Healthy Eating & Eating Disorders - Anorexia, Bulimia, Binging

- [Andrew Huberman] Welcome to the Huberman Lab Podcast,

where we discuss science

and science-based tools for everyday life.

- I'm Andrew Huberman.

And I'm a Professor of Neurobiology and Ophthalmology

at Stanford School of Medicine.

Today, we are going to talk all about healthy

and disordered eating.

And indeed, we are going to talk

about clinical eating disorders,

such as anorexia, bulimia, and binge eating disorder,

as well as some other related eating disorders.

However, before we get into this material,

I want to emphasize that today's discussion will include

what it is to have a healthy relationship with food.

We're going to talk about metabolism.

We're going to talk about how eating frequency

and what one eats influences things like appetite

and satiety, as well as whether or not we have a healthy,

psychological relationship to food and our body weight

and so-called body composition, the ratio of muscle to fat,

to bone, et cetera.

So, as we march into this conversation,

I'd like to share with you some interesting

and what I believe are important findings in the realm

of nutrition and human behavior.

I know these days,

many people are excited about or curious

about so-called intermittent fasting,

intermittent fasting is as the name implies,

simply restricting one's feeding behavior,

eating to a particular phase of the 24 hour

or so-called circadian cycle.

Other forms of intermittent fasting involve not eating

for extended periods of time for an entire days,

or some people will extend to two days

or three days typically.

And hopefully they will drink water during those times,

sometimes referred to as water fasting,

which means that they are ingesting fluids.

And hopefully they are ingesting electrolytes such as salt,

potassium and magnesium as well,

because well one can survive for some period

of time without ingesting calories,

it is extremely important to continue to ingest plenty

of fluids and electrolytes.

And the reason for that is that the neurons of your brain

and body that control your movements, your thoughts,

clarity of thinking in general, et cetera,

is critically dependent on the presence of adequate levels

of sodium, potassium and magnesium, the electrolytes.

And that's because neurons can only be electrically active

by way of movement of particular ions,

which include things like sodium potassium and magnesium.

So, without those,

you can't think, you can't function and it actually

can be quite dangerous.

So, why all the excitement about intermittent fasting?

Well, a lot of the excitement relates to work that was done

by a former colleague of mine,

down at the Salk Institute for Biological Studies

in San Diego, named Satchin Panda,

Satchin's lab identified some very important

and impactful health benefits of restricting

one's feeding window to particular within the 24 hour cycle,

or even to having extended fasts that go for a day

or two days, or maybe even three days.

What they saw was an improvement

in liver enzymes and improvement in insulin sensitivity,

which is something that is good.

It means that you can utilize the calories

and the blood sugar that you happen to have,

being insulin insensitive is not good,

and is actually a form of diabetes.

What Satchin's lab and subsequently other labs showed,

was that restricting one's feeding window to anywhere

from four to eight or even 12 hours

during each 24 hour cycle was beneficial in mice.

And some studies in humans have also shown

that it can be beneficial for various health parameters.

However, the excitement about intermittent fasting seems

to be related to the foundational truth about metabolism

and weight loss and weight maintenance and weight gain,

which is that regardless of whether or not you intermittent

fast or whether or not you eat small meals all day long,

or you eat one meal in the evening and snack up until then,

it really doesn't matter in the sense that the calories

that you ingest from whatever source,

are going to be filtered through the calories that you burn,

by way of exercise, basal metabolic rate,

which is just the calories that you happen to burn,

just being alive and thinking and breathing

and your heart beating, et cetera.

And the reason why many people will prefer intermittent

fasting to other forms of let's just call it what it is diet

or nutritional framework is that many people find it easier

to not eat, then to limit their portion size.

And here I'm not talking necessarily about eating disorders.

I'm talking about the general population.

So, I think that's one reason why there's so much excitement

about intermittent fasting.

Now, within the context of intermittent fasting

on a circadian timescale, once every 24 hours,

you generally find two categories of people,

people who prefer to not eat in the morning,

either because they are not hungry in the morning,

or because they find it relatively straightforward

to just drink things like coffee or water, et cetera,

and push their feeding window out to noon or 2:00 P.M.

or 3:00 P.M. and then they'll eat between,

say 1:00 P.M. and 8:00 P.M. or 9:00 P.M..

It depends on the individual.

Other groups of people find that they are very hungry

when they wake up in the morning,

they don't feel well if they don't eat breakfast.

And so they prefer to eat early in the day,

but then they limit their feeding window such that they cut

off their food intake or stop ingesting any calories

of any kind, somewhere around 5:00 P.M.

or 6:00 P.M., et cetera.

So, the duration of the feeding window

has not been broken down into the kind of nuanced type

of information that one would really want.

At least not in human studies saying,

well, a six hour feeding window

or an eight hour feeding window is ideal.

It really is going to vary based on lifestyle

and circumstances, for instance,

some families really want

to eat dinner together every night.

So, do you want to be the person that's sitting

there watching everybody eat?

Because you're fasting from 5:00 P.M. onwards?

I don't know.

That's an individual difference.

What you can start to identify, however,

is that people tend to fall into either one category.

The other people who prefer to skip eating in the morning

or people that prefer to,

or managed to skip eating in the evening.

And there has been no evidence thus far,

that one is better or worse,

at least in terms of weight loss

or overall health parameters.

Now, you can imagine that some people

might eat breakfast and dinner.

And indeed I have several many colleagues

in fact who just choose to skip lunch,

because they're busy during the day,

they eat breakfast and dinner, that doesn't afford the long,

fast associated with sleep.

What do I mean by that?

Well, if you went to sleep at 11:00 P.M.

and you wake up at 6:00 A.M.

by extending your fast until 1:00 P.M. in the afternoon,

you get quite a long period of no ingesting any calories.

Whereas when you don't eat during the middle of the day,

you are getting a fasting period.

That's probably anywhere from four to seven hours,

but it's not linked to the longer fasting period

of not eating while you are asleep, because most,

all people and I want to emphasize most,

do not eat while they are asleep.

But we are going to talk about any new disorder

that does exist, where people actually eat in their sleep.

I know it sounds pretty wild, but indeed it,

that eating disorder does exist.

And it has a very interesting underlying mechanism.

So, why are we talking about this?

And in particular, why are we talking about this during

an episode that includes a discussion

about eating disorders?

The reason is, nobody not the government, no nutritionists,

no individual, no matter how knowledgeable

they are about food and nutrition and food intake,

can define the best plan for eating for any one individual.

I'm going to repeat that.

Nobody knows what truly healthy eating is.

We only know the measurements we can take, liver enzymes,

blood lipid profiles, body weight, athletic performance,

mental performance, whether or not you're cranky all day,

whether or not you're feeling relaxed,

nobody knows how to define these.

And these have strong cultural and familial

and socio-societal influence.

So, if you hang out with people that intermittent fast all

day, that will seem normal.

If you spend time with people that have never heard

of intermittent fasting,

intermittent fasting is going to seem very abnormal.

Now we are going to talk about eating disorders

that really fall into the category

of clinically diagnosable eating disorders,

for which there's actually serious health hazards

and even the serious risk of death,

we will get to that topic.

But for the time being,

I want to emphasize a new set of findings

that I think many people will find interesting.

And at least we'll want to consider in light

of their current nutritional plan or pattern of eating,

whether or not you're intermittent fasting or not.

And I want to cue up an important framework

for the rest of the conversation on healthy

and disordered eating,

which includes an understanding of thinking, decision-making

and what we call homeostatic processes,

meaning regulation of things that are going on in our brain

and body and reward mechanisms.

So, I'm going to return to that in a moment,

but first I want to share with you these new findings

that were just published in the Journal Cell Reports,

a Cell Press Journal, excellent journal.

This was a study that was performed both in mice

and it included a crossover study with a human population.

The human population was women,

but it relates to a previous study that was also carried

out in men.

I'm going to simplify this study.

We will provide a link to the full study so you can explore

it in more detail.

And if you're really excited about the results,

I would encourage you to explore some of the references

within that paper as well.

What was the study?

The study looked at giving mice or humans, two meals.

And explored whether or not putting those meals early

in the day or late in the day,

had an impact on muscle hypertrophy,

muscle growth and overall protein synthesis of muscle.

So, when we eat, the amino acids from various foods

are broken down and synthesized

into different types of tissues.

They can be utilized for energy,

burned up for moving about and thinking et cetera,

or it can be synthesize.

Those amino acids can be synthesized into skeletal muscle.

The sorts of skeletal muscles that allow you

to move your limbs.

This study explored how protein intake,

which included what are called branch chain amino acids,

and amino acids, like leucine,

which are important for muscle protein synthesis.

Explored whether or not emphasizing

or skewing the protein intake toward early day

or late day was better in terms of muscle hypertrophy.

And they also looked at some parameters of strength,

like grip strength.

Now mice are nocturnal.

So, before you say wait, mice are nocturnal,

how did they look during the day?

And it's completely,

it doesn't apply because it's in mice.

Of course they knew that.

And they looked during the mice's active phase

of their circadian cycle, which corresponds to our day.

And in humans, they looked at whether or not eating

most of one's protein early in the day,

was better than if the protein intake

and the sprint chain amino acids

were placed later in the day.

And yes, they had the mice do resistance training.

They did that by emphasizing overload to one limb

of the mouse.

And that actually generates hypertrophy.

It's a form of resistance training in mice.

So, they don't have them weight training.

They weren't doing curls and dips and squats

and things of that sort.

They were moving their own body weight,

but they skewed that distribution of body weight

by restricting a limb and forcing them to use one limb

that did indeed grow in response to that.

And then in humans,

there was an exploration of grip strength.

And then with resistance training that was also carried

out through a peripheral study.

Basically the takeaway from this study was that mice

and humans can utilize amino acids that are ingested early

in the day,

better than they can utilize amino acids ingested later

in the day in particular toward muscle hypertrophy

and growth or maintenance of muscle,

which for those of you that aren't interested

in much muscle hypertrophy that aren't trying

to grow your muscles.

I've talked before in the episode on building strength

and hypertrophy, that maintaining muscle,

regardless of one's athletic prowess,

regardless of one's age is extremely important

because loss of skeletal muscle

is one of the major causes of injury.

As we age.

It's one of the major causes,

believe it or not, of cognitive and metabolic deficits

as we age.

So, maintaining muscle is important.

Building muscle might be important to some of you,

but what they found was ingesting protein early in the day.

And these amino acids early in the day,

led to more muscle hypertrophy than if the majority

of amino acids and proteins were ingested late in the day.

So, this translates to intermittent fasting,

such that if you are interested in muscle hypertrophy,

you might, and I want to emphasize,

might consider making sure that you're getting sufficient

protein intake early in the day.

What sources of protein you use,

is going to be highly individual.

Some of you are meat eaters.

Some of you don't eat red meat.

Some of you eat chicken and fish and eggs.

Some of you don't, some of you are vegans.

It has been shown that the amino acid leucine is vital

for the cell growth process,

including muscle growth, because of its relationship

to the so-called mTOR pathway,

mammalian target of rapamycin.

We can talk about that more if you like in a future episode,

this means that if you're somebody who wants to maintain

or increase the amount of muscle mass that you have,

ingesting a high protein meal early in the day ought

to be beneficial for that.

Does it mean that you should not eat protein

in the afternoon and evening?

No.

I think a lot of people might've misinterpreted this study

and I don't want that to happen.

This is only pointing out the fact

that ingesting sufficient quality amino acids,

including leucine, early in the day can be beneficial

for maintenance and growth of muscle tissue.

