A Hail Mary for the Dying
Anorexia nervosa holds the somber distinction of having the highest mortality rate of any mental disorder. The havoc that chronic starvation can wreak on the human body is extreme, swift, and systemic.
Compounding this grim statistic is the fact that anorexia is notoriously difficult to treat. It is an incredibly complex disorder, with multiple interrelated independent and dependent variables. It has a soberingly low recovery rate, with only 1/3 of survivors showing improvement in their condition over their lifetimes.
I am a data point in these statistics. I suffered anorexia for 23 years, failed an institutional treatment program, vacillated in severity for more than two decades, and only recently joined the ranks of the 1/3 of those with documented improvement. Since February 2018, I have gained nearly 20lbs, resumed eating meat, improved my dysmorphia, and changed my relationship with food.
I consider myself lucky as hell.
And I accomplished all of this by eschewing a primary tenet of the Eating Disorder Anonymous’s (EDA’s) dietary recommendations for those in recovery — to avoid regimented, restricted, or “extreme” eating behaviors. EDA believes that these behaviors are evidence of being “out of balance” — that they indicate an unhealthy fixation with controlling food and that any attempt to artificially regulate one’s nutritional intake puts a sufferer at risk for triggering and relapse.
And that makes perfect, reasonable, rational sense. I totally get it.
Except it didn’t work for me, and it hasn’t worked for a lot of sufferers, many of whom are no longer here to tell us why it didn’t work for them.
But I am here, and I am not okay with these stats.
And it took taking the opposite of EDA’s dietary suggestions to get me solidly into recovery.
It’s not as simple as just eating whatever I wanted, just in moderation.
I’m going to preface here that I do not claim I have some enlightened awareness about how to improve outcomes for all anorexic people. That would be irresponsible and potentially dangerous and anorexia is a fucking monster. What I do have is one data point (Me), a somewhat cogent idea, an interesting study, and — more than all else — a desire to do something about the lack of effective treatment options.
I’m also want to hammer home that anorexics have to change our brains before we change our bodies. My current stage of treatment — the part where you talk about what and what not to eat — can only come after our brains have healed to the point that they will allow us to put any food in our mouths at all.
The term “comfort food” was always an oxymoron for me. There was never anything comfortable for me about the typical American diet.
Pre-recovery, an unrestricted, “balanced” diet produced generalized anxiety in me that was overwhelming — so much so that I struggled to cope with basic decisions about what to eat and what to feed my family.
My relationship with food was contentious. In high school, I chose a more palatable alternative to the standard Midwestern fare I was offered daily. My breakfast, and only meal of the day during the school week, was a caffeinated soda and two aspirin, which I would knockback on the way to school to ensure no one would see me. On the weekends, I’d pick at nachos with my friends to keep the rumors about my thinness at bay or indulge in a baked potato at my family dinner, stating that I refused to eat the meat out of solidarity with mistreated animals. It was the “all-carb” diet, and since all food was the enemy, I thought it didn’t matter what I ate because I wasn’t eating very much and it all made me anxious.
For the 23 years I was sick, I claimed to have a lot of dietary restrictions — including vegetarianism and food allergies — to disguise my anorexia, and its this part of me that most understand the EDA recommendations. I have first-hand experience with exactly how anorexic people use less extreme food restrictions to cloak their disorder, and I understand why it makes sense to them that following an “unrestricted” diet could help solve the problem that is characterized by food restriction.
It makes so much sense.
It just didn’t work out that way for me.
By February of 2018, I was pretty damn satisfied with reaching the lowest weight I’d seen since I was a teenage runway model. Twenty years and five childbirths later — and in the middle of an acrimonious divorce — I was 6'1" tall and 125lbs.
I had a BMI of 16.5 and 12.1% body fat, and I was reasonably happy — or at least as happy as an actively anorexic person can be with their body.
Then I went on a week-long trip to a foreign country with a man I was dating at the time, and I didn’t feel the need to obsess about what I ate. We ate together and I simply didn’t feel anxiety about it. When we got back, he innocently said, “Babe, you look like you’ve gained 5lbs” and meant it as a compliment. It sent me into a tailspin that resulted in near-starvation, excruciating emotional upheaval, and our break-up.
He had no idea that his statement would trigger me because he didn’t know I was anorexic. And not only because I was so good at hiding it, but also because I ate well whenever we were together. Food being enjoyable was a novel experience. He would always order for me, which took the anxiety out of choosing. He had excellent taste in food. He took the pressure off by saying, “And if you don’t like it, we’ll send it back and get something else. We’ll go through the whole menu if we have to until we find something that is great.”
We never sent anything back. It was always excellent, because his approach set my anxiety at ease, and he fed me wholesome, delicious, nutritionally-dense food. I didn’t know it, but when I was with him, I was eating his ketogenic diet. I’d spend whole weekends at his place, eating like a normal human. I’d marvel at how easy it was when I was there — and how difficult it became when I got home to my fridge full of cheap crap.
