Welcome to the huberman. Lab podcast. 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.
Too fat to Bone, Etc.
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 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 while one can survive for some period of time,
I'm 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 and general Etc. 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
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, name's Sachin, Panda saw Chen's lab identified, some very important and impactful. Health benefits of restricting, one's feeding window
to particular times within the
Or our cycle,
or even to having extended
fast 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 sogdians lab and
Subsequently, other lab 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,
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
King and breathing and your heart beating Etc.
And the reason why many people 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,
Text of intermittent fasting on a circadian time scale, 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. Etc. And push their feeding window out to noon or 2 p.m. Or 3 p.m. And then they'll eat
between say, 1 p.m. And 8 p.m. Or 9 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 Windows such that they cut off their food
intake or stop ingesting, any calories of any kind, somewhere around 5 p.m. Or 6 p.m. Etc.
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 6
hour feeding.
No, or an 8 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 p.m. On word. 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 of 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, our 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 p.m. And you wake up at 6 a.m. By extending your fast until 1 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 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?
Jewel. 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 fasting
They, that will seem normal. If you spend time with people
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 will want to consider
Siddur in light of their current nutritional plan or pattern of eating whether or not your intermittent fasting or not.
And I want to queue 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. I'm going to return to that in a
moment, but first I want to share with you these
Findings that were just published in the journal cell report to sell. 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.
Whereas well, what was the study? The study looked at giving mice, or humans to 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 etcetera or it can
be synthesized. Those amino acids can be synthesized into skeletal
muscle. Sorts of skeletal muscles that allow you to move your
limbs.
This study explored how protein intake which included what are called branched chain, amino acids and amino acids, like leucine
which are important for muscle
protein synthesis it 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
these branched 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, you know, 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.
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 high.
/ trophy 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 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
Oh 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 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 have 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.
First, my
first, meal of the day would be in the early
afternoon, mostly protein and salad in my case animal protein. Because that's in alignment with my values.
Then in the evening. I would eat pasta vegetables, Etc. 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 a
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 around 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 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
Flat. 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 seem to be
beneficial how early between the hours of about 5 a.m. And 10 a.m.
For humans.
Now,
just a bit of mechanism to explain why this
happens. So why would it be then injesting protein early in the
day would lead to more synthesis
of muscle then injesting 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 contain. 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, do your retinal cells to your toe on
both feet.
These cells, make a gene called B. Mel B, Mel, B. Mal is a clock
Gene, and the expression of this clock chain varies across the 24-hour
cycle, and proteins that are Downstream of this beam Al Jean influence protein synthesis.
The Circadian regulation of this beam, Al Jean 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 be Mal. The gene was knocked out. They had a 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 beam out. And indeed it was
absent. In other words, the effect of increased.
Gene synthesis early in the day was eliminated in the absence of the beam Al Jean. So what this means is that when you wake up in the morning, assuming you're following a standard scheduled
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 wait trained the night before at eight pm, where you don't wait train at all. Or you weight training afterwards, or before
I said, 5 to 10 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 cannot train at all. That's an 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,
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.
Show. 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 foods that can also get you essential amino acids, but it requires more calories
to access those essential amino acids. Now, that's a debate that has many exceptions and nuances and I for one am 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 takeaway is our every cell in your muscles has a clock Gene. The clock.
Jeans, very 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, then the proteins that are ingested late in the day. And of course, there are the caveats of
if you're training hard laid in the day, if you're adjusting your
hormone status through whatever mechanism, that cetera
protein synthesis can also,
OB High later in the day, but for most people, it's going to taper off due to this circadian be Mal 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
Why I believe that the internet in particular social media are so filled with contradictory opinions,
but the calories in versus calories out, calories burned. Formula is the 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
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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
we'll talk about that 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. Doesn't really matter what the disorder is to ask the question. Well do I have
that? So and so that I know have that eye. I see
this sort of behavior that pattern of
thinking in that individual. It's
In to diagnose them and or
ourselves as either having or not having a particular disorder. However, diagnosis really need to be carried out by people who are trained in that particular field and that have deep expertise in recognizing the symptomatology,
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 the disorder, I would take that.