It does not say that you should avoid protein later

in the day.

Now for you intermittent fasters, this could be relevant.

I, for instance,

with somebody who for a very long time skipped breakfast,

my first meal of the day would be in the early afternoon,

mostly protein and salad, in my case, animal protein.

'Cause that's in alignment with my values.

Then in the evening I would eat pasta,

vegetables, et cetera.

I might have some protein,

some small piece of fish or chicken or something like that,

but I didn't really emphasize that.

On the basis of these results.

I am experimenting with.

I want to emphasize experimenting with,

I haven't completely tossed out my old protocol,

but I'm experimenting with eating proteins early in the day

and eating lunch.

And then dinner might be light supper of some sort,

but not so much protein later in the evening.

Again, if you want to eat six meals a day,

you want to eat round the clock.

I'm not going to stop you.

I'm not telling anybody what to do.

As I mentioned earlier,

nobody knows exactly how to eat for one's particular goals.

But this study was really interesting,

because it really did show that we can utilize

the proteins that are ingested early in the day,

better than we can utilize the proteins that are ingested

later in the day.

And of course there will be factors that can shift that.

For instance, if you work out very hard

with resistance training later in the day,

resistance training is known to increase protein synthesis.

So, it stands to reason that ingesting amino acids

after that training would be beneficial.

However, in this study,

it did not seem to matter when the resistance training fell

within the 24 hour schedule.

The morning ingestion or early day ingestion

of amino acids seemed to be beneficial.

How early?

Between the hours of about 5:00 A.M.

and 10:00 A.M. for humans.

Now just a bit of mechanism to explain why this happens.

So, why would it be that ingesting protein early in the day

would lead to more synthesis of muscle

than ingesting protein later in the day?

And the reason it turns out is related

to the circadian clock mechanism

that is present in all cells, including muscle cells.

So, muscles have fibers.

I think most people are aware of that,

that your muscles are not just one big blob of tissue.

A lot of these little fibers that contract.

Within those fibers, however, there are cells with nuclei.

Those nuclei contained DNA.

DNA is transcribed into RNA.

RNA is translated into proteins.

The DNA of your cells,

including these muscle cells

are under strong circadian regulation.

Each one has a pattern of gene expression that is different

at different times during the 24 hour cycle,

this is an unescapable reality of all cells in your body,

right from your hair cells to your brain cells,

to your retinal cells, to your toe on both feet.

These cells make a gene called, BMAL, BMAL, B-M-A-L

is a clock gene.

And the expression of this clock gene varies

across the 24 hour cycle,

and proteins that are downstream

of this BMAL gene influence protein synthesis.

The circadian regulation of this BMAL gene turns

out to be vitally important

for this protein synthesis mechanism.

How do we know that?

Well, in this particular study,

because they had a mouse that lacked BMAL,

the gene was knocked out, they had bunch of these mice.

They were able to explore whether or not this early day

feeding effect was present or absent

in these mice that lack the gene BMAL.

And indeed it was absent.

In other words,

the effect of increased protein synthesis early in the day

was eliminated in the absence of the BMAL gene.

So, what this means is that when you wake up in the morning,

assuming you're following a standard schedule

of being asleep at night and awake during the day,

your muscle cells are primed to incorporate amino acids

and synthesize muscle,

regardless of whether or not you weight trained

the night before 8:00 P.M.,

or you don't weight train at all,

or you weight train afterwards or before.

I said five to 10:00 P.M. is the sort of critical

window for this increased protein synthesis.

All this means is that if you are interested in maintaining

or enhancing muscle tissue volume,

that you might want to consider eating quality,

protein and amino acids early in the day,

you could train first.

You could train after, you can not train at all.

That's entirely different discussion.

What is quality protein,

well quality protein is going to be a protein

that includes most of the essential amino acids.

And in particular leucine.

Now, there's a lot of debate as to whether

or not you can get all the essential amino acids

from a purely plant based diet

or whether or not you need

to ingest animal-based foods or not.

The term quality protein

has no strict scientific definition.

Some people define quality protein as a protein

that has a high essential amino acid to caloric ratio.

Now, what that means is, a small piece of chicken

or steak or eggs for instance,

will have many essential amino acids

with a low caloric content relative to say beans

or plant-based food that can also get

you essential amino acids,

but it requires more calories to access

those essential amino acids.

Now that's that has many exceptions and nuances.

And I for one, and perfectly respectful of the folks

that just want to ingest plant-based foods in order to get

their high quality protein.

I think that actually can be done.

One has to be careful and thoughtful in their choices

about how to do that.

So, this really isn't about animal based

versus non-animal based foods.

This is about getting quality amino acids early in the day

from whatever foods are in alignment with your particular

values in your particular eating plan.

So, that's a lot of information,

but the key takeaways are every cell in your muscles

has a clock gene.

The clock genes vary such that protein synthesis

is greater early in the day than it is later in the day,

such that in both mice and in humans,

ingestion of quality proteins early in the day will be more

so incorporated into muscle.

Than the proteins that are ingested late in the day.

And of course there are the caveats of if you're training

hard late in the day,

if you're adjusting your hormone status

through whatever mechanism et cetera,

protein synthesis can also be high later in the day.

But for most people it's going to taper off due

to this circadian BMAL gene related mechanism.

Again, we will provide a link to the study

and the other key takeaways were that nobody knows.

Nobody can tell you what healthy feeding windows are,

what the best feeding windows are.

There's absolutely no information in that context,

you talk to 10 nutritionists or academics or trainers

or individuals about what healthy eating is,

and you are going to get vastly different answers.

And that's one of the reasons why I believe

that the internet in particular social media,

are so filled with contradictory opinions,

but the calories in versus calories burned formula,

is that more or less holy foundation of all things

about nutrition, eating and weight.

And as we transition today into the discussion

about eating disorders,

I'd like you to keep this in mind because for the treatment

of eating disorders,

it doesn't matter what psychological

or early trauma based effects led to the eating disorder.

If the person isn't adjusting their feeding behavior

in a way that is going to ameliorate the symptoms

of that disorder, which is ultimately the goal.

Before we begin, I'd like to emphasize that this podcast

is separate from my teaching and research roles at Stanford.

It is however, part of my desire and effort

to bring zero cost to consumer information about science

and science related tools to the general public.

In keeping with that theme,

I'd like to thank the sponsors of today's podcast.

Our first sponsor is Belcampo,

Belcampo is a regenerative farm in Northern California

that raises organic grass fed

and finished certified humane meats.

I don't eat a lot of meat, but I eat meat about once a day.

That means a small piece of steak or chicken, et cetera,

and usually a salad.

I usually do that for breakfast or for lunch.

And then in the evening I tend to follow a more

or less vegetarian diet.

I tend to eat pastas and vegetables and things of that sort.

Well I don't eat a lot of meat.

It's important that the meat that I eat be a very high

quality and that I am certain that the animals were raised

and treated humanely up until the point of slaughter.

Belcampo's animals, graze on open pastures

and seasonal grasses, their entire lives resulting

in meat that's higher in nutrients and healthy fats.

It also results in healthy happy cows.

Often talk about how important omega-3 fatty acids are.

They've been shown to be important for regulating mood,

for the microbiome,

for restricting inflammation in the brain

and elsewhere in the body.

Belcampo's meats are known to be high in omega threes.

And given that the meat is grass fed and grass finished,

that combines all the features of the nutrition

and the animal wellbeing that I want to see

for any meat that I ingest.

If you'd like to try Belcampo, first-time customers can get

20% off by going to belcampo.com/huberman

and using the code huberman@checkout,

that's belcampo.com/huberman for 20% off.

Your first order.

Today's podcast is also brought to us by Headspace.

Headspace is a meditation app.

That's backed by 25 published studies

and has over 600,000 five-star reviews.

I've been meditating for a very long time.

Although I admit I meditate on and off,

meaning I'll go a few weeks or months meditating regularly.

And then I tend to stop.

A few years ago, I got into a regular meditation practice

because I started using Headspace meditation app.

The thing I really like about their meditation app

is it has meditations of different durations.

So, sometimes I'll just meditate for three minutes

or five minutes,

or ideally I'm doing two 20 minute sessions per day,

but I confess I don't always manage that,

but they have a ton of different meditations

on the Headspace app that allow you

to tailor your meditation practice

to your particular schedule.

And there are now a plethora of studies showing the benefits

of a regular meditation practice.

If you want to try Headspace,

you can go to headspace.com/special offer.

And if you do that,

you'll get a free one month trial with Headspace's full

library of meditations.

You get them all.

That's the best deal offer by Headspace right now.

So, again, if you're interested,

go to headspace.com/specialoffer.

Today's episode is also brought to us by Athletic Greens.

Athletic Greens is a vitamin mineral probiotic drink,

and it's one that I've been drinking since 2012.

The reason I started drinking Athletic Greens and the reason

I still take Athletic Greens is that it really helps me

cover all of my nutritional basis with respect to vitamins

and minerals and probiotics.

And we now know that a healthy gut microbiome

is supported by probiotics.

And for me,

Athletic Greens is the best way to get those probiotics.

I also ingest some fermented foods,

but by ingesting Athletic Greens,

I'm certain to get all the things I need.

And also, I just feel better when I drink it.

I genuinely feel like I have more energy

and I just feel better.

And I happen to really like the way it tastes.

I mix mine with some water and some lemon juice.

And in doing that, I'm certain to get all my nutritional

basis covered and the probiotics support

a healthy gut microbiome,

which is important for mood,

regulating inflammation and so on.

If you want to try Athletic Greens,

you can go to athleticgreens.com/huberman.

And if you do that, you can claim a special offer.

They'll give you five free travel packs.

In addition to your Athletic Greens order,

those travel packs make it really easy

to mix up Athletic Greens while you're on the road,

in the car, on the plane, et cetera.

And they will give you a year supply

of vitamin D3, K2,

vitamin D3 and K2 have been shown to be important

for blood lipid profiles for metabolism and a whole bunch

of other metabolic and neural processes.

So, go to athleticgreens.com/huberman

to get the Athletic Greens,

the five free travel packs and the year supply

of D3 and K2.

So, let's talk about eating disorders.

And as we do that, I want to emphasize again,

that nobody can really define what healthy eating is,

with a single protocol.

However, there is some general agreement

about what unhealthy and disordered eating is.

There are clear criteria in the psychiatric

and psychological communities to define things like anorexia

bulimia, binge eating disorder,

all of which we will talk about,

but as we have that discussion,

I want to emphasize that self-diagnosis

can be both a terrific, but also a very precarious thing.

We talked about this a little bit in the episode

about depression, there's always a temptation as one learns

about the symptomology of a given disorder.

It doesn't really matter what the disorder is,

to ask the question.

Well, do I have that?

Does so-and-so that I know have that, ah,

I see this sort of behavior or that pattern of thinking.

In that individual, it's tempting to diagnose them

and or ourselves as either having or not

having a particular disorder.

However, diagnoses really need to be carried out by people

who are trained in that particular field,

and that have deep expertise in recognizing

the symptomology, including some

of the more subtle symptomology of eating disorders.

So, if any of the symptoms resonate with you,

by way of you thinking

that you have this particular disorder or someone that,

you know, has this disorder, I would take that seriously,

but I would take that information

to a qualified healthcare professional that could diagnose

or rule out any of these possible disorders.

I say that not to protect us,

but to protect you, because information is valuable.

