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?

Is it ok to skip meals, even occasionally? Here's what happens to your body

Between waking up and getting ready for work, you might have just enough time to down a cup of coffee before you have to get out of the house. Or your boss just handed you a report at 12pm that needs completing in an hour’s time.

Whatever the reason, meal-skipping happens. So, what’s the big deal, right? We over-eat anyway, so we can stand to miss a couple of meals in a day.

You might lose a little weight but there are other health issues to contend with, say experts.

For starters, skipping just one meal causes your blood sugar levels to plummet. If you skip breakfast, it means your body has gone without fuel for nearly 12 hours – assuming your last meal was at 8pm and you begin your day at 7am. Imagine starting your car’s engine when its tank is empty, and you get the picture.

“Consistently (skipping meals) might lead to issues such as poor concentration, poor-quality diet and slowed metabolism for some,” said Apple Chan, a dietitian from Gleneagles Hospital. “This usually does not happen overnight. It’s the chronic, low consumption that happens over months or even years.”

In fact, unsated hunger pangs may cause you to over-eat at your next meal – not a good thing if you’re watching your calorie intake. More importantly, there’s also the diabetes risk.

In a study published in the medical journal Metabolism, researchers found that skipping meals during the day and eating one large meal in the evening created elevated fasting glucose levels and a delayed insulin response – conditions that can lead to diabetes in the long run.

But what if you try to redeem yourself by grabbing a cup of Milo or a couple of biscuits? Don’t these stop-gap measures go some ways in placating your rumbling tummy? Yes, but not nearly enough. “That is definitely not going to last you till your next meal,” said Chan.

At the very least, she said, ensure that your snack has the basic nutrient components: Carbohydrates, fats and protein. “All of these provide for the different functions the body requires for energy sustenance.”

Instead of just a cup of Milo, she recommended adding a tuna sandwich with avocado. That way, you get some carbs from the bread, protein from the tuna, and fats from the avocado and Milo. No time to head to the deli? Fix yourself some wholemeal crackers, cheese and Milo from the pantry. Or stash some cereal bars (they usually contain all three nutrients) in your office drawer.

Here’s a look at what other health issues can happen when you skip meals.

YOU WON’T LOSE WEIGHT IN THE LONG RUN

You might notice your clothes feeling looser and think you’ve lost weight from skipping meals. But it’d be a bad idea to use this method to pursue your ideal weight. “More than 50 per cent of the rapid weight reduction is fluid, which can lead to serious low blood pressure,” cautioned Chan.

She said that a study on obese individuals showed that at the 5-per-cent weight loss mark, continued fasting will actually result in less fat burning and more water loss. So, there might be an initial drop in weight due to the loss of water, but it will plateau after a while, she said.

Incidentally, once your body detects a shortage in food, it goes into self-preservation mode. Chan explained: “If the body detects that it is constantly receiving less than the required amount of food intake, it compensates by reducing energy expenditure.”

Some individuals may think that skipping meals can help them drop their weight as it is rather similar to the popular diet method known as intermittent fasting. Basically, it oscillates between periods (it can be hours, days or even weeks) of eating and fasting without having to mind what foods to stay away from.

“Skipping meals and other types of intermittent fasting may not be realistic for most people, and it does have the potential to backfire if it triggers unhealthy snacking or overeating later on,” Chan said.

“Even though intermittent fasting results in quick weight loss, it's often fluid loss and might not be substantial and sustainable in the long run. There are also some risks associated, such as dehydration and heartburn.

“Although I might not oppose healthy individuals opting for such diets for short periods of time, individuals with medical issues, such as diabetics and eating disorders, should refrain from them,” cautioned Chan.

YOU LOSE MUSCLE MASS

Say goodbye to the muscle gains you’ve worked so hard for at the gym because your body will start to cannibalise your muscles, usually within four to six hours of not eating, said Chan.

“During the early stages of fasting, the body can tap on back-up glycogen reserves. But even so, these stores can be depleted within 24 hours,” she said.

If you’re counting on increasing your fat burn through ketosis (the process where fats get broken down by the body for use as energy), it is only after one week of fasting or food deprivation that it happens, said Chan. By then, your body would have torched through considerable amounts of muscle for fuel.

YOU GET GASTRIC PROBLEMS

You’re not giving your stomach a break by skipping a meal or two. The reason is this: Your stomach produces digestive juices to break down the food that you eat. Even when there is no food to digest, it continues to do its job at the usual time that you eat.

“Prolonged periods without food tend to lead to acid reflux, gastritis and stomach acid. Excessive amounts of digestive juices might erode your intestinal lining and cause ulcers,” said Chan.

YOU START TO EAT JUNK FOOD

Ever notice how your resolve to stay away from doughnuts and fried chicken dissolves when you’re super hungry? That’s because when your blood sugar levels are low, your body wants you to grab hold of the easiest fuel to burn.

Unfortunately for us, that’s usually sugar and fat as they can raise the blood sugar levels quickly, said Chan. “You also tend to eat more ravenously when food becomes available, so your diet goes out of the window.”

YOU GET BAD BREATH

During the periods when you skip meals, your mouth produces less saliva and you might end up with a dry mouth. It is the perfect condition for bacteria to flourish, which in turn, can generate odour in your breath.

“If you have to skip a meal, drink sufficient water to keep your mouth moist and help to stimulate saliva production,” said Chan.


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Is it ok to skip meals, even occasionally? Here's what happens to your body