That
seriously. But I would take that information to a
qualified health care 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, in 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 brains attempt to lower energy output. They will have low
blood pressure. They will 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
D because of loss of body heat, when you're that
thin loss of bone density or 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 place. The anorexic into a very risky state, which is why mortality from anorexia gone, untreated is
Really 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
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 Sixteen hundreds and perhaps, even earlier.
What you find is that rates of anorexia are not going up. So this idea that the images that were 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 our
Healthy for their psychological state of mind. But classically defined anorexia has existed as essentially the same prevalence.
For the last hundred, 200, 300 and 400 years which is incredible and really speaks to the likelihood. That there is a strong
biological contribution to what we call anorexia. Nervosa.
Anorexia. Nervosa is extremely common. It's anywhere from one to two percent 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.
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 stem 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 in boys
and young, men, these days that's probably due to better diagnosis and detection. Then it is to some sort of societal
shift related to imagery Etc.
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.
Been deadly that has existed for a very long time. And seems to be
somewhat hard wired into the biology of individuals that suffer from it. Now, when I say hard wire, 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, its
more common in young girls
and 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 it. Same form for a long period of time or whether or not their 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
Asik 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-analyses have
been done. It just simply is not the case. And in both instances both anorexia and bulimia. There are clear
biological.
Us to what's driving the undereating 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
I 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.
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
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, 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 Etc.
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 where 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
Nos and NOS is eating disorder, not otherwise specified. So that's a sub
categorization or
office, feds. So office, feds is other 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, were
mainly going to talk about anorexia, bulimia binge eating
disorder and body dysmorphia.
You can even find Eating Disorders like
Pika where people actually
ingest things like dirt or rocks or metal because they have a genuine apatite for those things. I certainly do not recommend sampling, any of those non-food items as Foods.
Incredibly dangerous people, often poison 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
Behavior
sometimes pikas 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 realize that not everyone out, there has an eating disorder. And to I want people to understand this relationship between how they think the decisions they take about what they eat
and how
How the body and the Brain at subconscious
levels are driving some of
those 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? So tidy, 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? I mean by mechanical information, well, if you take a deep breath,
Any 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.
It's 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 we consider doing or not doing likewise chemical effects, when we ingest food are so-called blood sugar or blood glucose levels, go up, that
information is signal 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.
In 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 for brain which
tells you it's in the front, but it's at the base of your forbearance. It's more or less above the roof of your mouth hypothalamus. Contains. Lots of different kinds of
neurons including
neurons that stimulates sexual activity and desire regulate your body
temperature and control appetite
and
Ceasing of eating an appetite.
There are two types of neurons within a particular area of your hypothalamus that are
relevant here. There are the
so-called P om C
neurons. Okay? Pro opioid, melanic Orton
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.
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 a grp neurons. The, a grp 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, you ever seen kids heading in to get ice cream. They're absolutely excited. You see people getting ready to sit down.
I need 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 a grp 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 a grp neurons
and what you find
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, a
grp neurons are like an accelerator on
wanting to eat. Whereas, if you stimulate these, a grp neurons or in
humans that have say, a small
tumor near these, a grp neurons. They become hyperphagia. Kick. They will eat to the point of bursting both
animals and humans that have elevated levels of
these. A grp neurons are
anxious.
I 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 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, LEP TI 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 is disrupted. The I've 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
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 sort of like a savings
account for energy because that's what body fat is 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 there's 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
Guys, 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 over year
to the testes and cause the ovaries and testes to ovulate or to produce more sperm. So the reason why anorexic stop having
periods when they stop 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 you 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
That you're there, sufficient body fat, there doesn't even have to be a lot
but it has in some cases been shown to
rescue the menstrual cycle and 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 fat to ingest.
Amino acids coming from
proteins, you ingest and sugars coming from carbohydrates and sugars things like free.
Otto's glucose, etc.
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 towards eating more or eating less. So, you've got two categories of neurons. One that acts as an
accelerator, the a grp doron saying, eat, eat and get you excited to
eat.
And then you have a category of neurons, the pmo C 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 and 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 and a 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 from 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.
Has go up for instance, glp-1 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 signaled. 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
that 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, you know, 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, Etc. 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 loss is 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. 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 the Inhumans very similar types of Pathways and affects. How is it that human beings who have plenty of fat on reserve
and plenty of glycogen in their liver Etc.