And I do believe that knowledge of knowledge

can be very valuable in navigating any topic

and improving our thoughts and behaviors around that topic.

But one doesn't want to, or I should say,

one, shouldn't start to self-diagnose simply on the basis

of information without running that through the filter

of a qualified professional.

So, what is an eating disorder?

Well, we have to take a step back,

and confess to the fact that every society, every culture,

every family, and every individual

has a different relationship to food,

eating disorders, however, have particular criteria

that allow us to define them and to think

about different modes of treatment.

As it relates to the particular symptoms and particular,

the psychological and biological symptoms

of those disorders.

Now that's a mouthful, no pun intended.

What are the major eating disorders?

Anorexia nervosa, most commonly referred to as anorexia

is perhaps the most prevalent and the most dangerous

of all eating disorders.

In fact, anorexia is the most dangerous psychiatric disorder

of all, even more than depression.

The probability of death for untreated anorexia

is very high, and sadly the prevalence

of anorexia is very high.

So, what is anorexia and how prevalent is it?

Anorexia, if you look it up online or you talk

to a qualified professional, is essentially a failure

to eat enough, to maintain a healthy weight.

You can see all sorts of very troubling symptoms of somebody

who's been anorexic for some period of time,

a general loss of muscle mass because they're ingesting

fewer calories than they burn.

Muscle is very metabolically active.

They tend to lose a lot of muscle mass.

They will have a low heart rate.

This is the body and brain's attempt to lower energy output.

They will have low blood pressure.

They'll sometimes have symptoms like fainting.

They will have sometimes even hair growth on the face,

something called lanugo,

which is essentially the body's attempt

to insulate the body because of loss of body heat.

When you're that thin.

Loss of bone density,

osteoporosis, loss of periods in girls and women,

and all sorts of disrupted gut and immune functions.

So, there are just tons of terrible symptoms

of anorexia that really placed the anorexic

into a very risky state, which is why mortality

from anorexia gone untreated is extremely high.

Now, one of the misconceptions about anorexia,

is that it stems from an overemphasis on perfectionism,

or that because of all the images in social media

and in advertising of extremely thin and fit

or muscular people that individuals are looking

at themselves and comparing themselves to those images

and thinking that they don't match up

and developing anorexia,

that turns out to not be the case.

If you look at the prevalence or the rates of anorexia,

in the last 10 years or 20 years,

and you compare that to when anorexia was first identified,

which was in the 1600s, and perhaps even earlier,

what you find is that rates of anorexia are not going up.

So, this idea that the images that we're being bombarded

with are causing anorexia doesn't seem to be true.

Now, that is not to say that the images

that we in particular young people are being bombarded

with are healthy for the psychological state of mind.

But classically define anorexia has existed at essentially

the same prevalence for the last 100, 200,

300 and 400 years,

which is incredible and really speaks to the likelihood

that there's a strong biological contribution

to what we call anorexia nervosa.

Anorexia nervosa is extremely common.

It's anywhere from one to 2% of women.

And the typical onset is in adolescence close to puberty,

but it can show up later in life as well.

In fact, the identification and diagnosis of anorexia tends

to be in the early '20s.

But if you look back at the history of those individuals,

there were typically signs of anorexia that back

into their early teens.

Or maybe even before that.

Now, of course, men can be anorexic as well,

but anorexia nervosa does seem to occur at 10 times the rate

in women and young girls,

than it does in men and young boys.

So, while there does seem to be more

of a prevalence of anorexia in boys and young men,

these days, that's probably due to better diagnosis

and detection than it is to some sort

of societal shift related to imagery, et cetera.

Later, we will talk about body dysmorphia

and some of the images that are present in media

and social media and how those are impacting other forms

of eating disorders.

But when you look at anorexia nervosa,

this failure to maintain weight,

even to healthy levels and often drops in weight

that are very dangerous or even deadly,

that has existed for a very long time,

and seems to be somewhat hardwired into the biology

of individuals that suffer from it.

Now, when I say hard wired,

that doesn't mean that it can't be treated or cured,

and indeed it can.

Bulimia which is defined as binge eating or overeating.

Let me explain what that is.

Binge eating is consuming vast amounts of calories

in a short period of time.

Overeating can be ingesting more calories than one needs,

but over an extended period of time,

both can exist of course, but bulimia is also very common.

It's more common in young girls

and in women that it is in young boys and in men,

but it is present in both sexes.

Bulimia and rates of bulimia might be increasing.

That's sort of an interesting finding.

It's not quite clear whether or not it's existed

in its same form for a long period of time

or within other new forms that are evolving or showing up,

we're going to drill into bulimia

and what it actually is and what it represents.

But one thing I want to be clear about,

just as the perfectionist mindset has been associated

with anorexia, and it turns out that's not the case.

It can be, but it's not always associated with anorexia.

There was the idea that bulimia is associated

with early trauma in childhood, in particular sexual trauma.

And while that can be the case,

there's no direct correlation between the two.

Now, obviously psychological phenomena and trauma

can have a profound impact on the way

that the brain wires up and the way

that people approach food and other types of behaviors.

But the sort of classic idea was that all anorexics

are perfectionists, they want to perform well.

It's all about control and autonomy.

And bulimics are kind of dysregulated and acting

out against some early sexual trauma,

those stereotypes of the psychological framework

of anorexics and bulimics, doesn't hold up.

When you look at the data, many,

many meta analysis have been done.

It just simply is not the case.

And in both instances, both anorexia and bulimia,

there are clear biological underpinnings,

to what's driving the under-eating or the overeating.

So, we're going to talk about the biology of under eating

and overeating and appropriate levels of eating.

And by doing that,

we will start to identify some of the mechanisms

that serve as entry points for the treatment

of both anorexia and bulimia.

And as some of you are probably aware,

anorexia and bulimia can be comorbid,

they can exist with one another.

There are anorexics who will binge and then purge

in order to maintain that unhealthily low weight.

There are bulimics

who fit the psychological criteria of anorexia.

And so there's a lot of overlap

between those two categories.

Now let's talk about the categorization for a second and why

the categorization has led to now a bunch

of other eating disorders as defined

by the psychiatric community.

One of the classic symptoms of anorexia

is a loss of menstrual cycles, loss of periods.

And the reason for that is when the body is undernourished,

the body fat stores, send signals to the brain

to inform that the body is undernourished,

or they turn off the signals that say, look,

there are enough body fat cells out here

to support healthy metabolism.

And therefore let's shut down ovulation,

literally signal sent from the fat and muscle

to the brain and the brain,

the hypothalamus and pituitary will send signals down

to the ovaries,

or they will turn off the signals heading to the ovaries

to deploy eggs,

to maturation of eggs in the follicle, et cetera.

So, there are instances in which people have anorexia

or have bulimia,

but are still maintaining healthy menstrual cycles

or at least menstrual cycles.

And that has led to a whole set of other categorizations

of eating disorders, like binge eating disorder,

where there tends to be a lot of overeating,

but not the purging or categorizations of anorexia,

in which people are under feeding,

but they are not losing their periods.

And so these have a number of different names and acronyms.

Some of them include things like, EDNOS,

EDNOS is eating disorder, not otherwise specified.

So, that's a sub categorization or OSFEDs.

So, OSFEDs is or specified feeding or eating disorder.

So, right now,

if you were to look online or you're looking

to the psychiatric and psychological textbooks,

what you would find is that there's a huge constellation

of eating disorders today.

We're mainly going to talk about anorexia,

bulimia, binge eating disorder and body dysmorphia.

You can even find eating disorders like pica,

where people actually ingest things like dirt or rocks

or metal because they have a genuine appetite

for those things.

I certainly do not recommend sampling any

of those non food items.

As foods, is incredibly dangerous.

People often poisoned themselves.

They often can cause structural blockages

some people have died from those sorts of things.

But nonetheless, there are aspects of our brain

and biology that when disrupted can lead

to very bizarre types of eating behavior,

sometimes pica is caused by malnutrition, but not always.

And so today we're going to focus

on the most prevalent eating disorders,

but we are going to build up toward that understanding

by looking at what healthy metabolism and eating

and satiety and hunger looks like.

Because one, I realized that not everyone

out there has an eating disorder.

And two, I want people to understand this relationship

between how they think, the decisions they take

about what they eat

and how the body and the brain at subconscious levels

are driving some of these behaviors healthy or otherwise.

Because I do think that it can lead us to a better

understanding of what healthy eating is for most of us,

and to increase compassion and hopefully

even increased improvement in treatment of eating disorders

for those that are suffering from them.

So, what is hunger and what is satiety?

Satiety, of course being sated

or feeling like we've had enough food.

I want to remind people of the basic mechanisms

by which the brain and body communicate.

This is vitally important, not just for this discussion,

but for any discussion, about how we think, how we behave,

how we feel, the body is communicating two types

of information to the brain on a regular basis,

but in particular around feeding, and those two types

of information are mechanical information,

and chemical information.

What do I mean by mechanical information?

Well, if you take a deep breath, oh,

and you hold your breath,

what you'll find is that you can hold your breath

a lot longer than if you exhale all your air

and you hold your breath with lungs empty.

And the reason is not because when your lungs are full,

you have enough oxygen

and therefore you can hold your breath.

It's because when your lungs are full,

a particular class of neurons called baroreceptors,

send information to the brain and say,

there's pressure in the lungs.

And that means that there's probably oxygen in here.

And so the trigger to breathe is actually suppressed,

when your lungs are empty.

Even if you have plenty of oxygen in your system,

those baroreceptors send a different signal to the brain,

which is there's no oxygen in here and you should breathe.

And so the impulse to breathe comes earlier.

Likewise, when your stomach is full,

it sends signals to your brain that are purely based

on this mechanical fullness,

has nothing to do with nutrients, that says I'm full.

And therefore don't be as hungry.

Don't motivate to find or ingest food.

Whereas when our gut is empty,

even if we have plenty of nutrients

or plenty of body fat stores,

we tend to focus on food a bit more.

So, volume and mechanical influences have a profound effect

on how we think.

And what consider doing or not doing,

likewise chemical effects.

When we ingest food,

our so-called blood sugar or blood glucose levels go up.

That information is signaled to the brain

via neuronal pathways and hormonal pathways.

And in particular, there are neurons within our gut,

that signal to areas of our brain stem that are involved

in satiety in our sense of having enough

that there's food in our system.

So, that's chemical information.

So, how our hunger and feeding and satiety regulated

by way of mechanical and chemical signaling.

You have, I have,

we all have neurons in our hypothalamus that trigger eating

and neurons that trigger cessation or stopping of eating.

We have an accelerator on eating and we have a break.

And I covered all of this in a lot of detail in the episode

on feeding and metabolism and hunger.

So, if you want a lot more detail, see that episode,

but right now,

I'm just going to give you the top contour

of how all that works.

Your hypothalamus is an area of your forebrain,

which tells you it's in the front,

but it's at the base of your forebrain sits more or less

above the roof of your mouth.

The hypothalamus contains lots of different kinds

of neurons, including neurons that stimulate sexual activity

and desire, regulate your body temperature

and control appetite and ceasing of eating and appetite.

There are two types of neurons within a particular area

of your hypothalamus that are relevant here.

There are the so-called POMC neurons, okay?

Pro-opiomelanocortin neurons that tend to act as more

of a break on appetite,

by way of another hormone

called melanocytes stimulating hormone.

And not so incidentally when you're getting

a lot of sunlight and you're viewing a lot of sunlight,

that system is ramped up.

This is why appetite is lower in the summer months

than it is in the winter months.

