Showing posts with label Eating Disorders. Show all posts
Showing posts with label Eating Disorders. Show all posts

Thursday, January 21, 2010

Health benefits of dietary nut intake


Dietary nut intake is strongly associated with a variety of health benefits, particularly a lower risk of developing cardiovascular disease. Here is a link to a recent review of the subject:
http://www.ncbi.nlm.nih.gov/pubmed/19321572

This 2009 article describes a carefully controlled, inpatient, 4-day randomized study in which subjects were given a breakfast containing walnuts; or a "placebo" breakfast containing the same number of calories, and the same amount of carbs & fat, but no walnuts. The results showed that a breakfast containing walnuts leads to a significantly greater feeling of satiation (contentment and satisfaction with respect to food), at lunchtime:
http://www.ncbi.nlm.nih.gov/pubmed/19910942

Therefore, eating walnuts, as part of a balanced diet, is likely to maintain a feeling of satiation, and therefore reduce some of the physiological drives which can contribute to unhealthy eating behaviours.

This is a reference to a large prospective study of over 50 000 women followed over 8 years. The results included a multivariate analysis controlling for many other factors, such as physical activity, smoking, other dietary habits, etc. There was a slight reduction in weight gain or obesity in those who included more nuts in their diet, and in fact the more frequent the nut intake, the lower the risk of obesity:
http://www.ncbi.nlm.nih.gov/pubmed/19403639

With respect to mental health, I think that a balanced, healthy diet is important. Lifestyle habits, including nutritional choices, which reduce risk of cardiovascular disease, are likely also to reduce risk of degenerative brain disease. Walnuts are a source of omega-3 fatty acids, for which there is modest evidence of beneficial effects on mood.

Treatment of eating disorders requires deliberate attention to healthy, regular nutritional habits. Many individuals with eating disorders exclude certain types of food from their diets, based on an unfounded belief that the exclusion would lead to improved control of appetite or caloric intake.

Nuts in particular clearly deserve to be part of a healthy diet, unless there are issues such as food allergy.

Wednesday, July 15, 2009

Benefits and Risks of Zinc Supplementation in Eating Disorders, ADHD, and Depression

Zinc supplementation may help treat anorexia nervosa, ADHD, and treatment-resistant depression.

Zinc is a metallic element involved in multiple aspects of human cellular function, metabolism, growth, and immune function. It is required for the function of about 100 human enzymes. The human body contains about 2000-3000 mg of zinc, of which about 2-3 mg are lost daily through kidneys, bowel, and sweat glands. The biologic half-life of zinc in the body is about 9 months, so it can take months or years for changes in dietary habits to substantially change zinc status, unless the intake is very high for short periods.

Red meat is a particularly rich source of zinc. Vegetarians may have a harder time getting an adequate amount from the diet. The prevalence of zinc deficiency may be as high as 40% worldwide.

When referring to zinc dosage, it is best to refer to "elemental zinc". Different types of zinc preparations (e.g. zinc gluconate or zinc sulphate) have different amounts of elemental zinc. For example, 100 mg of zinc gluconate contains about 14 mg of elemental zinc. 110 mg of zinc sulphate contains about 25 mg of elemental zinc.

Here are references to articles written by a Vancouver eating disorders specialist between 1994 and 2006, advising supplementation of 14 mg elemental zinc daily (corresponding to 100 mg zinc gluconate daily) for 2 months in all anorexic patients:
http://www.ncbi.nlm.nih.gov/pubmed/17272939
http://www.ncbi.nlm.nih.gov/pubmed/11930982
http://www.ncbi.nlm.nih.gov/pubmed/8199605

Here's a 1987 article from a pediatrics journal, showing improvement in depression and anxiety following 50 mg/d elemental zinc supplementation in anorexic adolescents:
http://www.ncbi.nlm.nih.gov/pubmed/3312133