In other words, plenty of energy, why they would be hungry, why they would eat it
all seems like that, just shouldn't happen.
And he had a very important and I think clear,
ER and intuitive way of framing
up. All this stuff around eating and motivated behaviors and how they can go. Awry. Not just an 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, it sounds crazy. I was told to eat not too often.
Not too much and to eat slowly and chew my food, but as dr. Halperin, 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 was like, food would hit the table and it was just it
War for portions. And who got what? And how much and who got a slightly bigger piece of cake, Etc. Turned out to be a frequent happening
in these meals and at these birthday parties,
whereas the only children perhaps we're 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
Eating 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 P Moc 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.
Anger 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. Halperin pointed out that you actually have an
Later, that increases your level of awareness, and anxiety, and sort of constricts, your field of view and all your senses, any time 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 change 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
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. Halperin, 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 realize that many of you are listening to this, not watching this Unity. 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 the 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
Should and shouldn't 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 hear what I'm saying. Is that the person who starves themselves to the point where
they might die? And in some cases, sadly, dude, I
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, 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
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
Headed,
what you will find based on the data clinical data experiments done, very carefully and very well by excellent
groups. What you'll find is that 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.
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 individual is at risk
of death. And if not death, then, severe metabolic disorders, lack of bone density, Etc.
So, I mentioned earlier anorexia and things that almost certainly
were and are anorexia.
Been described as early as the 1600 and maybe even earlier. There are some records from
the Saints from the Fourteen hundreds 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 etcetera, not true, a careful analysis.
Through medical epidemiology has shown that you fine. 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 were makes them feel better. If they
don't eat, despite the fact that there
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, a 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 sperm production that 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 life span. 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. The controlling the production of the so-called sex steroid hormones.
Things like testosterone, estrogen and related hormones, prolactin, etc. 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 wear. I refuse to and that
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, their start producing sperm Etc.
So there a lot of bodily changes that also Drive perceptual changes in perceptual
changes. That drive bodily changes in 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.
Are just a subset of the effects hypogonadism, that's the
lack of sperm production or healthy egg production. There is a Min oriya, 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,
Resting 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. 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.
Were will start generating its own cholesterol, will often
over shoot them, 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 attend to have elevated levels of things like
vasopressin, which are hormones that regulate body, temperature, and salt and bought a 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. Its, 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, a grp 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
All right. I'm making this up but you can imagine a hypothetical scenario where
the 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.
Be that individuals 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 of really
extreme. Deprivation of oneself from food. However, there's 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 are for whatever reasons, that happen 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 or schizophrenia, but it's not deterministic in the same way that there are genes that determine your eye color or your skin color or hair color? Okay. So there's a genetic predisposition
there and that genetic predisposition could exists 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 it. 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.
Sure 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 category of chemicals that are particularly important.
That if you listen to this podcast
before, even if you haven't or 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 neurotransmitters in the sense that neuromodulators
modulate 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 norepinephrine 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,
Tonin, 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 lead 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.
On 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, Stein,
glass 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 seem 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 anorexic, giving them a
gallery of pictures of different foods
and allowing those anorexic patients to arrange those Foods. According to preference about what they would select about food. Nutrient content about caloric content. They essentially ask 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 that anorexics rather than being anxious in the presence of
food and that anxiety driving an 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 savants 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 food fat, rather, or looking at an apple and say, 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, content, 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 there.
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 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
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 I'm going to scratch that. In
fact, just to take a little bit of a moment
of respite and talk about habits in general. There's a beautiful study that was done out of Cal Tech 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 at Caltech. This kind of thing that the nerdy kids at Caltech. Do I think it Caltech? If you call someone a nerd is I think it's a compliment. So
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, because they're on the driver side or passenger side in the same place.
They turn and pivot their body at approximately the same rate every day. They closed.
The door, they 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 stereotype. 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 to, you don't realize it because
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 and kind of
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 neural circuitry 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. Stein, glass, 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. Stein glass and colleagues
did is they took anorexics
and they of course, had to 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, you, I've actually been in one of these things, you're biting down on a bite bar and your most of the time and most all of these scanners your 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
Views 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, adoration path outcome type process. We can shorten with DPO DP O 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.
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 I 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 in. What's preventing you from accomplishing, what you want to do and what's
helping you are 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
And 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, Etc. So,
duration, path, outcome, and that
entire process relies
on.