This is true in animals.

And this is true in humans.

And you have a class of neurons called the AgRP neurons.

The AgRP neurons are the ones that stimulate feeding,

and they create a sort of anxiety or excitement about food,

can be positive anxiety, or it can be negative anxiety.

What do I mean by that?

Well, if you ever seen kids heading in to get ice cream,

they're absolutely excited.

You see people getting raised, sit down and eat a big meal.

They're excited to eat.

Sometimes that's due to social factors,

but they have an increase in overall levels

of autonomic arousal.

And depending on the context,

they can feel excited or anxious,

but it is a ramping up of energy.

These AgRP neurons are what caused that,

in fact so much so that if you eliminate

or kill these neurons, which has been done

in experimental mouse models in the laboratory,

but also there are humans that have lesions

or neurotoxic effects on these AgRP neurons.

And what you find is that they don't want to eat.

They essentially become anorexic,

meaning they don't want to ingest food.

They have no appetite for food whatsoever.

Now that's not exactly what anorexia is,

but these AgRP neurons are like an accelerator

on wanting to eat.

Whereas if you stimulate these AgRP neurons

or in humans that have say a small tumor near

these AgRP neurons, they become hyperphagic.

They will eat to the point of bursting,

both animals and humans that have elevated levels

of these AgRP neurons are anxious.

They want to eat,

and they will ingest food to the point where they override

those mechanical and chemical signals in the body.

And I know it sounds horrible, and it is horrible.

They will eat until the point that they burst.

Now, there are signals coming back from the body

to inform the brain about presence

of different levels of nutrients.

And that generally comes from three sources.

First of all, is body fat.

The more body fat we have,

the more we secrete a hormone called leptin, L-E-P-T-I-N,

leptin from body fat,

leptin goes to the brain and suppresses appetite.

This is a body to brain signaling mechanism that says, look,

I've had enough,

not incidentally, leptin signaling is disrupted

in people that have bulimia and obesity

and certain forms of binge eating disorder.

So, that system has disrupted they have had enough signal

or there's enough body fat here such that you don't need

to eat more right here, I'm sort of in the voice

of the body fat, trying to talk to the brain, that signal,

that dialogue is mixed up or messed up.

In some cases it's absent entirely.

So, the body fat is signaling to the brain

about how much reserve you have.

It's sort of like a savings account for energy,

'cause that's what body fat is.

You've got lipids in there and through lipolysis,

that can be metabolized.

If you're interested in that process,

both how to increase it.

And just generally how it works.

You can see the episode on the science of fat loss.

The body fat is doing something else really interesting

that relates to anorexia,

when they're sufficient levels of body fat

and leptin circulating in the blood.

And that leptin signal gets to the brain,

the hypothalamus and the pituitary gland

register that signal.

And in a completely subconscious way,

trigger the deployment of eggs in females and the production

of sperm in males.

So, when body fat stores are very low,

the reason why periods shut off or sperm production

is reduced or even shut off is because there's not enough

leptin getting to the hypothalamus and to the pituitary.

And they shut off the signals, the hormones,

things like gonadotropin-releasing hormone,

luteinizing hormone, follicle-stimulating hormone,

all these hormones.

So, you don't have to remember the names

of if you don't want to that travel to the ovary

or to the testes and cause the ovary and testes

to ovulate or to produce more sperm.

So, the reason why anorexic stopped having periods,

while they stopped cycling,

is because there isn't sufficient leptin in the bloodstream.

Now there have been attempts to give leptin to anorexics

because leptin has been sequenced and the peptide

has been synthesized.

And so you can inject leptin into people.

There are studies where they've done that,

when that happens, it does not tend to alleviate

the anorexia, does not cause

people to start eating again.

And that actually makes sense because leptin is also a way

of shutting off the hunger signals saying,

it's the body fats way of saying, hey,

there's a lot of body fat here,

or there is sufficient body fat.

There doesn't even have to be a lot, but it has,

in some cases been shown to rescue the menstrual,

cycling in some anorexics, okay?

So, body fat is signaling to the brain.

The gut is signaling to the brain.

There are neurons in your gut that are primarily responding

to meaning they fire electrical signals.

When there are sufficient fatty acids coming

from fats you ingest, amino acids coming

from proteins you ingest and sugars coming

from carbohydrates and sugars.

Things like fructose, glucose, et cetera.

Those signals are being sent from the fat and from the gut

up to the brain.

And therefore your body has multiple signals

of directing you toward eating more or eating less.

So, you've got two categories of neurons.

One that acts as an accelerator, the AgRP neuron saying,

eat, eat, and get you excited to eat.

And then you have a category of neurons.

The POMC neurons that are suppressing hunger.

They're acting like a break, and the body is informing

the brain all the time about the status

of the body and whether or not it needs more food or not.

So, you might ask why is it that people who are overweight

and have a lot of body fat,

why they would continue to eat a lot,

well past a certain threshold of body fat that's

when you start getting

into these so-called metabolic disorders,

where blood glucose metabolism is disrupted,

leptin signaling is disrupted and there are all sorts

of changes on both the brain side and the body end

of things, such that they're hungry,

despite the fact that the body has plenty

of energy on reserve.

Okay, that I think is sufficient to explain the basics

of hunger and satiety are kind of a biological mechanism.

And the important thing again,

to remember is that they're mechanical and chemical signals

that come from fullness or absence of fullness

that come in the presence of glucose in the blood

or the absence of glucose in the blood.

When you haven't eaten for a long time,

glucagon levels go up, for instance,

GLP1 levels go up and those will drive you

to seek out food and want food.

And then there are the signals that are coming from body fat

and from neurons in the gut.

So, there's a lot of convergence, in a lot of pathways.

I don't offer you all those pathways to confuse you.

I offer you those pathways to clarify the extent

to which something as simple as eating or the decision

to not eat is complicated.

We've perhaps heard,

or I've certainly heard that, oh, you know,

it takes about 20 minutes for satiety to set in,

so you should eat slowly that you won't realize that you're

full until about 20 minutes.

That's actually not true.

I don't know where that got started,

but we should probably all chew our food better

and eat more slowly,

be more mindful of what we're eating, et cetera.

So, in anticipation of this episode,

I consulted extensively with a colleague

of mine at Stanford,

who sadly for us is going off to University of Pennsylvania.

So, our losses University of Pennsylvania's win.

His name is Dr. Casey Halpern.

He's a MD, Medical Doctor and Neurosurgeon,

and a PhD who studies binge-eating disorder

and other types of eating disorders and how they arise

in the brain.

And he's developed some

really pioneering treatments for them.

We'll talk more about his work a little bit later

in the episode, but we got to the discussion

of why a body that has sufficient energy levels

would desire to eat more at all.

And this is not just the case for binge eating disorder

for bulimia, but why that would be the case.

You know, this is primitive biology

that evolved over many tens.

If not hundreds of thousands of years, you see it in mice,

you see it in humans,

very similar types of pathways and effects.

How is it that human beings who have plenty

of fat on reserve and plenty of glycogen

in their liver, et cetera.

In other words, plenty of energy, why they would be hungry,

why they would eat at all.

It seems like that just shouldn't happen.

And he had a very important,

and I think clear and intuitive way

of framing up all this stuff around eating

and motivated behaviors and how they can go awry,

not just in eating disorders, but in all of us.

Basically what he said was, from an evolutionary standpoint,

it makes sense that we should eat as often as we can,

as much as we can, and as fast as we can.

Well, that sounds crazy.

I've was told to eat not too often, not too much,

and to eat slowly and chew my food.

But as Dr. Halpern pointed out,

there are circuits in the brain to reward eating

often eating fast and cramming as much food

into you as possible.

Because from a purely evolutionary standpoint,

food was scarce, and seeking food was dangerous,

whether or not it was from animal sources or not.

And it's always been competitive, for those of you that grew

up in families with a lot of siblings.

This may resonate with you.

I just one sibling,

we were competitive about certain things,

but typically not competitive about food,

but I had friends that had a lot of siblings.

It was really interesting to see how food was served up

and how it was taken in those households.

It was like food would hit the table and it was just

an absolute war for portions and who got what

and how much and who got a slightly bigger piece

of cake, et cetera,

turned out to be a frequent happening in these meals

and that these birthday parties,

whereas the only children perhaps were used

to having more food presented to them without having

to compete with other members of the species.

Every animal, including humans has a hardwired circuit

that we were born with that pays attention

to how much food is available, how much we are getting now

and how much we are likely to get in the future.

And without going down the rabbit hole

of arcuate nucleus biology, in two sentences,

you have a hypothalamic area called the arcuate nucleus.

It's a fascinating area.

It's actually the area that houses,

these PMOC neurons and these other types of neurons

that regulate hunger and satiety.

And these neurons

in the arcuate nucleus start getting active.

When we see food and think about food,

they drive hunger, and they drive hunger

in a way that's responsive to what the food looks like,

what it smells like,

but also our prior history of interactions with that food.

And it takes into account social context,

whether or not we are going to get the whole pizza

to ourselves or whether or not there are going to be others

that we are going to have to compete with.

So, there are a lot of signals that this arcuate nucleus

in your brain are paying attention to.

So, Dr. Halpern pointed out that you actually

have an accelerator that increases your level of awareness

and anxiety and sort

of constricts your field of view and all your senses.

Anytime you interact with food and is driving

a primitive reflex to ingest as much food as you can,

as quickly as you can,

and then move on from there,

and presumably to do the same elsewhere.

So, that changed the way that I think about eating behavior

and eating disorders.

In fact, we could think about eating disorders like bulimia

as an unmasking of that mechanism

without the so-called top-down control,

without the mechanisms that we use to regulate our behavior.

And indeed bulimia and binge-eating disorder

are closely associated with impulsivity

and with impulsive behaviors of other kinds,

something that we also will discuss more.

What's the pathway?

How does this work?

What is Dr. Halpern and his colleagues doing in order

to try and treat things like binge eating disorder?

Well, you can frame all of behavior,

good decision making and bad decision-making.

In a pretty simple box diagram model.

And I realized that many of you are listening to this,

not watching this.

There is no diagram to look at.

I'll just explain it so that you can conceptualize

it in your mind.

We have knowledge of what we should do, in one box, okay?

We should eat that.

We shouldn't eat that.

We should wait for dinner.

We shouldn't wait for dinner.

And then we have what we actually do in another box, okay?

Now this is true for all behaviors,

we should say something or we want to say something,

but we don't, we shouldn't say something, but we do anyway.

That's the knowledge that kind of looping in your head.

I should do my homework.

I should go for a run.

I shouldn't do this right now.

I shouldn't be on social media,

all those kinds of shoulds and shouldn'ts

that are circulating your head.

That's one box.

Then there's what you actually do.

The behavior, whether or not you suppress the behavior,

you turn off your phone and you go read a book or you go

to sleep or whether or not you stay up all night,

or you stay up for another hour, even five minutes.

In between those two boxes are two intervening forces.

And those intervening forces are critically important.

Those intervening forces are homeostatic processes,

called by some processes, same thing,

homeostatic processes, that regulate the balance

of different systems in your body, hot and cold,

awake or asleep, dopamine and the desire to pursue things,

serotonin and the desire to just relax and chill.

So, homeostatic processes and reward systems.

And as we now move into discussion about anorexia,

and bulimia specifically,

what you'll see is that anorexia and bulimia

are not a breaking of the mindset of what one should do

or shouldn't do.

It's a disruption of these homeostatic and reward processes,

such that decision-making is completely disrupted.

