Commentary: Fight anorexia by confronting the fear of weight gain

SAN FRANCISCO: Anorexia nervosa is a psychiatric illness that primarily effects young people during their adolescence. While anorexia is relatively uncommon, it can be lethal.

Indeed, despite its relatively early onset, anorexia can last for several decades for more than half of those afflicted. It can lead to many associated psychiatric and medical risk factors, which in part explains why anorexia has the highest mortality rates of any psychiatric disorder.

There is an urgent need to understand the condition of anorexia better, as treatments to deal with it have had little effect, says one observer.

Those who suffer with anorexia have a powerful fear of weight gain and a cruelly distorted self-perception. As a result, some restrict caloric consumption to fewer than 400 calories per day, which is less than a quarter of what is typically recommended for adolescents.

Those with anorexia may quickly become emaciated and lose more than 25 per cent of their typical body weight. This rapid weight loss causes cardiac abnormalities, structural and functional brain alterations, irreparable bone disease, and in some instances, sudden death.

The effective treatment of anorexia is therefore very important.

FEW ADVANTAGES IN SPECIALISED TREATMENTS

Colleagues and I recently completed the largest analysis ever undertaken of outcomes for existing treatments for anorexia.

We pooled the findings from 35 randomised controlled trials between 1980 to 2017, which cumulatively assessed the outcomes of specialised treatments in over 2,500 patients with anorexia, and examined outcomes according to both weight, and the core cognitive symptoms of anorexia, such as fear of weight gain and a drive for thinness.

I am sad to say that what we found was bleak. In essence, specialised treatments for anorexia, such as cognitive behavioural therapy, family-based treatment and emerging medication treatments, appear to have few advantages over standard control treatment-as-usual, such as supportive counseling.

In fact, the only advantage of specialised treatments, relative to control treatment-as-usual conditions, was a greater chance of having a higher weight by the end of treatment. There was no difference in body weight across specialised versus control treatments at follow-up.

In addition, there were no differences in the core cognitive symptoms of anorexia between specialised versus control treatments at any one point.

This means that, even if a treatment helps restore normal weight, a focus on thinness and an unease around eating is common, making a relapse into low weight likely.

Equally importantly, specialised treatments do not appear to be more tolerable to patients, with comparable rates of patient dropout to control treatments.

When time trends within these data over the last four decades were analysed, it was found that the outcomes of specialised treatment are not incrementally improving over time.

MORE THAN WEIGHT

These findings are sobering. The notion that our best efforts to advance treatment outcomes over the last four decades have failed to move the needle is cause for grave concern.

However, an important outcome of this study lies in giving those of us who study and treat anorexia a better idea of how we might move the needle. We believe these findings speak to an urgent need to better understand the neurobiological mechanisms of anorexia.

We can no longer assume that improvements in patient weight ought to be the terminal goal of treatment for anorexia, and will confer improvements in cognitive symptoms.

While weight normalisation reduces the acute risk of complex medical events, ongoing fear of weight gain and food intake will likely mean future bouts of low weight and starvation.

We have reached a plateau in the treatment of anorexia. Future research endeavors must elucidate the precise mechanisms that underpin cognitive symptoms of anorexia, and altering these mechanisms must become the goal of treatment.

Stuart Murray is assistant professor of psychiatry at University of California, San Francisco. A version of this commentary first appeared on The Conversation. Read it here.


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Commentary: Fight anorexia by confronting the fear of weight gain

Can you – should you – eat food that has passed its expiry date?

It might have been a while since you last needed something from the larder. Other than the mustiness and odd strands of cobweb, there might also be a few forgotten cans, jars or packs of food and drinks from a while back that make you wonder: Are they still edible?

The expiry date is naturally your best indication. But when you look closer at the stamped date, it actually reads “Sell by”, “Use by” or “Best before” instead. Do they mean the same thing as the expiry date?

It seems like a waste to throw food out, but is that milk or bread safe to consume? CNA Lifestyle finds out from the experts.

No, according to Consumer Reports. The sell-by date is to inform retailers when to take the item off the shelves. But it isn’t the same as the expiry date. Milk, for one, could last five to seven days past its sell-by date before turning sour, said the website.

Use-by dates, on the other hand, are for highly perishable food, said Natalie Goh, Mount Elizabeth Novena Hospital’s chief dietitian. “It can be dangerous to eat foods that have passed their use-by dates,” she said.

Meanwhile, the best-before date indicates “how long the food will be at its best quality,” said Goh. For example, chips may not be crispy past this date but the lao hong snack may still be edible. But if you have any doubt, do not eat it even if the food is within the date, she said.