For 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,
Etc, 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.
And 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, etcetera.
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 dorsal lateral. 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
includes areas, like the caudate and putamen. Mm,
and I just want to mention as I threw out all
His name's 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 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 the beginning of the
episode 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,
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 were 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
In 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 dorsal lateral. 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 gonogo 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 neural
circuitry.
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 execute
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 automatic.
It's just like we just do it without thinking.
Well, the gonogo
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 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 is 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 shut down. Sperm production in testosterone is lowered, bone density is down clearly. This is overriding all those homeostatic
processes. All the
That would say, 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, Etc. 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 me 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 minibar taken out of the room. I don't want to television in the room, Etc. 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 interception, 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.
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 toward 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.
Operate in order to rewire any habit of any kind.
There are two main features of thinking that go into the sorts of
habits that interacts 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. 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 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. Then do non anorexics, which is really interesting. Right?
They somehow are able to home 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 in whatever one finds is that you can't run find 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 is 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 missed the big picture. The other is a challenge in set shifting that once you identify something that's a particular interest and that's driving some sort of reward
for the anorexic. That would be identifying the high fat
foods. We're identifying
I'm 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, to 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 played a lot. They become
masterful.
At trying to keep people's awareness away from what they're doing, which is to home 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 task? They are 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
ORD 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 pre-selected 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 individuals challenges with a particular eating disorder, other disorder
and in understanding some of the biology and psychology around it. They stop
condemning the individual. They start to support that individual through
cuing them towards their own.
It's 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 co-workers. 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 therapies 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 look really good
that especially when it
individuals are taught this early and adolescents.
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 Reformation
seems to be fairly effective in at present. Might be the most effective treatment. Now, there are additional treatment starting to surface and that takes us into the realm of chemical
treatments for anorexia.
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 psilocybin 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 psilocybin 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 had amazing experiences and relief from various things. Not just eating disorders, but depression, Etc. 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 having ticks that they 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
Current 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 US and in other countries where this stuff is being done, more regularly
and there to 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, couldn't you have just told us that in one sentence,
but I
want to return us to this model about homeostatic processes, reward processes Etc. That leads us to a place where the short answer is. No, you can't simply say break the habit
and individual needs to be informed about where
That habit comes from in 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 over-exercising. This is a
area that anyone who's treated anorexics or interacted with anorexics, as
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 as a whole 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 over all other types of exercises, like resistance training or anabolic. They allow muscle to be put on
And
there's some interesting studies, not a, 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.
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. Wait.
Hopefully, they're, you know, 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 thousands of calories a day, anywhere from 800 to 2000
calories a day that can be beneficial for the folks that are overweight and want and have a healthy mindset about food, but are trying to lose weight. And they it turns out that by, you know, 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.
Provide your in a caloric deficit. You'll your 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.
Earning 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 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 in that episode on depression. We
talked about a very powerful aspect of major depression.
Which is this anti self confabulation, that people who are depressed,
seemed to genuinely believe,
and even confabulate about the fact that they are performing poorly in life, and that they are no good or not worthless. Etc. 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 called it. 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 there are
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 are it's because of some really important and beautiful studies that were done in my colleague. Jeremy bailenson slab at
Stanford. He's in the department of communications. He's actually. Collaborated with a dr. Halperin that I mentioned earlier.
It'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.
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 cognitive 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.
Leif released, 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. I of the brain are not very
amenable to neuroplasticity mean, they don't change that
easily. Whereas it appears that the circuitry that's related to Habit
formation and decision-making in the reward circuitry. That stuff can be rewired.
And so anorexics as they progress out of
Are anorexic State
into one which they are
intervening in their reflexes, gaining better habits around food eating more,
more accurately, assessing
foods. And 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 catabolism 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 non-existent 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 and, you know, 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.
It's
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 a grp neuron stimulated. These neurons that will eat until they almost burst or burst. So you wonder is it these a grp 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 that we're going to talk about other types of interventions.
There are 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
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's doing this, at least once a month, over a period of anywhere from 2 to 3 months, then it like,
Polly 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 and 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 neural circuitry.
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 reflex. 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 is cosmically sky-high. And yet they're just what we, you know, the
Nerds call hyperphagia. They're just eating like crazy.
