Richard G. Petty, MD

Emotional Eating

A new study from Miriam Hospital’s Weight Control and Diabetes Research Center in Providence, Rhode Island, has just been published in the journal Obesity. The research suggests that dieters who tend to eat in response to external factors like parties and celebrations, have fewer problems with their weight loss than those who eat in response to internal factors such as emotions. The study also found that emotional eating was associated with weight regain in people who had successfully lost weight

The researchers analyzed individual’s responses to questions in a well-known research tool called the Eating Inventory which is designed to assess three aspects of eating behavior:

  1. Cognitive restraint
  2. Hunger
  3. Disinhibition

The main focus was on the third item, since some previous research has suggested that disinhibition as a whole is an accurate predictor of weight loss.

The disinhibition scale evaluates impulsive eating in response to emotional, cognitive, or social cues.

There were two groups in the study. The first consisted of 286 overweight men and women who were currently participating in a behavioral weight loss program. The second group included 3,345 members of the National Weight Control Registry (NWCR), an ongoing study of adults who have lost at least 30 pounds and kept it off for at least one year.

The investigators found that the components within the disinhibition scale could be grouped into two distinct factors: external and internal disinhibition.

An example of external disinhibition would be the person who overeats when they are with someone who is also overeating, or the person who just overeats at a party, picnic or celebration.

The person with internal disinhibition eats in response to thoughts and feelings such as loneliness, upset or anxiety.

In both groups internal disinhibition was a significant predictor of weight over time. For participants in the weight loss program, the higher the level of internal disinhibition, the less weight an individual lost over time. The same was true for maintainers in the NWCR: Internal disinhibition predicted weight regain over the first year of registry membership.

Before starting a weight management program it is very helpful to know which group you are in. It provides us with a quick and easy method of tailoring the program to the individual, and tells us where to put our efforts.

Medication-induced Weight Gain

It is not really a surprise that medicines that are designed to have effects on emotion might also have other effects. After all, emotion originally evolved as an outgrowth of the sympathetic nervous system, which, as every student of biology knows, is involved in the "Four F’s:"

  • Fear
  • Fight
  • Flight
  • Sexual activity

So if powerful medicines influence emotion, they will likely also influence one or more of these.

Cocaine and amphetamine lead to a loss of appetite for food, though I am told that marijuana makes people hungry. I do not, of course, know that from personal experience.

Many antipsychotics, mood stabilizers and antidepressants cause weight gain by an array of different mechanisms.

New research published by colleagues from Johns Hopkins has done a lot to clarify the role of histamine in the appetite problems that often occur with antipsychotics.

You may be interested in reading more here.

The conclusion? Histamine has a major role to play in antipsychotic-induced appetite increase.

But it is not the only factor in the weight gain, insulin resistance and diabetes problems that seem to bedevil some of these medicines.

Before the book comes out, I shall write some more about the ways in which the Atlanta Approach successfully – and uniquely – deals with all of those problems.

Mindfulness and Eating Disorders

There is a very interesting report about a study that is going on at Griffith University in Brisbane, Australia.

They are using a psychological technique called "mindfulness" that is firmly rooted in Buddhist philosophy, in which a person becomes intentionally aware of his or her thoughts and actions in the present moment, non-judgmentally. Mindfulness is applied to both bodily actions and the mind’s own thoughts and feelings.

The idea is  to help them understand and deal with the emotions that trigger their binges. Unlike many other therapies used in the treatment of eating disorders, there is less focus on food and controlling eating and more on providing freedom from negative thoughts and emotions.

Psychologists Michelle Hanisch and Angela Morgan said that women who binged were often high-achievers and perfectionists and  when they perceived that they didn’t measure up to self-imposed standards or were not in control of situations, they indulged in secretive eating binges.

It is well known that many women with eating disorders develop elaborate methods of hiding the evidence of their binges. Some feel so guilty afterwards they also induce vomiting, overuse laxatives or exercise excessively to counteract the effects of the binge.

The researchers say, "Binge eating is largely a distraction – a temporary escape from events and emotions that nevertheless can cause long-term physical problems including electrolyte imbalances. Instead, women need to learn how to react in a different way… Women who have been through the program report less dissatisfaction with their bodies, increased self-esteem and improved personal relationships," and "They learn that thoughts and emotions don’t have any power over us as they are just passing phenomena and aren’t permanent."

Mindfulness involves techniques and exercises that are very similar to meditation. They could help people live more in the moment, and develop a healthy acceptance of self and become aware of potentially destructive habitual responses.

There is quite a large literature on the use of mindfulness in a variety of clinical situations including substance abuse, oncology, chronic stress, reducing symptoms after organ transplantation, chronic headache and perhaps anxiety.

It will be interesting to see the final results of this study: I shall keep you informed about this and other studies on mindfulness, meditation and acceptance and committment therapy (ACT).

“Peace can be reached through meditation on the knowledge which dreams can give. Peace can also be reached through concentration upon that which is dearest to the heart.”

–Patanjali (Indian Philosopher said to be the Compiler of the Yoga Sutras, Dates Unknown)

"Meditation is not to escape from society, but to come 
back to ourselves and see what is going on. Once there is 
seeing, there must be acting. With mindfulness, we know 
what to do and what not to do to help.”
Thich Nhat Hanh (Vietnamese Buddhist Monk, 1926-)

“Generosity is another quality which, like patience, letting go, non-judging, and trust, provides a solid foundation for mindfulness practice. You might experiment with using the cultivation of generosity as a vehicle for deep self-observation and inquiry as well as an exercise in giving. A good place to start is with yourself. See if you can give yourself gifts that may be true blessings, such as self-acceptance, or some time each day with no purpose. Practice feeling deserving enough to accept these gifts without obligation — to simply receive from yourself, and from the universe.”
–Jon Kabat Zinn (American Mindfulness Meditation Teacher and Associate Professor of Medicine at the University of Massachusetts Medical School, 1944-)

Hormonal Disturbances and Bulimia

Bulimia, more accurately called bulimia nervosa, is an eating disorder that was first described by  Professor Gerald Russell in 1977 whilst he worked at the Royal Free Hospital,in London in 1977.