HOW EXPIRY DATES ARE DETERMINED

“The expiry dates of food products are determined by a combination of factors, such as the types of the ingredients used, the manufacturing process, the type of packaging used, and how the food product is stored,” said a spokesperson from the Agri-Food & Veterinary Authority Of Singapore (AVA).

It can be dangerous to eat foods that have passed their use-by dates.

Some food companies commission microbial challenge studies, which deliberately introduce harmful micro-organisms such as Listeria moncytogenes into the food that is being tested, according to Londa Nwadike, assistant professor of Food Safety, Extension Food Safety Specialist at University Of Missouri, Kansas State University.

The contaminated food is kept under conditions that it is likely to encounter during transportation, in storage, in the store and at home – and tested at various lengths of time, wrote Asst Prof Nwadike in her article in The Conversation. This helps to determine the point at which the level of micro-organisms present is too high for safety.

Sometimes, micro-organisms are not added at all, and the test simply monitors the taste, smell, texture and appearance of the food to determine the longest possible time it can be kept without compromising its quality and safety, wrote Asst Prof Nwadike.

Food companies then remove at least several days from this duration to set the use-by date. However, there is no “standard for the length of this safety margin” and the margin is “set at the manufacturer’s discretion”, noted Asst Prof Nwadike.

The testing isn’t a once-off affair either. According to the HACCP Mentor, food manufacturers should submit their food products for retesting every time they introduce new equipment to the manufacturing process, or change the recipe, formulation or even the pack size.

To ensure that the manufacturers – both local and overseas – comply with Singapore’s food safety standards and requirements, the AVA “monitors, inspects and samples” the food products. However, the onus of setting the expiry dates lies with the food manufacturers,” said the spokesperson.

EXTENDING FOOD’S SHELF LIFE

Whether it’s sardines or orange juice, the same tricks are generally used to extend the product's life span: Less moisture and/or more acidity, sugar or salt levels. Sometimes, heat and preservatives such as benzoates are used, too.

As a result, the shelf life of foods such as eggs, bread and milk can be extended from days to months, depending on the food, processing and packaging techniques, said Dr Matthew Zhao, packaging technologist with Singapore Polytechnic’s Food Innovation And Resource Centre.

Even for food products that are still within the expiry dates, if you suspect any spoilage, just discard. Don't risk food poisoning.

Jarred items such as jam, peanut butter and sauces can be extended for months, while juices and stock in tetra packs can last from months to years, he said.

That canned food and convenient frozen bites, including fish balls, fish fingers, crab sticks, nuggets and dumplings, which you stash in the freezer for emergencies? They should be good for a couple of years, said Dr Zhao.

WHAT TO THROW OUT, WHAT TO KEEP

What if the can of fruit cocktail in your larder has just exceeded its expiry date by a mere few days? Seems like a waste to chuck it.

Chances are, you can go ahead and dig in as canned foods can still be eaten a few days after their expiry date, said Toby Amidor, a nutrition expert and author of The Easy 5-Ingredient Healthy Cookbook. That is provided the can looks fine and you have stored it properly in a cool, dry, dark place, he said.

Dairy products such as yoghurt, milk and cheese are generally safe a few days past their sell-by dates, unless you see signs of spoilage, said Amidor. Milk, for instance, is drinkable up to five days past the sell-by date, he said. Cheese, especially the hard varieties, can last a little longer.

Obviously, rusty and/or bloated cans as well as anything that has sprouted mould belong in the bin. Other signs to look out for include badly dented cans; leaking or bulging cans/lids; cracked jars or jars with loose lids, or those that appear to have been opened, said Goh from Mount Elizabeth Novena Hospital.

But what about food such as cereals, chips, biscuits and other foods that have lost their crunch? Is it still ok to eat them if they are just a little after their expiry dates? The rule of thumb: If the packaging’s appearance is different from the norm, or it has an unusual odour after opening, do not eat its contents.

Still undecided? You're better off skipping food you're not sure of, said Goh. “Even when it comes to food products that are still within the expiry dates, if you suspect any spoilage, just discard. Don't risk food poisoning,” she said.

For a second opinion on how long a food stays safe to eat, you can check the free app created by the US Department Of Agriculture.

What if you only realise the food has passed its expiry date after eating it? Wait and see if there are any symptoms, said Dr Reuben Wong, gastroenterologist from Gleneagles Hospital. These would include diarrhoea, vomiting and/or fever. You should seek medical help immediately if you do.

“The body has a defense system in the form of strong acid in the stomach that will help kill incoming germs. It is believed that taking activated carbon or probiotics might help, but there is no firm evidence that this would prevent food poisoning per se," he said.


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Can you – should you – eat food that has passed its expiry date?