So what's going on there? Well, there's been a lot of
ideas, you know 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
Found elevated thyroid hormone levels. Thyroid hormone is involved in metabolism and not just the burning of energy but the use of energy and converting it to different tissues of the body. Cartilage, bone fat and muscle Etc. 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
All the
terrible things that happen with this. Binge Purge cycle. It 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 mucous lining of the digestive tract. Can severely disrupt the gut microbiome it can cause all sorts of even ulceration of the esophagus and just really terrible stuff. There's a
lot of Shame associated with Bulimia.
Often times because people are vomiting and it's hard to hide that. Vomiting Behavior. People are aware of it. There's some social isolation as you recall from the beginning. It does not appear that sexual trauma is a prerequisite for bulimia. Although sometimes, it can occur. The the Hallmark
feature of bulimia that distinguishes it from
anorexia, aside from the fact that it's over eating, 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 there's a general issue with satiety.
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,
etcetera. Those things often times can be
effective in bulimia. Some of the drugs that are used.
To treat attention deficit hyperactivity disorder and 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
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 under active 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.
Are plowing through the cupboards and then they're ordering food and then they're feeling horrible about themselves. Their 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, what
we call top-down control. Why do we call it top down?
The prefrontal cortex is suppressing the
activity of deeper limbic and hypothalamic circuitry, and things of that sort anytime. You feel like you want to say something really offensive and you don't, that's top-down control. That's your prefrontal cortex. Anytime. Someone says something and you like, but grit your teeth because you know, you shouldn't say anything, gritting your teeth as top-down control. Okay? When you explode or burst or say the wrong thing.
Or say the thing that you shouldn't say or do the thing, you shouldn't do that, slack of prefrontal control and indeed people who have frontotemporal dementia due to aging or head injuries. See this a lot and people play sports that get a lot of front frontal damage. They become more
impulsive. So bulimics
have an issue with impulsivity and therefore drugs that can increase serotonin and sometimes these drugs that increase dopamine. And adrenaline also caught up a Nephron.
Will increase the tone
as we call it the dopaminergic, tone, or the, nor up, and it's called adrenergic, but norepinephrine levels in the brain, allow for more top down control. And that's also why they're used to treat ADHD and attention deficit disorder. They tend to create a hyper-focus. They tend to push the brain into these drugs tend to create a hyper focus and tend to push the brain and General Motors processing into one in which you think if this then that if this then that so anticipating outcomes.
And for that reason, drugs like Wellbutrin proprietor own, which is an antidepressant which mainly increases the amount of dopamine and
norepinephrine and less. So serotonin that can also be effective for certain types of binge eating disorders, actually used to treat smoking to
for promoting smoking cessation and for depression, but also
for certain forms of obesity related to binge eating disorder and the data are pretty good and there are timed release forms of this and non time.
These forms. I think you have to
consult with a psychiatrist in order to get these prescribed because they are prescription drugs,
but it's a very different constellation of
neurochemicals and brain areas and and approaches for bulimia. The treatment of binge eating disorder
has been explored
from a new standpoint recently. And that's the work of this now, sadly, former colleague of mine. Dr. Casey Halpern, who's at University of Pennsylvania, that I mentioned earlier, they are.
Using deep brain stimulation. In order to treat binge eating disorder. Now, why deep brain stimulation? Well
work from Doctor Halpern and others. While at Stanford showed that there are particular patterns of brain activity in both the prefrontal cortex, but also in an area of the brain called the nucleus accumbens very
important and very relevant area of the brain in this context and in any discussion about motivated Behavior,
Any kind of feeding sex drug drug related Behavior people exercise compulsively. The nucleus accumbens is in a
ongoing dialogue with the prefrontal cortex and the nucleus accumbens has no mind of its own but it's associated with dopamine release. Its part of this
so-called reward pathway
and what dr. Halpern and colleagues discovered is that there are particular patterns of activity that
Ripple through the brain through these, prefrontal networks and through this nucleus accumbens area.
Those areas are connected. It's called Delta oscillations. Delta just being a particular frequency of electrical activity for you. If it's an Autos is 124 hurt
activity. But in any case those Delta oscillations in the nucleus accumbens are associated with food, reward in both mice and humans, somehow this Reverb ettore activity, creates a
perception in the individual. That food is hyper
rewarding. That's interesting and is allowed.