And in many cases is not available

to the anorexic or bulimic.

Now, I don't want to be abstract here.

What I'm saying is that the person who starves themselves

to the point where they might die and in some cases,

sadly do die.

They can know perfectly well that their behavior is leading

to bad outcomes and possibly even death.

And yet they are not able to intervene unless

they get particular clinical help,

because the homeostatic processes, the signals from the body

and brain that say, you need food.

Those aren't registering in the same way

that they are for other individuals.

and for the bulimic or the person that suffers

from binge eating disorder.

They don't necessarily want to eat that food.

They simply cannot help it.

It's like a reflex for them,

because the homeostatic processes

and the reward processes associated with food,

are such that they can't intervene

between the should do X, Y, or Z,

or shouldn't do X, Y, or Z.

And what their actual behavior is.

Now, this isn't just a biological mechanistic explanation

for what could have been summarized in two sentences.

What this is,

is a roadmap of where interventions

can really make a difference.

So, as we talk about different drug based interventions

or behavioral interventions or social interventions,

I'd like you to think

about whether or not those interventions are breaking into,

or tapping into this box of the thinking,

the sort of pattern of thinking around food,

whether or not it's the behavior,

the actual ingestion or the restriction of food,

or whether or not it's tapping into the homeostatic process,

the balance of energy systems and kind of getting enough,

but not too much, or it's tapping into the reward system.

And just as a little teaser of where we're headed,

what you'll find based on the data clinical data experiments

done very carefully and very well by excellent groups.

What you'll find is the anorexics have a sort

of switch that's been flipped,

such that their decision-making

is actually pretty darn good.

It might even be better than yours in terms

of evaluating food, nutritional content,

but their habits are disrupted.

So, they're not even consciously aware of the fact

that they're making terrible.

And in some cases, very dangerous food choices,

and turns out that habits.

And the way that we build and break and rebuild new habits

is one of the most effective treatments for anorexia.

So, now let's talk about anorexia,

this failure to consume enough energy,

such that the individuals at risk of death,

and if not death, then severe metabolic disorders,

lack of bone density, et cetera.

As I mentioned earlier,

anorexia and things that almost certainly were,

and are anorexia have been described as early

as the 1600s.

And maybe even earlier,

there are some records from the saints,

from the 1400s of people that refuse to ingest food.

Another common myth is that anorexia is only the sort

of thing that you see in rich societies.

These are spoiled children with so much food

that they decide they're only going to focus

on how slim they are,

how they look in bathing suits, et cetera, not true.

A careful analysis through medical epidemiology has shown

that you find anorexia even in cultures

and societies where food is scarce.

So, that really speaks to biological mechanism.

Now it's hard to unveil in societies where food is scarce,

because a lot of people are starving and hungry,

but there are individuals that choose still to avoid food

and seem to have some sort of reward mechanism that rewards

them, where makes them feel better if they don't eat,

despite the fact that their body

is severely depleted of nutrients.

So, that's very interesting and points again

to some disruption in some biological mechanism.

Now, I want to make sure that I'm emphasizing

that I'm not in favor of people,

in particular young children, adolescents,

and teenagers being bombarded

with unrealistic imagery about bodies.

But the idea that that's the cause of,

or is amplifying anorexia, the data just don't seem

to support that, anorexia in its classic sense,

requires that there be an endocrine,

meaning a hormonal disruption,

menstrual abnormalities, lack of sperm production,

or low testosterone in males, in order to meet

the classification for anorexia.

But as I mentioned earlier,

there are now nuanced and new classifications of anorexia

that even for individuals that still menstruate

or that maintain a sperm production anorexia,

can still be considered

a clinically diagnosable disorder.

Now, typically anorexia starts in adolescence,

right around puberty.

Let's take a look at what puberty is.

Puberty at a very broad level is the most significant

and dramatic developmental step.

Anyone goes through in their lifespan.

The body changes, the brain changes, perceptions,

change, one's own self perception, changes.

And most of those changes are driven by changes in circuitry

within the hypothalamus.

So, neurons that are controlling the production

of the so-called sex steroid hormones,

things like testosterone,

estrogen, and related hormones, prolactin, et cetera.

Those are all changing at very rapid rates.

Anorexia tends to show up around this time in a subset

of individuals who on the face of it seem to find food,

aversive, now the purely psychological theory

of this is that they are fighting for autonomy.

They want control.

Puberty is also a time in which children and parents

are in a tug of war over control.

You were once a small child being told when to go to bed

sent to your room.

Now you're a child that can talk back and say,

I don't want to, or I refuse to.

And that happens a lot in various households,

as I'm sure you're familiar with.

Adolescence and puberty

is also when girls start menstruating typically,

or boys develop deeper voice,

they start producing sperm, et cetera.

So, there are a lot of bodily changes

that also drive perceptual changes and perceptual changes

that drive bodily changes.

And it is a dramatic shift for a young girl

or boy that doesn't nourish themselves sufficiently.

During that period,

there are a number of downstream negative effects.

I'll list out some of them,

these are just a subset of the effects, hypogonadism.

That's the lack of sperm production

or healthy egg production.

There is amenorrhea,

which is the lack of menstrual cycling, okay?

So, a failure to have a menstrual cycle.

Reduced insulin secretion, insulin is this hormone

that's released in order to help shuttle glucose

into various tissues for energy utilization.

That's down because energy levels are down so much.

One of the symptoms that's a little more cryptic,

and that has actually interesting implications

for sake of the cholesterol hypothesis is that anorexics

who ingest very little food often have cosmically

high levels of cholesterol, including LDL,

low density, lipoprotein cholesterol.

You say, well, how could that possibly be?

We were all told and continue to be told

from many sources that ingestion of dietary cholesterol

is what drives high levels of bodily cholesterol.

Cholesterol is manufactured by the liver and in anorexics

who consume very little food.

They often have cosmically high levels of cholesterol,

which is one of the kind of wrinkles

in the so-called dietary cholesterol hypothesis

that all of our cholesterol that we see on a blood panel

is due to what we eat.

But the explanation for it is that under conditions

where there's not sufficient cholesterol

to synthesize the sex steroid hormones,

things like testosterone and estrogen,

which are required in both males and females,

those are made from cholesterol that the body,

the liver will start generating its own cholesterol

will often overshoot the mark to a dramatic degree.

So, the blood lipid profiles and anorexics

are often very unhealthy despite the fact

that they're eating very little food.

In addition, they tend to have elevated levels

of things like vasopressin,

which are hormones that regulate body temperature

and salt and blood volume.

They tend to have low blood pressure.

They can pass out.

I mentioned some of the other symptoms earlier.

In other words, there are a huge number

of terrible things happening.

Thyroid levels are down.

Heart rates are down, if I'm painting a very bleak

picture here is indeed a bleak picture.

So, we have to ask ourselves what can be done

for the anorexic, right?

Let's say it's a failure of the AgRP neurons

to stimulate appetite and feeding.

Let's say it's too much anxiety around food.

Let's say it's because of the way that food restriction

was used for reward in the household, right?

I'm making this up,

but you can imagine a hypothetical scenario

where let's just say the mother of a particular individual

is very vocal about her avoidance of food.

We've seen this before, right?

You've probably seen somebody who loves to cook

and prepare food, but then sits down

and doesn't seem to eat.

And they always seem to in air quotes have eaten earlier.

I ate while I cooked, I ate while I cooked, right?

These people that you never actually see eating,

we all know people like this, are they anorexic?

Possibly, we don't know.

A child observes that kind of behavior.

Maybe that individual is being always being told how

beautiful they look or how wonderful or fit they look,

what incredible meals they produce.

And you could imagine a purely psychosocial set of events

that could lead a child to be anorexic.

That doesn't seem to be the case,

at least not in terms of driving classic,

anorexia, a really extreme deprivation of oneself from food.

However, there is a strong genetic component for anorexia.

So, you could imagine a mild form of anorexia in a parent

that is supported or exacerbated by praise,

so that the person feels good from the praise

they're getting, that they want to be a low body weight

for whatever reason,

for aesthetic reasons or for whatever reasons that happened

to appeal to them.

And the child has a genetic predisposition, right?

We never think about genes in terms of controlling behavior,

genes, bias, probabilities for behavior, okay?

So, you can have a gene for depression of schizophrenia,

but it's not deterministic, in the same way

that there are genes that determine your eye color,

or your skin color or your hair color, okay?

So, there's a genetic predisposition there.

And that genetic predisposition could exist such that if one

is rewarded enough times for a particular behavior,

that behavior can start to ratchet in

to our neural circuitry,

because behavior drives neural changes,

so called neuroplasticity.

And you could imagine that that child could develop

a full-blown case of anorexia.

And this is why I raised at the beginning that no one really

knows how to define healthy eating.

And so therefore we have to rely on just identification

of unhealthy behaviors,

but what do we point people to in terms

of what healthy replacement behaviors would be.

So, rather than just look at anorexics and say,

they're not eating enough.

And there's this huge array of terrible things

that they're doing to their body, and they need to eat more.

We need to rescue them from themselves.

Let's look under the hood.

Let's look at, what's known about the neural circuitry

and the sorts of perceptions and behaviors

of the neural circuitry is driving,

in order to understand what they are truly suffering from,

at the level of cause ,not just symptoms,

it's clear what they're suffering from at the level

of symptoms, symptoms are how we diagnose.

I listed off a number of those things,

but let's look under the hood and try and identify

where one could intervene in theory,

in order to try and rescue the anorexic

or help the anorexic rescue themselves.

Because it turns out that the answer or at least one

of the answers of how to do that is not intuitive at all.

At least to me was very surprising.

I would be remiss if I didn't start with the obvious,

which is, is there a chemical defect?

Meaning is there some disruption in one of the major

chemical systems in the brain that makes anorexics anorexic

and therefore, can we replace that chemical?

Or can we reduce some chemical

and essentially eliminate anorexia?

And the answer is not really sort of maybe no,

here's why, there are a lot of different chemicals

in the brain and body,

but there are a category of chemicals that are particularly

important that if you've listened to this podcast before,

even if you haven't are going to come up again

and again and again,

and that is the category of chemicals in the brain

and body called the neuromodulators,

neuromodulators are different than neuro-transmitters

in the sense that neuromodulators modulator

or change the activity of brain areas in neural circuits,

you can think of them as microphones that are held

between particular sets of connections in the brain

that make those connections in the brain,

more likely to be active relative to others, okay?

They make them louder so to speak,

there are many neuromodulators,

but the ones that are important for sake

of today's discussion are the classic ones,

dopamine, acetylcholine,

or epinephrin and serotonin.

Let's focus on serotonin.

Serotonin is a neuromodulator that tends to increase

the activity of certain neural circuits,

including within the hypothalamus,

but also within the body that trigger a sense of satiety,

of having enough, enough food, enough warmth,

enough social connection,

enough of any motivated goal or drive or any type of thing

or behavior that one would want more of,

serotonin tends to make those circuits quiet down.

Now, there are many categories of drugs that emphasize

the serotonergic circuitry, meaning they cause the release

of, or the efficiency of serotonin in the brain and body.

Things like Prozac, Zoloft, Paxil, things of that variety.

Those drugs have been used to some degree of success.

Although not much to treat things like anorexia nervosa.

That should make sense, because if these drugs increase

serotonin, if their general effect is to increase serotonin,

it will be to lower anxiety.

That sounds like a great thing.

A lot of anorexics are really anxious around food.