In this 1990 open study, anorexic patients were treated with 45-90 mg elemental zinc daily, most of whom had significant improvement in their eating disorder symptoms over 2 years of follow-up.
http://www.ncbi.nlm.nih.gov/pubmed/2291418

Here's a 1992 case report of substantial improvement in severe anorexia following zinc supplementation:
http://www.ncbi.nlm.nih.gov/pubmed/1526438

Zinc depletion may lead to an abnormal sense of taste (hypogeusia or dysgeusia). This sensory abnormality improves with zinc supplementation. Here's a reference:
http://www.ncbi.nlm.nih.gov/pubmed/8835055

Here's a randomized , controlled 2009 Turkish study showing that 10 weeks of 15 mg/day zinc supplementation led to improvement in ADHD symptoms in children. However, a close look at the study shows a bizarre lack of statistical analysis comparing the supplemented group directly with the placebo group. When you look at the data from the article, both groups improved to a modest degree on most measures, with perhaps a little bit more improvement in the zinc group. The analysis here was insufficient, I'm surprised a journal would accept this.
http://www.ncbi.nlm.nih.gov/pubmed/19133873

Here's a 2004 reference to a study showing that 6 weeks of 15 mg elemental zinc daily as an adjunct to stimulant therapy improved ADHD symptoms in children, compared to stimulant therapy plus placebo. In this case, there was a valid statistical analysis:
http://www.ncbi.nlm.nih.gov/pubmed/15070418

Here's a 2009 study showing that zinc supplementation improves the response to antidepressants in treatment-resistant depression. The dose they used was 25 mg elemental zinc daily, over 12 weeks.
http://www.ncbi.nlm.nih.gov/pubmed/19278731

Here's an excellent 2008 review article about zinc deficiency, and about the potential role of zinc supplementation in a wide variety of diseases (e.g. infections ranging from the common cold, to TB, to warts; arthritis; diarrhea; mouth ulcers). The review shows that zinc may have benefit for some of these conditions, but the evidence is a bit inconsistent:
http://www.ncbi.nlm.nih.gov/pubmed/18221847

Here is a warning about zinc toxicity:

http://www.ncbi.nlm.nih.gov/pubmed/12368702 {hematological toxicity from taking 50-300 mg zinc daily for 6-7 months. The toxicity was thought to be due to zinc-induced copper malabsorption leading to sideroblastic anemia}

Here is a nice website from NIH summarizing the role of zinc in the diet, in the body, some of the research about health effects, and about toxicity. It sticks to a recommended daily intake of 10-15 mg elemental zinc for adults, or about 5 mg for young children. It states that the maximum tolerable daily intake levels are about 5-10 mg for young children, 20-30 mg for adolescents, and 40 mg daily for adults:
http://ods.od.nih.gov/FactSheets/Zinc.asp

Here is a reference to another excellent review of zinc requirements, benefits, and risks. It makes more cautious recommendations about zinc supplementation, advising no more than 20 mg/day of zinc intake in adults. In order to prevent copper deficiency, it also advises that that the ratio between zinc intake and copper intake does not exceed 10.
http://www.ncbi.nlm.nih.gov/pubmed/16632171

So, were I to make a recommendation about a zinc supplementation trial, I would advise sticking to amounts under 20 mg (elemental) per day for adults, and to ensure that you are getting 2 mg of copper per day with that.

Monday, June 15, 2009

Inositol


Inositol is chemically similar to glucose (the type of sugar required by the brain for energy). It is a precursor in a so-called "second messenger system," which cells require to communicate with each other. In the brain, these second messenger systems are activated by various neurotransmitters including serotonin. There is some evidence that brain levels of inositol are reduced in depression and anxiety disorders. Inositol is present in a typical diet, in amounts of about 1 gram per day. Doses of supplemental inositol are typically 10-20 grams per day.