To use a targeted deep brain, stimulation approach to treat binge eating disorder and this deep brain stimulation is appearing to be an effective treatment there. Still more studies that need to be done. Actually. If you think you have been G eating
disorder, you can find the criteria for that and you could contact dr. Halpern. He's as I mentioned, he's moving to University of Pennsylvania. They
are recruiting patients for these studies. All the time. The studies are fairly invasive. They involve a
They approved approach of literally placing a wire down into an area of the brain that and allows the individual to stimulate a particular brain area to offset some of these activity patterns, that lead to
a elevated sense of reward from food and binge eating and the data look really promising. Now. I realize that's a very invasive approach. Not everybody is going to be willing to have this
wire inserted into the brain but for people,
Suffer from binge eating disorder. This is a great and very exciting potential treatment because what I didn't tell you is that many people have been G eating disorder. Are obese to the point where their health is greatly at risk. Now, obesity
causes all sorts of shifts in the dialogue
between the brain and body, some of which you'll recognize from earlier in the discussion. For instance. Leptin, signaling is disrupted. So the fat, there's lots of
Of body fat.
But even though that body fat is secreting, this hormone leptin in that signal, should shut down the desire
to eat The receptors to leptin in the brain or totally screwed up. And so the signal to eat is there. But the signal to stop eating is not there. So again, you have an accelerator in a break and it's like the accelerator is always pushed down some of these brain. Stimulation approaches seem to be able to bypass some of that
and of course, they're all the metabolic syndromes in the problems
with Having excess levels of body fat.
Things like insulin resistance type 2 diabetes. I mean as disturbing as is to hear, there are many individuals. Actually. I know some who are so obese that they start getting bodily sores. They, they're not just bed sores, but they have skin sores that are very disruptive to them. They don't like having these sores. And in addition to that, they can get peripheral neuropathies, because they're because of some of these metabolic issues. They're not getting enough you.
Relation of the nutrients in the tissue because the way that insulin is disrupted, insulin signaling. And they actually have to have certain portions of their limbs amputated and yet they continue to overeat.
So this is not an issue of self-control
that can easily be dealt with simply by telling the person look you have to stop eating or you're going to die or you're gonna have your legs amputated like with anorexia. There's, there's a distortion in the relationship to food, but
the homeostatic and the reward aspects are disrupted.
And so unlike anorexia where it seems to be a
habit based mechanism with bulimia and binge eating disorder,
something deep within the neural circuitry is
causing food to
be hyper attractive
and the brake is off. So if you want to develop some empathy for what these people are dealing with consider this, it's like
driving a
car, you get onto a grade, maybe 10 or 15 degree grade, and you're heading down and you figure. Well, you'll just pump the brakes a little bit.
There is no break, right? She started going faster and faster and
faster. And your only choice is to use the
accelerator or just to Coast through it. That's essentially what's happening to these neural
circuits. So the work of dr. Halperin and others. I think is really exciting. And even though it's highly invasive, I think is going to lead to not
just some relief for the patients that do get that deep brain, stimulation. But also the identification of what sorts of receptors are present in those brain areas that could help. What that means. Is that once we understand which brain areas are
Involved in the disorder and we understand what receptors those brain areas
Express. Then there can start
to be additional interventions by way of non-invasive treatments things like drug treatments.
Do behavioral
interventions work for bulimia in some cases. Yes. Provided that those interventions are done early enough.
Regardless behavioral interventions coupled with
drug based interventions are always more effective than either one alone. Fortunately. There is a
Decent size kit of drugs that can help with bulimia. I mentioned some of them before things like prepare our own on Wellbutrin some of the serotonergic drugs and some of the drugs used to treat impulsivity. So
we have on the one hand anorexia, which seems to be
a disruption in habit and a coupling of unhealthy habits in this case food
restriction, to the reward pathway.
And on the flip side. We have binge eating disorder and bulimia. We're a very unhealthy habit of gorging ones.
