in disordered behaviors such as concealing what I was/ or wasn’t eating, for months.

I haven’t listened to the voice tearing me to shreds in the mirror for the longest time ever.

But suddenly it was all there I was right back in it. I found myself wanting to control my intake, to compensate for every “ unhealthy” choice I was making. I recognised a familiar welcome feeling of emptiness that in truth I had actually forgotten. The emptiness euphoria made me contemplate giving up on recovery. After all if I’ve fallen so easily after so long, what’s the point in continuing? The intense draw to the scales returned, I had to fight to not give in to the temptation. I know that no number on that scale would have had any importance, but to my eating disorder it would have been used as firewood.

I danced with the temptation of a full blown relapse. However, I reminded myself it was all lies. If I didn’t put this match out I’d be amidst a wild fire that only wants to destroy.

I needed help. I needed support. I’m not ashamed of that.

My eating disorder tried to make me carry the weight of shame. But that’s another reason I knew I needed to put the match out.

I enlisted support from my support network. I chose to let them in. For the few days following, making decisions around eating felt like an impossible task. The thoughts were so loud. I have now reinforced routine, I challenged the “fear foods” that re-emerged and I prioritised taking care of myself by resting, talking and eating. Instead of pulling myself apart and focusing on “failure” I’ve chosen to treat myself with compassion.

I feel back on track. Ive bounced back. With more knowledge and information for my next set of nights- I need to prepare further. I will carry more snacks on my person. I will increase my intake. Self care, such as yoga, journalling and talking each day will be a priority and not an after thought.

My tool kit is more substantial.

Recognising a slip is vital to enable you to seek help and the support you need.

Recognising it early can help you get out quickly.

It’s obvious to me these slips came from:

Skipping meals (no matter how innocent)

Eating in isolation.

Blasè attitude “no big deal”

These are known triggers for me. Knowing your triggers can help you prevent and identify potential setbacks/ relapses.

Preventing setbacks is not always possible.

But planning what to do in the event is key.

Make your relapse prevention plan. Update it with each learning experience.

Seek help.

Most of all- choose to get back on track. Choose to put the match out, don’t start the fire. A moment of struggle doesn’t mean failure. Be kind to yourself and keep going

Check these out:

Relapse prevention plan mirror-mirror: https://mirror-mirror.org/recovery/607-2

Relapse prevention/ recovery maintenance sheets from cci: https://www.cci.health.wa.gov.au/-/media/CCI/Consumer-Modules/Overcoming-Disordered-Eating—Part-B/Overcoming-disordered-eating—09—Relapse-Prevention.pdf

Two years in recovery..WAKE UP CALL

TW and this may be difficult to read.

Yesterday a memory came up on my Facebook feed.

A trip we made to Sri Lanka in March 2019. My final wake up call before seeking help for my eating disorder.

It was not the wonderful experience that it should have been, or our pictures from our travels captured. They say “a picture paints a thousand words’, but most of what you see is what my eating disorder did for years, fake an exterior. It was this trip that I for the first time in 15+years, began to see how much of an issue my eating disorder really was.

For years my eating disorder had concealed the negative impact it was having on me.

My eating disorder was slowly killing me. If you are starving, you’re slowly dying. My friend if you need this sobering reminder, people die from eating disorders. We forget this when we are dancing with the devil. Or perhaps, we no longer care, when it’s painful to sit, or our body is covered in fine hair because we can no longer keep ourselves warm. We ignore message after message from our bodies until, if we are lucky we WAKE the FUCK up. It’s not just us that our eating disorders impact upon. Truthfully when engaging in behaviours and driven by the numbers, I didn’t worry about the effect each action could have on my partner, parents, brother, friends. But our actions do matter, If I had have continued I would have likely ended up as a stark statistic. Remember, YOU matter, your life matters and you affect many people’s lives. Please wake up.

That trip I felt completely lost and trapped in my relentless behaviours that had been by my side for years. I had no idea how I was ever going to step outside of the grips my eating disorder held on me. But I knew something needed to change or I would slowly but surely die.

What made me wake-up?

I realised I wasn’t living. If I wasn’t living, what was I? It became so obvious to me on this trip because Sri Lanka is full of beauty, but I felt nothing but cold.