A Cochrane review from 2004 concluded that there was no clear evidence of supplemental inositol being beneficial in the treatment of depression:
http://www.ncbi.nlm.nih.gov/pubmed/15106232

Here's a 2006 reference from Bipolar Disorders showing that supplemental inositol could help treat bipolar depression in some patients already taking lithium or valproate. In 4 out of 9 patients taking 6-20 grams per day of inositol, their depression substantially improved over 6 weeks, with continuing improvement over an additional 8 weeks. However, the other 5 out of 9 patients either did not improve, or actually had worse symptoms. The patients who got worse had more manic or irritable symptoms at the beginning of the trial. When the results were averaged, the inositol did not appear to help significantly--however, it is notable that a subgroup of patients appeared to benefit significantly.
http://www.ncbi.nlm.nih.gov/pubmed/16542187

This 2001 study from the Journal of Clinical Psychopharmacology compared 1 month of inositol (up to 18 grams per day) with fluvoxamine (up to 150 mg per day) in the treatment of panic disorder. Both groups improved similarly. The fluvoxamine group had more side effects of tiredness and nausea. The study is limited by its short duration.
http://www.ncbi.nlm.nih.gov/pubmed/11386498

This 1995 study from the American Journal of Psychiatry compared 12 grams per day of inositol with placebo, for one month, in the treatment of panic disorder. The authors conclude that inositol was effective with no significant side effects. Mind you, when eyeballing the chart of data from individual patients, the results did not look very impressive.
http://www.ncbi.nlm.nih.gov/pubmed/7793450

Here's a negative study, showing no difference between inositol and placebo, when added to antidepressant therapy for OCD:
http://www.ncbi.nlm.nih.gov/pubmed/11281989

The same author as above published a study in 1996 showing that inositol on its own was superior to placebo for OCD treatment. However, despite "statistical significance" being found, eyeballing the data from each patient (presented in the body of the paper) reveals doubtful clinical significance (that is, the amount of benefit looked quite unimpressive to me):
http://www.ncbi.nlm.nih.gov/pubmed/8780431

Here's a reference to a 2001 study showing that inositol was superior to placebo in treating binge eating and bulimic symptoms. In this case, I found the data to be clinically significant. However, the study was limited by its small size.
http://www.ncbi.nlm.nih.gov/pubmed/11262515

Here's a small 1995 study showing that 4weeks of inositol (12 grams per day) was superior to placebo in treating depressive symptoms. The data appeared clinically significant, though modest.
http://www.ncbi.nlm.nih.gov/pubmed/7726322

Here's a 2004 reference from a dermatology journal showing that inositol supplementation led to improvement of psoriasis in patients taking lithium:
http://www.ncbi.nlm.nih.gov/pubmed/15149510

In conclusion, inositol may be modestly effective for treating anxiety, eating disorder, and depressive symptoms. It may perhaps be quite variable in its effectiveness, i.e. some individuals might have much more benefit than others. It appears to be well-tolerated with few side-effects. I could not find good data on long-term safety though. The quality of the evidence is not very robust-- the studies have involved only small numbers of patients, for short periods of time. More research is needed.

Thursday, May 21, 2009

Eating Disorders

Disordered eating is a complex problem which takes a variety of forms.

Anorexia nervosa is characterized by restrictive eating behaviours and excessive exercise which lead to medically dangerous weight loss.

Bulimia nervosa is characterized by binge-eating, and by purging (most commonly, self-induced vomiting). During binges, people often feel out of control, unable to stop.

In many cases, individuals have a mixture of anorexic and bulimic symptoms, without having a full syndrome of anorexia or bulimia.

In most cases of any eating disorder, there is a prominent disturbance of body image. Individuals may feel disgusted with their physical appearance. There may be an extremely strong preoccupation with fat. Fat (the word itself, as well as everything it represents) becomes something to be feared, avoided, and reviled. Any perception of normal subcutaneous fat is met with self-criticism or loathing. A perception of becoming thinner can be met with a feeling of satisfaction or addictive euphoria. Dietary fat, and dietary calories, often become subjects of intense preoccupation. Planning meals, or thinking about past meals, can lead to a great deal of anxiety. Eating socially with others can be extremely difficult. Situations in which people are more physically exposed (e.g. swimming pools, or the outdoors on a hot summer day) can cause increased self-consciousness and consequent self-loathing. Therefore, these situations are often avoided. Physical comparisons with other people can intensify symptoms. Many eating disorder behaviours (such as binges and purges) occur in secret.