Self with food, sometimes, followed by purging
is not necessarily couple to reward. They feel terrible when
they do that, right? The anorexic feels great about restricting their food intake, they feel like they're winning some sort of game. The circuitry is flipped somehow that way
with bulimia. They feel horrible about
the fact that they're binging. There's an immense shame, they can't control themselves. The reward is set up before the behavior. The
reward is set up in drawing them
to food and in
Making food look like something. That's incredibly appetizing and there's no impulse break. There's no way for them to stop that kind of behavior. So really kind of troubling thing to think about. I either case, I think for those of us that know, anorexics or observed anorexia. It's so hard to see somebody starve themselves to near death or to death. What what more could be
disturbing. Well, equally disturbing is
somebody who has an abundance of food in his gorging themselves and then feels terrible about it. So,
So these
are heavy topics. These are
topics that frankly, no one really wants to talk about unless they know someone who's suffering from them or they themselves suffer from them. What I've tried to do today is try and give you a window into what, really underlies these things that we call Eating Disorders.
I hope I've done that at the level of
biology neurocircuitry mechanism endocrinology and some of the psychology
as with any episode of this podcast, but especially
in this market,
We're, we're talking about mental health issues, and mental health, disorders, behavioral disorders. There's no way that I can exhaustively cover all the different forms of treatment. You have the mod Lee approach. You've got all these different approaches to depression into anorexia Etc. What I've tried to do is give you a framework
and in doing that. I've tried to give you a framework of understanding that also applies to this question. That's I think equally important and goes alongside. The treatment of eating disorders is what in the world is
Healthy eating. What in the world? Is a healthy
relationship to food. I like to think that I have a healthy relationship to food. I know the foods. I like I enjoy them. They're 10 or 15 foods in particular, that I like very much. I've mentioned a few of them on the podcast before and was sort of amused, surprised and perplexed. As to why, for instance. I do enjoy eating butter, not in huge amounts, but I do like
butter. So that seemed to be pretty triggering for folks out there
of small, selection of people decided that the ingestion
In a butter was a was a health concern. Look
to me ingesting butter in
small quantities something that I'm comfortable with and my blood lipid profiles feel
good. They look good to me for other people. That might not be the case. For some people, the idea of eating an animal-based food is probably so repulsive that
it actually can make them feel physically sick. And I think that we should be aware that, that kind of mental phenotype exists. I'm not calling it a pathology.
For other people like myself, things like butter and meat
feel healthy. Now, what quantities? Well, I enjoy eating very much. I'm not shy about this. I've talked about on the podcast before. I enjoy
eating. Some people
have a very complicated relationship to food. They don't think of it as nourishment. They don't enjoy it socially. It's a stressful thing for them, based on their personal history, or maybe just general anxiety around food. And I hope that in sharing this
information about the fact that anytime we
Food these neurons in our Hub, in the arcuate area of our hypothalamus actually increase our levels of anxiety. This is related to that point that dr. Halperin made which was that from an evolutionary standpoint. It is advantageous to ingest as much food as often as possible as quickly as possible. We now know that to not be healthy. In this age of abundance, where calories are essentially everywhere
and yet a
lot of people feel anxious in anticipation.
Ation of a meal, what
could be useful to them? Well, whether or not they have an eating disorder or not. It's very clear that developing methods to calm oneself in the
presence of any anxiety or fear inducing stimulus can be beneficial. I've talked about some of these and episodes related to stress things like the physiological side to inhale, through the nose and a long,
exhale things like mindfulness meditation certainly can help. There are data a lot of studies out there showing that meditation practice can help
people deal with eating related anxiety, and disorders, I
think as a general
Rule trying to avoid approaching a meal or sitting down to eat in an anxious state. Is probably a good idea. But let's be realistic. How often can we do that? I think most of us are going to have circumstances where we're rushing around trying to just eat before we head out, or get to a meal. And then we sit down and we find ourselves eating.
This is one of the first times in human evolution where we mostly eat out of a desire to consume food, not out of a need
for food. Most everybody could go.
Go Fairly long period of time, just ingesting water and electrolytes, and not that I'm suggesting people
do that. But let's face it. We largely eat
nowadays, because of a desire to eat, not a need to eat. And yet we need to eat on a fairly regular basis and so know topic is more complicated and nuanced than food and nutrition and in particular as it relates to eating disorder. So
the major takeaways today are we should all
be asking the question? What is healthy eating for us?