We'll talk about why, lowering anxiety you might think

would lead to ingestion of more food,

but that's not often what happens, increasing serotonin,

by way of some drug regimen will tend

to make one less hungry, because with heightened levels

of serotonin in the blood and brain,

there isn't the desire to go seek out the things

that will raise serotonin on their own.

Now, some anorexics do well or benefit

from these serotonergic drugs,

these drugs that increase the activity of these circuits

that leads to satiety.

But if you think about the major goal of treating

an anorexic it's to get them

to have more hunger, more appetite.

So, now I want to focus on some of the work that's been done

around the habits and behaviors of anorexics,

because those turned

out to be ideal places for intervention.

The work I'm about to describe was done

by Dr. Joanna Steinglass and colleagues

at Columbia University in New York.

And there are other groups as well.

Of course, they're doing this type of work,

but they did what I think are really some beautiful

experiments and some beautiful explorations

of potential treatments for anorexics.

That seemed to have a quite high degree

of effectiveness when they are applied correctly.

First of all, there's a challenge in studying anorexia

because in anorexia,

what you're essentially studying is the absence

of a behavior.

It's very hard to study the absence of a behavior,

as opposed to a behavior.

So, they did some experiments with anorexics,

giving them a gallery of pictures of different foods,

and allowing those anorexia patients

to arrange those foods,

according to preference about what they would select,

about food, nutrient content about caloric content.

They essentially asked these anorexics to evaluate food,

and in doing so,

they were able to identify something that's very unique

to anorexics at the level of their perception of food.

What they found is the anorexics,

rather than being anxious in the presence of food,

and that anxiety driving and avoidance of food.

What they found is that anorexics have a hyper acuity,

a hyper awareness of the fat content of foods,

almost to the point of being sort of fat content savant.

Now they don't necessarily know that they're doing this.

They're not looking at an avocado and thinking, okay,

that's X number of grams of fat rather,

or looking at an apple and saying, okay, that has no fat.

They start to do this more or less reflexively.

Now it's a well-known symptom of anorexia,

especially young anorexics that they have kind

of an obsession with food, caloric contents,

macronutrient ratios, meaning fat protein

and carbohydrate ratios.

They know caloric numbers,

but then they sort of pass that information

into a memory system in their brain that allows

their interactions with food, to be very reflexive

in a way that they are actively avoiding high-fat content,

foods, calorie rich foods,

and defaulting towards very low calorie foods.

If they have to eat.

Now, this might seem like an almost trivial result

on the face of it, you think, okay,

they don't like to eat when they do eat.

They eat low calorie, low fat foods, duh,

but it's the way in which they are doing this subconsciously

that they learn this information and then they pass

it off to a reflexive habit.

And that's very important because what that means

is that we need to look at what processes in the brain,

what brain areas,

what chemicals drive decision-making and knowledge.

And we also need to look at the areas of the brain

that drive habit formation and habit execution,

because for any of you that have habits.

And that means all of you,

the hallmark feature of a habit is that it's reflexive.

You have a mosquito bite on your leg, you scratch it.

You didn't necessarily even think, oh,

I'm going to scratch that.

In fact, just to take a little bit of a moment of respites

and talk about habits in general,

there's a beautiful study that was done out

of Caltech University,

looking at the parking lot of where people park

in the morning, without designated parking spots,

and the trajectories that they use to walk to their offices

in the morning.

So, they put cameras up on the roof of Caltech,

is the kind of thing that the nerdy kids at Caltech do.

I think at Caltech,

if you call someone a nerdy is I think it's a compliment.

So, my apologies to the non nerds at Caltech,

I think there's one or two of you and for the nerdy ones

of you at Caltech, you're welcome.

They videotaped the behaviors of these faculty

and students and staff.

And what they found, is that people follow trajectories

from their car that are remarkably stereotype.

First of all, they tend to park always in the same spot.

If they can, they tend to get out of their car.

Of course, 'cause they're on the driver's side

or passenger side in the same place.

They turn and pivot their body at approximately

the same rate every day.

They close the door,

they've put their bag on their shoulder

or across their chest,

or however it is that they carry their briefcase

or whatever it is.

And they follow trajectories onto campus

that are so stereotyped.

That you'd wonder if you just trace line,

after line after line.

What you'd find is that every day is almost exactly the same

and you do this too.

You don't realize it because if you're being videotaped

in this kind of behavior, it's not being released to you,

but your behaviors are so stereotyped to the point

where if you were to see them laid out in front of you,

in kind of diagrammatic format of the lines

and the trajectories that you follow throughout the day,

the lifting of your mug and how frequently

you drink each hour,

you would be amazed and probably a little bit scared

by how much of a robot we all are.

Now that robotic aspect of our neurocircuitry is vital,

because it's what allows us to think about other things

and do other things, and drive other behaviors.

But the work of Dr. Steinglass and colleagues showed

that in the case of the anorexic,

those habits are exactly the place where things start

to go awry.

And that drive this very dysfunctional under-eating behavior

that sadly often leads to death

or certainly bad medical outcomes.

And it turns out that the brain areas associated

with habit formation and execution

are the best point of intervention.

So, what Dr. Steinglass and colleagues did,

is they took anorexics and they of course had control groups

and they put them in an FMRI scanner,

which are these brain scanners that allow you to evaluate

which brain areas are active, during particular tasks.

And because when you're in one of those scanners,

you actually, you know,

I've actually been in one of these things.

You're biting down on a bite bar and you're most

of the time and most all of these scanners you're immobile.

So, you're looking at things on a TV screen.

Sometimes you can press buttons to select choices

and so forth, but you can't really eat within those things.

What they found was that reward based decision-making,

the drive to pursue a particular food or the drive

to perform a particular task,

which is a lot of what we do throughout our day,

that was controlled by a brain area called

the ventromedial prefrontal cortex.

Let me simplify a little bit of this,

but I'm going to simplify it by giving you a little detail,

because it's the Huberman Lab Podcast.

And I believe in mechanism,

mechanism is the way that you get true understanding

and that you can then be very quick and give overviews

of things, but you need the mechanism.

So, you have reflexes and you have neural processes

that include what are called duration path

and outcome type processes,

a duration path, outcome type process,

we can shorten with DPO.

DPO is for all types of goal related behaviors.

So, for instance,

if you want to get a particular grade on an exam,

you want to learn something, you want to complete a workout.

You want to go to the grocery store and pick some stuff up

and then head home.

You're going to think duration.

How long do I have, okay,

do I have 45 minutes to get to the store?

How long does it take to get to the store path?

Which way am I going to drive there?

Which way am I going to navigate through the grocery store,

outcome, was able to get in and get the items I need

and get home in time, okay?

DPO, duration path outcome.

It's a very conscious process.

You tend to take into account different criteria related

to what's preventing you from accomplishing

what you want to do

and what's helping you or assisting you.

So, of course,

as you get to the checkout line in the grocery store,

you're going to select the shortest line for instance.

So, that's all DPO stuff.

It requires decision-making and it's reward-based,

you use these DPO type processes in the short term

to pick up groceries and pick a line at the grocery store

and decide which trajectory to take home.

And you use them for navigating long extended processes

in life, trying to get a degree or raise children

or get through a particularly challenging year, et cetera.

So, duration path outcome,

and that entire process relies on your fore brain.

This prefrontal cortex,

the prefrontal cortex is what allows you

to take information from memory,

combine it with information about what's happening

in the present context, and then to direct your behavior,

your speech, et cetera, toward particular outcomes.

And if all that sounds like a mouthful, it is,

and it's very metabolically demanding,

decision-making is metabolically demanding.

It takes effort, okay?

Reflexes on the other hand,

don't involve the prefrontal cortex in the same way,

habits and reflexes.

Like once you know how to walk, you get up and you walk,

you don't have to think about right foot, left foot,

right foot, left foot.

You just do it.

That doesn't rely on prefrontal cortex.

It's subconscious as it's sometimes called,

but basically you don't have to use the parts of the brain

that are involved in duration path

and outcome type analysis.

Okay, so, in this particular study,

they examined brain activity in anorexics

who are selecting different foods.

And as I mentioned earlier,

they have a hyper acuity or awareness of which foods contain

more or less calories than other foods

and what the fat content of particular foods is,

in particular, et cetera,

they're doing all this while in a scanner.

And then they look at what sorts of brain areas

are active after that task is done.

And what they found was really interesting,

what they found was that the dorsal lateral prefrontal

cortex not surprisingly is involved in the decision-making

and the evaluation of this food,

which foods are going to be best to eat in this context,

which foods are going to be appropriate for at least

that anorexics framework about what's okay to eat

and what's not okay to eat and how much.

However, there are areas of the brain that were active after

that decision-making process.

And those are the brain areas that turn out to drive

the habit of avoiding particular foods

and approaching other foods.

And in that case,

it wasn't the dorsolateral prefrontal cortex.

It was an area of the brain called

the dorsal lateral striatum.

Now the striatum is a big area in the brain.

It's involved in a lot of different things.

It includes areas like the caudate and putamen.

And I just want to mention, as I throw out all these names,

you do not need to remember the names

of these different structures.

They're just there,

if you are interested in that level of detail,

but basically you have a brain area and anorexics

have a brain area that's involved in evaluating

and decision-making around food.

And then another brain area that's involved

in the reflexive consumption of particular foods

and the reflexive avoidance of other foods.

If you remember way back at the beginning of the episode,

I feel like that was a long time ago now.

When we talked about how you have these sorts of processes

in the brain,

but there are always homeostatic

and reward systems influencing this kind of thing.

Well, in the brain of the anorexic,

it turns out that the reward systems have been attached

to the execution of habits in a way that is unhealthy

for body weight,

but at least from a purely neural circuit perspective,

the reward is now given this chemical reward in the brain,

is given for avoiding particular foods and only approaching

these very low calorie, low fat foods.

So, there really does seem to be a flip in the switch,

in the anorexic brain that rewards them internally.

They feel good when they avoid certain foods

and they approach others.

So, it's not a deprivation based model

where they are flagellating themselves or masochistic

or actively avoiding food in order to punish themselves,

which is interesting because a lot of psychological theories

support that idea.

Rather, once this transitions into a set of habits,

they are actually getting a sense of reward.

They feel good, presumably from the release

of a different neuromodulator called dopamine,

by approaching foods that are low fat, low calorie content.

And so their whole brain circuitry

is skewed toward avoiding particular things.

And they actually are rewarded for that, and they feel good.

They feel better than if they were eating

in a healthy weight supporting way.

Now the dorsolateral striatum is a structure

that we should think about in a little bit more depth.

It's part of a set of circuits that are involved

in what are called go no-go tasks.

And I don't want to go into this in a lot

of detail right now,

because it would take us too far down

the rabbit hole of neurocircuitry.

But basically in terms of behaviors,

we both have DPO type behaviors.

So, decision-making, reward based behaviors.

And we have habits that we learn and we acquire.

And then we just start to reflexively, things like walking,

things like yawning when we're tired,

things like taking a particular route

through the parking lot, right?

We learned that the first time we go to a given parking lot

and walk into a building.

But after that, we tend to follow

the exact same trajectory becomes very automatized.

It's just like, we just do it without thinking.

Well, the go no-go circuitry is another aspect

of our behavior,

where we both have to select behaviors to perform.

And we have to select behaviors to suppress.

And the anorexic brain seems to reward suppression

of one set of behaviors,

ingestion of high calorie foods, and to reward focus,

or even hyper-focus and consumption of low fat,

low calorie foods.