After we broke up, and on his recommendation, I entered EDA treatment. I was devastated at losing the relationship and was determined not to let my anorexia derail any other important parts of my life. I got through 3–4 of the 12 Steps and realized that while I had made progress, the program wasn’t working for me. What did work for me was re-learning to eat with the man with whom I reconciled, and also with whom I remained able to eat without anxiety. Over the next six months, I gained 20lbs, got my BMI into the normal range, and now, 18 months later, my body fat hovers at a much more reasonable 14.5%.
And I didn’t do it with “balance.” I did it on another restrictive diet.
The man used to have his own eating disorder: he was clinically obese. Several years ago, he decided to take control of his body and his life and, by making changes to his lifestyle and diet, lost 60lbs. He’s a smart fellow: a college professor. He’s also the Father of a child who was diagnosed with Type 1 diabetes, and he did a lot of research on what is healthy to put into your body and what is not.
It was through his experience as a parent with a diabetic child that he initially found the ketogenic diet, which he adopted as part of his health-focused weight-loss strat. And it is this same diet, the one he taught me, that I credit with the successful, maintainable treatment of my anorexia.
I have a couple of theories about how Keto worked for me and why:
First — and I want you to think about this — food discipline was one of my greatest strengths. It’s almost like a superpower. The primary tenet of the EDA recommendation against food restriction takes away the one tool I cultivated over decades that was strong enough to make a dent in my illness: my self-control. Stripping that from me was incredibly threatening and anxiety-provoking. It wasn’t the answer.
What I really needed to do was learn how and what to eat that wouldn’t exacerbate my anxiety.
Anxiety is a huge part of anorexia. In EDA, they talk a lot about how it’s “not about the food.” And they are 100% correct. We develop anorexia, like any addiction, as a coping mechanism, to try to deal with something in our lives that isn’t working. Anxiety was a huge part of that for me. And anyone who has undertaken serious experiments in fasting and/or starvation knows that there comes the point after denying yourself food that there’s an anxiolytic effect.
Anxiolytic means “anxiety-reducing.” It’s a reasonable and natural assumption to make that the relief from the anxiety that anorexic people feel after denying themselves food for extended periods is one part feeling in control and one part the feeling of emptiness that comes with a long-empty stomach. And both of those play a part.
But there’s another part.
When we deprive our bodies of carbohydrates, which happens in starvation and fasting, our bodies stop burning sugar and begin to burn fat. The byproduct of this fat burning is ketones, and it turns out that having ketones in our systems also has an anxiolytic effect.
I find this beyond compelling. It is gripping. Ground-breaking.
I can eat on a regular schedule — like a normal person — and still get the relief from the anxiety that starving myself used to be the only way to alleviate. I simply have to be judicious in what I eat to keep myself in ketosis.
I have to be restrictive to achieve this feat. And I’m okay with that.
It feels kind of like a miracle. I feel hopeful…in a place without a lot of fucking hope.
As I already mentioned, I am now 20lbs heavier with a higher BMI and I still struggle with dysmorphia looking in the mirror, but I’m fundamentally different. I have no desire to starve myself. I feel the same anxiety-free satisfaction on the keto diet as I did when I would go two days with zero nutrition. And I have no trouble maintaining and continuing my recovery.
What I do have now is an aversion to carbs. I rarely eat them and feel physically and mentally awful if I do indulge. I have to wonder if that is because they take away my anxiolytic ketones. If so, we have to ask ourselves the question: “Can this work for other anorexic people?” and “Is it moral/ethical to trade one set of restrictions for another?”
If we look at the opioid/Subutex model, the answer is YES. Whatever keeps you on this earth and makes your life more manageable is progress. The goal needs to be staying alive.
There will be pushback to presenting this theory, which admittedly could be better and more thoroughly articulated. There will be claims that I am not really recovered and that its just a matter of time until I relapse. I will be accused of irresponsibly suggesting a band-aid for a bullet hole. Or maybe it will be ignored. And maybe that’s fair. As I mentioned at the beginning, anorexia has so many contributing components that are specific to the individual sufferer that it would be nearly impossible to find a “one-size-fits-all” treatment modality for any stage of the process.
That being said, when we acknowledge the huge role that anxiety plays in our anorexia and the anxiety-reducing effect that a keto diet can have, it seems clear that the connection warrants further investigation with respect to keeping people in recovery.
The bottom line is this: People are dying in droves from anorexia, and what we are doing isn’t working.
I get why people would be wary of presenting another restrictive diet as a treatment. It doesn’t line up with widely accepted beliefs about what constitutes recovery. However, at this point — with anorexia having the highest fatality rate of any mental disorder and current treatment methods having abysmal success rates — is people eating something really worse than people eating nothing?