How do we develop a relationship to food that we can enjoy food? Hopefully, both socially and on our own but that we are not neurotic and compulsive about it. For those of you that intermittent fast. This also applies. Right? What, you know, God forbid, if you eat 30 minutes before you're eating Windows
starts. What does that mean? If it means something catastrophic, do you have an eating disorder? Well, I don't know. Maybe you have an anxiety disorder
that's for you to explore, if you don't manage to eat
five meals a day and that's your obsession.
Well, then, you know the same thing applies to these are questions that we can all ask ourselves today. We focus on the extremes of food related behaviors that really qualify
as genuine disorders. They are in the psychiatric manuals and they are diagnosable and they are serious health concerns. They're not just mentally troubling and concerning for the people suffering from them in the people around them. But they are genuine. Health concerns
just want to reiterate that anorexia nervosa is
The most deadly psychiatric disorder by a huge margin. And if you look statistically at the number of people with eating disorders and that died of Eating Disorders,
it's not far off from the number of people that die from
automobile accidents. I know that, that sounds like a ridiculous number, but you can look this up. This is
particularly true in certain countries, why? That is we don't know. But again, this is not a new phenomenon. This is not
just related to body image issues that are created through.
Through social media media.
And as a final point on that, many of you are probably asking what about plastic surgery? What about all the steps that people are going to through scuse me to preen themselves and change themselves. Are
people addicted to plastic surgery. Is that a
form of body dysmorphia and indeed it is. And so we will do an episode
on exercise related and plastic surgery, related body dysmorphia. I think there is very little question that
Those types of disorders are clearly the related to what we're
observing in social media. And in media
that this shift of
for instance action heroes, if you look at action heroes in the 80s, there were very few men that were very large. You had your terminate, you had your Stallone's in your Schwarzenegger is and a few others,
but the men and movies tended to be, if they were muscular. They were far more
svelte than they are. Now. There's this kind of, there's a literally a
hypertrophy of the imagery.
And likewise,
there's been hypertrophy of the female body shape as its portrayed in the media. There are
body dysmorphia has that are
related to those types of things and that relate to things like plastic surgery, steroid, abuse, diet, drug abuse. And so on
definitely important to think
about and consider and definitely deserving of its own
episode.
You've learned a lot of Neuroscience today. I hope that was useful in thinking about these disorders and in thinking about other aspects
of feeding and motivated behaviors. I would love for you to take away this model that was handed off to me that I think is so powerful for thinking about all sorts of things. Not just eating but all kinds of behaviors and perceptions that you have one box for what you
think one box for what you do. And what is intervening between those? Why is it that you can know better and not do better? Well, it's because
You also have to cope with the subconscious homeostatic
processes and reward
processes. And those often times can be
disrupted in ways that we find ourselves doing things that are not good for us or not, good for other people, but fortunately, there is this great gift, which is that knowledge of knowledge can allow you to do better
without question and that knowledge of knowledge
allowing you to do better over time leads to this incredible phenomenon called neuroplasticity, which
Which essentially is translated into doing, better over time?
Even if difficult
eventually makes doing better reflexive. If you're enjoying this podcast and learning from it, please subscribe to our YouTube channel. That's huberman lab on YouTube
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and there there's a tab that you can click if you'd like to make a tax-deductible donation to the laboratory to explore the sorts of things that relate to neural circuits, stress, sleep, and Human Performance,
not today, but oftentimes on this podcast,
We discuss various compounds and supplements that people could
possibly take in order to help deal with anxiety, improve gut,
microbiome improve, their sleep etcetera. We didn't discuss those today. But for those of you interested in those compounds, if you want to see the ones that I take, you can go to Thorn, that's th orn
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/, the letter U / huberman. So, it's Thorn.com / you / huberman. See all the supplements that I take, you get 20% off any of those supplements.
And if you enter the thorn site through that portal, you can get 20% off any of the supplements that thorn makes we partnered with Thorne because they have the highest levels of
stringency with respect to the
quality of ingredients. The Precision of the amounts of those ingredients while supplements are certainly not required or necessary.
For anything really, you can always use behavioral tools. Many people benefit from taking supplements of various kinds and we do believe that getting supplements of the very highest quality is going to be important if that's the decision for you and
but not least. I want to
thank you for your time and attention
and thank you for your interest in signs.