So, this homeostatic process that we learn

about from like high school onward,

that, oh, everything in your body is designed

to keep everything in balance.

You stay awake for a certain amount of time.

You want to sleep, you don't eat for a while.

Then you want to eat to maintain weight, right?

You eat too much.

Then you want to eat less.

Those systems are disrupted.

And so what's so beautiful about this work

from the Columbia group, is that what it says

is the place to intervene has to be the habit.

This stuff has already passed through all the learning,

it's passed through all the reward systems.

It's clearly not being overrun by the homeostatic processes

of the body.

There's very little body fat.

There's no leptin,

whatever neurons in the brain respond to leptin are starved

for leptin, periods of shutdown, sperm production,

and testosterone is lowered.

Bone density is down.

Clearly, this is overriding all those homeostatic processes,

all the signals that would say eat, eat, eat.

Those don't matter in the brain of the anorexic.

In the brain of the anorexic is just performing habits

and they're being rewarded for it.

So, when you come along and say, look,

you should really eat this whole pie or this whole pizza

you'll feel better.

That's how she aversive to them.

So, since it appears to be a habit,

a reflex that's perpetuating the anorexic phenotype.

As we say, in science,

it's perpetuating anorexia in this individual

and telling them about all this terrible stuff

that's happening in their body won't work,

taking them away from all the images

of thin people online, et cetera.

That's not going to work.

What's going to work.

What's going to work is intervening in the neural circuitry.

That's related to the habit itself.

And it turns out that there are ways to do that.

So, how do you break a habit?

How do you rewire the brain circuitry

that's literally causing a reflex?

And in this case causing a reflex

that is killing the individual,

or at least leading to very bad health outcomes.

The way that you do that is through a cognitive mechanism

where you teach the individual,

what is leading up to the habit?

This is a little bit similar to the way that somebody

who suffers from addiction starts to put

in different constraint type behaviors,

constraint type behaviors,

are the sorts of things like where the alcoholic

will call a hotel ahead of time and say, listen,

I want the mini bar taken out of the room.

I don't want a television in the room, et cetera,

constraint type behaviors.

Those are really ways of keeping oneself

from the temptation.

But with these habits,

they work at such a subconscious level.

That what seems to work best is a combination of teaching

the individual about their internal state

and how to register their internal state.

What we call interoception this ability

to perceive your internal state,

so that they can start to learn,

to associate the interactions with different types of food,

with the sorts of cues that are occurring within their body,

quickening of heart rate,

hyper acuity of focus that we talked about earlier.

Once they start to be able to notice that those things

are happening, then they can start to intervene.

So, let's talk about what those things are that lead

into a habit,

because those turn out to be the exact points of entry

for changing and eliminating and rewiring habits,

to a more healthy behaviors.

And I should highlight that this isn't just about rewiring

habits for sake of the anorexic.

These are also the same types of mechanisms that one would

want to incorporate in order to rewire any habit

of any kind.

There are two main features of thinking

that go into the sorts of habits that anorexics execute.

The first is something called weak central coherence.

Weak central coherence is essentially an inability

to see the forest through the trees.

It's a hyper acuity and focus on details

within a given environment.

And there's actually an interesting probe test for anorexia

that involves something akin to kind of a where's Waldo type

of puzzle, where an image is put up.

The one that I saw was one

in which there is a big array of coffee beans.

Actually, they're all brown coffee beans.

And your job is to identify where in that array

of coffee beans, there's a face.

And indeed there's a face embedded in there.

It looks a little bit like a coffee bean,

but once you see it, you realize it's a face,

not a coffee bean.

And it becomes very hard to not notice the face after that.

Anorexics, are very good at identifying the face.

They find it much faster than do non-anorexics,

which is really interesting, right?

They somehow are able to hone in on details

and find those details and fixate on those details.

Now eventually, most, if not all people find the face,

but once you do what you will find and what everyone finds

is that you can't unfine the face, it just jumps out.

So, what essentially you've lost is the ability

to see the whole picture,

because there's some detail within that picture

that you're obsessed by.

So, this has kind of elements

of obsessive compulsive disorder,

but it's not really obsessive compulsive disorder per se.

So, we call that weak central coherence.

It's a hyper acuity on one particular feature.

You miss the big picture.

The other is a challenge in set shifting

that once you identify something

that's of particular interest and that's driving some sort

of reward, for the anorexic

that would be identifying the high-fat foods or identifying

the one food on the table that one could eat without anyone,

hopefully noticing that they're eating just the green beans

and not touching any of the other food.

If you ever had a meal with an anorexic.

You might be familiar with this.

It's kind of uncomfortable to be around.

Actually they go through a lot of elaborate procedures

to kind of hide food too.

They'll sometimes even chew food,

hold it in their mouth and then go to the bathroom

and discard it things, very elaborate,

very troubling types of things to hear about,

and to be around.

But you'll notice that they push food

around their plate a lot.

They become masterful actually at trying

to keep people's awareness away from what they're doing,

which is to hone in on these low fat, low calorie foods.

And they can't seem to set shift.

They can't just relax and enjoy the meal, because the meal

for them is essentially like this where's Waldo

or find the face in the coffee being tasked.

They're constantly monitoring how much people are observing

them and trying to navigate this.

What would otherwise be a really pleasant circumstance

for most people they're trying to navigate

through this because remember for them,

the reward is in the avoidance of certain things

and the acquiring of only the foods

that their brain rewards them for,

because those are the foods that have been preselected

and are now habit.

What's amazing.

And frankly also important are these findings

that once you teach anorexics, what's happening to them,

that they're doing this, they are able to intervene.

Now they need support, right?

And another form of therapy that seems to work well

for anorexics that ideally is combined

with this habit rewiring, is a family-based model.

Family-based models are starting to surface a lot now

in various therapy settings,

therapy based models in short are basically

where the entire family is made aware

of the individual's challenges

with a particular eating disorder or other disorder.

And in understanding some of the biology and psychology

around it, they stopped condemning the individual.

They start to support that individual through queuing them

towards their own habits that they observe.

They give them some autonomy.

They realize that none of this changes overnight,

but they're taught about things like neuroplasticity

and the ability to change one's brain

in response to experience.

And so there's a whole internal support network.

Now, for people that live alone,

this isn't available to them.

This isn't the kind of thing that you share

with your coworkers.

You might involve a close friend or a spouse,

but it's not the sort of thing that people that don't live

in a family context can really benefit from.

All of these things fall under the umbrella

of cognitive behavioral therapy.

And I should mention that cognitive behavioral therapies

are often done in conjunction with pharmacologic therapies.

I think that there's this idea out there that it's either,

or when often it's both.

So, cognitive behavioral are often combined with this habit

recognition and rewiring approach,

which is starting to become more and more common.

And I think the date on it looked really good

that especially when it individuals are taught this early

in adolescence, that there are positive outcomes over time,

the relapse rate of anorexia is quite high.

It's about 50% of individuals will relapse at some point

often triggered by a stressful life circumstance.

But the combination of cognitive behavioral therapy

that includes this family model,

or at least habit reformulation seems

to be fairly effective.

And at present might be the most effective treatment.

Now there are additional treatments starting to surface,

and that takes us into the realm

of chemical treatments for anorexia.

And I just want to mention that there are clinical trials,

meaning legal clinical trials being done

at Johns Hopkins School of Medicine by Matthew Johnson

and others, exploring how drugs like MDMA,

which increases dopamine and serotonin to very high levels

or siliciden so-called magic mushrooms,

which increases serotonin and other compounds

to very high levels within the confines

of a professionally supported therapeutic environment

can help people rewire their brain,

such that they can get relief from major depression

and various forms of trauma.

And now eating disorders are also being explored

in the context of MDMA and siliciden clinical trials.

I do want to emphasize that those are clinical trials,

that those compounds are not yet legal.

And in many cases, most cases they are still illegal.

I do not think that they should be explored

without a properly trained medical doctor,

that the clinical trials are essential to complete before

one explores those compounds in particular,

because lately I get a lot of emails about these compounds.

People telling me that they've had amazing experiences

and relief from various things, not just eating disorders,

but depression, et cetera.

However, I get an equal number of emails from people saying

that they worked with some self appointed guide.

This would be outside the clinical trials I was referring

to, and they are now experiencing chronic visual, snow.

They're getting genuine visual field deficits.

They are havering ticks that they have never had before,

they have chronic insomnia.

So, I'm not passing judgment on any of these compounds

or the people that are doing this sort of thing.

I just want to see the clinical data.

And I do believe that we should wait until these clinical

trials are done before people start approaching the stuff.

And that's because they are serious compounds.

They can open plasticity,

but whether or not they work quote unquote

for different types of eating disorders

or depression and trauma, the data are looking promising,

but that the clinical trials are still not done.

And I know a number of people are going out of the U.S.

and into other countries where this stuff is being done

more regularly and there too.

I've gotten reports back of people doing

so-called ibogaine treatments.

Some of you who are familiar with eating disorders

will immediately be asking, well, what about ibogaine?

Does it work?

Does it work?

Well, the clinical trials in this country are not complete.

I've heard evidence direct.

I've heard directly from people who have benefited

from the sorts of things, for treatment of eating disorders.

But I've also heard of people that have developed chronic

seizure disorders from pursuing things like ibogaine

for the treatment of eating disorders.

So, again, I'm not passing judgment.

I would just like to see more data.

And it's very important that the safety aspects

of safety be in place.

So, this is definitely not something to get renegade about.

So, it appears that once anorexia has established

that habit breaking through self-awareness

of what the habits are,

is going to be a primary entry point.

That might seem kind of trivial.

You might say, well,

could you have just told us that in one sentence,

but I want to return us to this model

about homeostatic processes, reward, processes, et cetera.

That leads us to a place where the short answer is no,

you can't simply say break the habit.

An individual needs to be informed

about where that habit comes from.

And the fact that what currently seems

like a rewarded habit should actually be a punished habit.

Now, I don't mean by actual punishment,

but what I mean is within the brain,

there's been a switch and the anorexic needs

to learn that there's been a switch such that what should

be rewarding is now punished and what should be punished.

Starvation is now rewarded.

The beauty of being a human being is that knowledge

of knowledge can allow you to make better decisions.

I'll say that again,

the beauty of being a human being is that knowledge

of knowledge can allow you to make better decisions.

Now, of course, when we are anxious, when we are tired,

when we are intoxicated,

we have less access to that ability to use knowledge

of knowledge, to intervene.

The anorexic will often do things that are in keeping

with their habits, such as overexercising.

This is a area that anyone who's treated anorexics

or interacted with anorexics is well aware of,

that they are constantly moving.

They're constantly on the treadmill.

They're constantly running.

They always want to be moving and burning calories,

so that they can feel okay about interacting

with food or because they have the distorted body image.

Well, does breaking a habit mean

that they should stop moving around and exercising?

No, not necessarily.

There's some really interesting studies that show

that shifting anorexics towards activities

that for instance, build muscle resistance training

and allow them to eat a bit more food

without necessarily losing weight,

but rather to put more muscle on their body

can actually be beneficial.

Now I'm not talking about anorexics becoming bodybuilders,

has all body dysmorphia associated with bodybuilding,

but certain forms of exercise are just catabolic.

Meaning they break down the amount of muscle.

They reduce body weight, overall,

other types of exercises like resistance training

or anabolic, they allow muscle to be put on.