There are five criteria that have to be met for someone to be diagnosed with bulimia nervosa:

  1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
    • Eating, in a discrete period of time (e.g., within any two-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
    • A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
  2. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercise.
  3. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for three months.
  4. Self-evaluation is unduly influenced by body shape and weight.
  5. The disturbance does not occur exclusively during episodes of anorexia nervosa.

It has long been known that there can be a number of hormonal disturbances in people with both anorexia nervosa and bulimia, but it has never been clear whether they are a result of malnutrition, vomiting and/or the use of laxatives and diuretics. When we were both at the Maudsley Hospital in London, Gerald and I once spent several hours talking through the possibilities of doing some collaborative work on the hormonal problems in people with eating disorders. The list of disturbances was so long that we decided that we had other priorities.

So I am fascinated to see some new research from the Karolinska Hospital in Stockholm.

Amongst the most prominent problems in people with bulimia are menstrual irregularities and increased rates of polycystic ovarian syndrome (PCOS). A Dr Sabine Naessén studied 77 women with bulimia and 59 healthy volunteers.

As expected the women with bulimia had higher rates of menstrual disturbances, hirsutism and PCOS. And in line with previous research, levels of testosterone correlated with amounts of hirsutism.

The women with bulimia also had lower bone density, particularly if their menstrual cycles had stopped or if they had ever had anorexia nervosa.

She also found an association between two common polymorphisms in the estrogen receptor (ER) β gene and bulimia. She has speculated that this genetic variation might predispose women to the development of bulimia.

Her results suggest that some women with the condition may have too much of the male hormone testosterone. Half of the people treated for this imbalance reported less hunger, and fewer cravings for fatty and sugary foods.

This is important work. It is highly unlikely that eating disorders could ever be reduced to biochemical disturbances in the brain. There are so many environmental factors, for instance sexual abuse or other types of trauma, and even social pressure, that have been implicated in the etiology of the illness.

But the key point is this: why do some people develop an eating disorder after trauma while other do not? And why do some people develop eating disorders, even when they have never been traumatized in their lives?

The answer as always lies in the ways in which genes and the environment interact. If confirmed, this research may point the way toward some new ways of helping some people with this group of illnesses.

Food, Reward and Weight Gain

There’s a short review with a link to an online research paper that you might find interesting.

Although the paper has to do with the mechanisms of weight gain in people with schizophrenia, many of the same principles apply to many people with weight problems. The systems of the brain involved in salience – deciding what is important in the environment – appear to be disrupted.

Gene-Jack Wang at the Brookhaven National Laboratory has discovered that the brains of morbidly obese people seem constantly to be turned toward finding food: The regions of the brain connected to the mouth lips and tongue are overly active, and, like the addicts who get the biggest rush from drugs, they seem to have fewer dopamine receptors in the reward systems. Perhaps like the addict, the morbidly obese eat to compensate for an underactive dopamine system.

In Healing, Meaning and Purpose, we coined the term, “Salience Disruption Syndrome,” to describe a group of problems that are normally thought of as separate entities, but which are inextricably linked. They include not just over-eating, but:

  • Impulse control disorders
  • Substance abuse disorders
  • Pathological gambling
  • Pathological shopping
  • Attention deficit with ot without hyperactivity
  • Bipolar disorder

The list is a long one and the reason for highlighting it is that we have been able to devise new treatments based on this new principle of a disruption in salience. If there is interest, I shall post some more about the methods that we have devised.

Appetite Suppression

Appetite is a complex phenomenon controlled by many neurochemical and hormonal signals, as well as psychological and social factors.

An article by a group of investigators lead by Gilles Mithieux from the French research body, INSERM, published in the journal Cell Metabolism, may explain why many people on high protein diets, like Atkins, report a reduction in their hunger pangs.

The study was done in rats that were fed a high protein diet. It was found that this diet increased the activity of genes involved in glucose production in the animals’ small intestine. This increased glucose production was sensed by the liver and then chemical signals were relayed to the brain indicating that the stomach was full, and thus causing the animals to reduce their food intake.

Previous research has indicated that high protein diets do not seem to do anything magical to metabolism, but may work by reducing the overall intake of calories. The same effect on intestinal glucose production can be achieved with a low carbohydrate diet, showing us that both types of diet are probably working by the same mechanism. There are some interesting points here:

1. This study re-affirms the importance of calorie reduction as the key to weight loss, and it answers the “how” question: how do some of these diets work?

2. It illustrates something that is not widely known: glucose is produced in many parts of the body and glucose is a key regulator of appetite. The vast majority of the glucose circulating in your blood has come from the liver, and not directly from what you eat. It is only if you soak yourself in simple carbohydrates, as might happen if you drink something containing a lot of sugar, that your blood glucose may rise. But in most people who have healthy metabolism, the body rapidly corrects the elevated glucose.

3. The types of genes being stimulated to work in the intestine cannot be stimulated indefinitely. Eventually they will stop responding. You can only fool the body for a limited amount of time. That would explain why so many people who lose a lot of weight on one of the popular diets, find that the weight does not stay off. The lesson must be to make small but significant dietary changes, with the emphasis on keeping your food intake balanced. (You might like to have another look at my entry from January 6th)

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