I was done with the comments from peers and concerned looks. I hated it.

I was done with feeling nothing but bone cold, ALL OF THE TIME. Even in 30 degrees heat. I wanted to see past the brain fog and constant chatter.

I didn’t want to live like that anymore. I couldn’t live like it anymore.

This was not the first time I had had a moment of clarity, a few years prior I knew things were far from in control, but I didn’t seek help. I thought I could fix myself by eating a little more. Things got better for a time, but without support things soon descended back to the familiar chaos and calm of my eating disorder.

But this trip was different. Something needed to alter. I had reached “rock bottom” and I had to crawl out.

I wanted to be present, to share the experience but my eating disorder bled into everything. It was all encompassing. I was afraid for the first time. I was scared this was either going to be my life, or it would take my life.

It was the first time I realised how much stronger the eating disorder voice had become and how buried I was. I feared I had lost myself forever, I couldn’t recall when I was last in the driver’s seat of my thoughts. This was a sobering moment, at the same time I felt powerless to do anything about it.

These moments of clarity would pass again, and my eating disorder would begin to fool me once more that I was in fact fine, convinced me I wasn’t “sick enough” or that I even had an issue. However my healthy thoughts, were desperate to be heard and me listen. And so, it was this trip, I shared with my partner some of my story, although by this time it was hardly a secret.

Even though this trip was incredibly painful, I remain grateful for it, because it was like a wake up call and it kickstarted my true recovery process. Seeing pictures of the trip makes me sad for memories and experiences my eating disorder stole from me but I’m so thankful to be where I am now. Writing this.

If you’re in this dark place, THERE is always hope, It is never too late to seek help. And, you don’t have to go at it alone. You don’t have to have answers. Choosing to reach out of help is the biggest step, the rest will follow if you trust in the process and take that massive leap of faith.

There are stages we go through prior to starting recovery and then during recovery itself. I think we flip flop between them whilst we go to war with the two voices in our head. But we can all win, it is possible.

To me the stages look something like this:

◦ The “I’m fine. I’m just super healthy. I’m totally in control” stage.

◦ “Something’s not quite right with what I’m doing, but it’s ok right? I know I can stop if I want to. But I don’t want to” stage.

◦ The “Shit, I can’t stop. Well better just keep going. It will pass. It’s not that big a deal?” Stage

◦ The, “Ok, I think this is probably a problem. Not sure I want to do anything about it. But not sure how long I can keep going on like this” stage

◦ “Ok, I’m so done with this, I can’t keep living this way. But I don’t feel I have any control. I’m not sure I can stop” stage. This is the point I got to when I sought recovery. It’s one of the scariest decisions I’ve ever made.

◦ “Let’s try this recovery malarkey out. What do I have to lose? But I’m so scared of the thought of change”. Stage

◦ The, “Oh my god, this is way too hard. I’m never going to recover. Why even bother trying” stage. I think it’s common here, we often resort to old behaviours intermittently whilst making small changes in recovery. But the small changes matter and count.

Then something clicks/ it’s like a switch. Recovery becomes easier. It’s still bloody hard but it’s less of a monster than the one that’s been dictating your life. This stage, you start to question your eating disorder thoughts, your own thoughts start to become clearer and in the foreground more frequently.

It doesn’t take much for your ED to lure you back, a slip or relapse happens. But you learn from them and each slip you get wiser. Recovery gets stronger, you get stronger.

◦ Now you really want this, recovery feels achievable . You begin to see who you really are, what your life can be without this hitchhiker. You remain vigilant and know how recovery can look and you make it your mission to not go back. You’ve got this. Your actions and thoughts are all protective of your recovery, you have worked harder than anyone will ever know to be here.

Recovery is always possible, no matter how deeply trapped, lost or afraid you feel. Wake up, and rejoin the world, you deserve a full life and the world deserves to have you in it.

Check out the links below for seeking support/ starting the conversation:

  1. https://www.beateatingdisorders.org.uk/recovery-information/tell-someone
  2. https://www.nationaleatingdisorders.org/toolkit/parent-toolkit/how-to-talk-to-a-loved-one
  3. https://www.ed.org.nz/getting-help/what-to-do/