And there are some interesting studies, not a lot,

but some interesting studies trying to encourage anorexics,

not to stop exercising,

but rather to stop exercising in this neurotic catabolic way

of breaking oneself down,

but rather getting them shifted toward breaking habits

of only approaching low calorie, low fat foods,

while also encouraging them to embark on resistance training

and to start to learn and reward the relationship

between exercise for sake of making one's body strong,

including the bones, not just the muscles, but the bones,

which is important, especially in anorexics.

And then to see food as a way to nourish that process,

to building a body that could be of the stable weight.

Hopefully there, once the anorexic is of a healthy weight

that they're maintaining that weight,

but that they don't have to constantly be on this treadmill,

no pun intended of balancing whatever food intake

they have with activity.

And along the lines of that.

During the episode on fat loss and metabolism as well,

I talked about this neat and non-exercise induced

thermogenesis where people who tend to be thin,

tend to bounce around a lot.

They're kind of fidgety and that burns 1000

of calories a day, anywhere from 800 to 2000 calories a day.

Now that can be beneficial for the folks that are overweight

and have a healthy mindset about food,

but are trying to lose weight.

And it turns out that by, you

literally fidgeting and bouncing around, like,

this is why I'm doing this.

It looks ridiculous.

You actually burn a lot of body fat and calories.

That way provide you're in a caloric deficit,

you'll burn body fat because body fat is not just

a passive tissue.

It actually receives input from neurons

that release noradrenaline and adrenaline.

And this neat.

Has been described for several decades now.

And it actually is a pretty terrific way

to burn off more calories.

So, with the anorexic,

you actually want to encourage them to not constantly

be trying to burn off calories.

That can be very challenging.

So, shifting them toward activities like weight bearing

activities or resistance training that promote

this more anabolic type of relationship to activity,

as opposed to catabolic can be beneficial.

Before we move on to talking about bulimia and some related

disorders, I want to talk about an aspect of anorexia.

That's very interesting, quite troubling in fact,

but that has received a lot of attention

and that's the distorted self image.

Now, episode and depression,

we talked about a very powerful aspect of major depression,

which is this anti-self confabulation that people

who are depressed seem to genuinely believe.

And even confabulate about the fact

that they are performing poorly in life

and that they are no good or not, or worthless, et cetera.

It's literally a lie that they believe and their statements

and their feelings and their behaviors start

to reflect that lie.

They're not conscious of it.

That's why we call it a confabulation.

Anorexics often will see themselves as overweight

or imperfect in ways that are of an obsession for them,

they'll think, oh, you know,

their arms are a little bit fat, you know,

or, you know, the contour,

their face makes they don't like the pictures

of themselves or they.

What I'm describing here is actually pretty typical behavior

of a lot of people.

I mean, how many people do you know that after you take

a picture of them, they say, can I see the picture?

And then they tell you that you have to throw it away.

That doesn't necessarily mean they're anorexic

or they're suffering from some sort of disorder.

That just means that they're a human being that cares

about how they appear in the world.

We're not here to judge that in the case of the anorexic.

The problem seems to be that they have a genuine distortion

of their self image so much so that they don't actually see

themselves accurately, their visual perceptions are off.

And the reason we know this,

it's because of some really important

and beautiful studies that were done with my colleague,

Jeremy Bailenson's lab at Stanford,

he's in the department of communications,

he's actually collaborated

with a Dr. Halpern that I mentioned earlier.

What's really interesting about these studies is they give

us a window into the perceptual defect that anorexics have.

I've actually done one of these experiments.

I'm fortunate to not be anorexic,

but I've done some work with the VR lab over there.

And what you get to do is you get to adjust this avatar

of yourself to the point where you think it's,

as accurate as it could possibly be,

and anorexics, really distort this avatar.

In other words,

they create this serious mismatch between their perception

of themselves and the reality.

So, indeed it does seem to be the case now what's relieving,

or I should say what's encouraging

about some of the therapies that we talked

about before the family based model,

the Connie behavioral treatments.

Yes, and the drug treatments as well.

But this habit intervention model is that as one starts

to shift those things,

it does appear that the perception of self seems

to follow that the perception of self seems

to shift along with the change in habits.

And that's a relief,

or at least I find that reassuring

because changing one's perception is actually very hard,

as somebody who's worked almost his entire career

on visual perception and related things.

The perceptual apparatus of the brain are not very amenable

to neuroplasticity, meaning they don't change that easily.

Whereas it appears that the circuitry

that's related to habit formation, and decision-making

and the reward, circuitry, that stuff can be rewired.

And so anorexics as they progress

out of their anorexic state into one,

which they are intervening in their reflexes,

gaining better habits around food, eating more,

more accurately, assessing foods

and environments that they're in related to food,

as they change their behavior.

And they start to put on healthy weight,

maybe they're also doing the sorts of exercises that allow

them to put on healthy weight and avoiding kind

of extreme exercises of cannibalism

and breaking themselves down.

They also managed to somehow just as a consequence

of all that rewire their perception of self.

So, it doesn't seem that trying to tell someone,

oh my gosh, you're so thin.

You really need to eat.

That doesn't seem to work.

They just don't see themselves the same way

that you see them.

And so I offer that as a point of consideration,

if you know someone that's anorexic,

or if you look at an anorexic and you think,

how is it that they are still critical of the small,

even nonexistent amount of body fat

on their triceps or something?

How is that?

Well, it's literally that their brain,

as it relates to perceptions,

visual perceptions in particular, they're completely off.

And fortunately by changing habits,

you rewire those circuits as well.

Okay, so let's talk about bulimia,

which is overeating and then purging typically

by self-induced vomiting or by ingestion

of laxatives, sometimes also in concert

with people taking stimulants and fat burners,

over ingestion of stimulus to try and burn off more energy.

And then we'll also talk about binge eating disorder,

which has a lot of the same features as bulimia,

but typically no purging.

I'm not going to list off all the clinical criteria

that would allow someone to be diagnosed as bulimic

or binge eating disorder.

But the general features are that they ingest far more

calories than they need, anywhere from 10 to 30 times,

their daily caloric intake,

oftentimes within a two hour period,

which is just a staggering amount of food and nutrients

in a short period of time.

Oftentimes they're overriding those mechanical signals

from the body that they're full.

It's a really troubling thing to think about,

but people are literally gorging themselves with food.

This looks a lot like a laboratory animal

that has these AgRP neurons stimulated,

these neurons that will eat

until they almost burst or burst.

So, you wonder is that these AgRP neurons that are active

almost certainly yes.

That they're involved.

Although I don't think that that's going

to be the major point of intervention,

but we're going to talk about other types of interventions.

There are a number of clinical criteria.

For instance, if somebody has one of these binges

once a year, does that make them bulimic?

Technically, no, but I certainly

don't recommend people do this.

If you are one of these people

who has so-called cheat days, right?

Some of you may be familiar with cheat days.

I think they're a little less common now,

but the idea is you eat clean for six days

or five days a week or two weeks.

And then you have a so-called cheat day where you just kind

of go wild and eat whatever you want and whatever volumes

is that bulimia.

And it has some of the contour of bulimia.

If you're vomiting afterwards or binge eating disorder,

if you're not,

does it constitute full blown bulimia

or binge eating disorder?

And it's pretty hard to say,

the criteria that were described

to me is that if somebody is doing this at least once

a month, over a period of anywhere from two to three months,

then it likely would qualify.

And I certainly know people who do these cheat days

and by those criteria,

they have something like binge eating disorder.

But in general,

one of the hallmark features of bulimia binge eating

disorder is that people are unable to control their eating.

They're just simply,

they're not making the decision to have a cheat day.

They're not making the decision to overeat.

They are simply driven from the inside without question

by way of neurocircuitry.

They are driven from the inside to ingest far more food

than they need.

And in some cases than they would want to eat.

So, it's a lot like the habit

that we described for anorexia,

it's almost like it's turned into a reflux once

they get going, all the homeostatic signals

are being overridden, all the signals from the body,

the leptin, the insulin, the glucose,

all that stuff has cosmically sky high.

And yet they're just what we,

the nerds call hyperphagic, they're just eating like crazy.

So, what's going on there?

Well, there've been a lot of ideas,

about why this arises.

There's the so-called thyroid hormone hypothesis.

That one's a tricky one.

It turns out that cortisol

and thyroid hormone concentrations vary according

to when the binge purge happened.

So, there were some studies that looked

at thyroid hormone levels

and they found elevated thyroid hormone levels.

Thyroid hormone is involved in metabolism

and not just the burning of energy,

but the use of energy in converting it to different tissues

of the body, cartilage bone, fat, and muscle, et cetera,

did a whole episode on thyroid and growth hormone.

By the way,

if you're interested in learning more about thyroid hormone,

but thyroid hormone can also be depleted at other phases

of the binge purge cycle.

Now, without listing off all the terrible things

that happen with this binge purge cycle,

there are a number of things

that are really worth pointing out.

One is that the vomiting itself,

the use of laxatives that can cause severe disruption

to the mucosal lining the mucus lining

of the digestive tract can severely disrupt

the gut microbiome.

It can cause all sorts of even a ulceration of the esophagus

and just really terrible stuff.

There's a lot of shame associated with bulimia,

oftentimes because people are vomiting and it's hard to hide

that vomiting behavior, people are aware of it.

There's some social isolation.

So, you recall from the beginning,

it does not appear that sexual trauma

is a prerequisite for bulimia.

Although sometimes it can occur the hallmark feature

of bulimia that distinguishes it from anorexia,

aside from the fact that it's overeating as opposed

to under-eating is a lack

of what they call inhibitory control.

And that might come as no surprise.

But first of all, the bulimic,

unlike the anorexic is hyper impulsive and oftentimes

has other types of impulse behaviors.

They might have a little bit of alcohol

and then start to eat like crazy.

Whereas normally they're very restrictive.

That's a common feature of bulimia,

sometimes they over ingest alcohol during these binges.

Sometimes they are sexually promiscuous, not always,

but it's a general issue with satiety

once they start eating and with impulse control generally.

And for that reason,

many of the treatments that you see for bulimia

and binge eating disorder are the sorts of treatments

that don't seem to work so well,

or at least most of the time for anorexia.

So, the drugs that increase the neuromodulator serotonin,

for instance, fluoxetine

also called Prozac, Paxil, et cetera.

Those things oftentimes can be effective in bulimia.

Some of the drugs that are used to treat attention deficit

hyperactivity disorder an ADD, a topic that we're going

to talk about in depth here on the podcast soon,

some of those same drugs like Adderall,

Vyvanse and things of that sort can also be used

to treat bulimia and binge eating disorder.

Why would that work?

Well now you are familiar with the prefrontal cortex.

You probably know more about prefrontal cortex

than you ever wanted to, just from this episode,

prefrontal cortex is involved in this analysis of duration

path and outcome.

Duration path and outcome is how we avoid impulsivity.

It's how we think.

Okay, if this, then that, if that, then this,

you can imagine how for the obsessive compulsive

or for the anorexic, these are circuits that are overactive.

For the bulimic this is the circuit that's going

to essentially be underactive and is under conditions

where they think, oh, you know, I shouldn't eat anything.

I shouldn't eat anything.

And then they just tear the refrigerator open

and plow through that.

And then at that point they're plowing through the cupboards

and then they're ordering food.

And then they're feeling horrible about themselves.

There do tend to be these cycles of binge and purge followed

by feelings of real shame

because they just can't control their behavior.

And what is more embarrassing than not being able to control

one's behavior as an adult or as a young adult.

So, really the polar opposite of what you see in anorexia.

So, this lack of impulsivity implies

a lack of prefrontal control.