Eating disorders can be medically dangerous: severe anorexia nervosa can be fatal. Other metabolic abnormalities from starvation or purging can cause weakness, cognitive impairments, bone demineralization, and abnormal heart rhythms. Repeated vomiting can cause damage to the esophagus. Overall poor nutrition makes it hard to treat other mental health problems, such as anxiety or depression.

In the treatment of eating disorders, sometimes a hospital stay is needed if weight is dangerously low.

Effective long-term resolution of severe symptoms can begin with an intensive multi-disciplinary day program, and may require lifelong treatment.

But here are a few basic ideas that I think can help in a less intensive outpatient setting:

1) It is important to be well-educated about basic nutrition -- to know what your body needs in a day, in terms of calories, fat, protein, vitamins, etc -- and to have a good sense of what foods might contain this balance of nutrients in a typical day. A consult with a dietician can be helpful.

2) Regular meals are important. Having regular meals can reduce the tendency to binge, since hunger will not build up as intensely. Experiencing meals is a component of behavioural therapy: planning the meal, obtaining & preparing the food, consuming the food, and then allowing the food to stay inside and be digested without purging. Each of these aspects may carry a lot of anxiety and stress. Having interpersonal support during these times can be powerfully helpful. Cognitive-behavioural techniques could also be helpful to manage the anxiety.

3)It can be important to recognize familiar patterns of thinking (e.g. having to do with fat or caloric calculations, dieting, weight loss plans, etc.) and practicing ways of directing attention away from these themes. It is also unhelpful to be bombarded with these themes in your social or cultural life, so I encourage a practice of redirecting social, cultural, or conversational energy away from subjects such as dieting, weight loss, etc.

4) Antidepressants such as SSRIs can help with bulimia (reference: http://www.ncbi.nlm.nih.gov/pubmed/14583971). The anticonvulsant topiramate can help reduce binge eating (references: http://www.ncbi.nlm.nih.gov/pubmed/18774432; http://www.ncbi.nlm.nih.gov/pubmed/14728106). Pharmacologic treatments for anorexia have not yet been very successful.

5) I think a very important element to work on is the confrontation and challenge of negative body image, its associated language, and its associated impairment in sensuality. Steps may need to be taken to stop or challenge "negative self-talk" and criticism about your body--about the way your body looks in a mirror, or the way your body feels to touch. This negative self-talk, and the ensuing negative emotions, need to be replaced by affirmations and by enjoyment. I think this type of work needs to be done every day. It can sometimes require work to gain pleasure from something, or to learn how to experience pleasure: this is a theme strongly present in the treatment of depression as well. Actually, I think it is a theme present in life generally -- we need to learn and practice something, to be with it consistently, in order for love or enjoyment to grow.

6) Similarly, I think it is important to reclaim the sensuality of food: the process of planning, preparing, consuming, and digesting food needs to be transformed from a source of dread or anxiety to a set of simple life pleasures. I think this type of sensuality should be emphasized in behavioural therapeutic techniques. Mindfulness meditation techniques can be helpful along these lines.

Tuesday, March 17, 2009

Drum Circles

Drum circles are groups where people gather to pound drums together: producing, hearing, and appreciating rhythms.

The perception of rhythm is one of the core elements of human experience.

Over hundreds of thousands of years of human evolution--even before the development of culture--the perception of rhythm must have been a very important part of daily life experience.

Here are some examples of rhythms that have been part of life experience for millions of years:

-The rhythmic pounding of ocean waves
-The beating of the heart (as perceived by feeling the pulses through touch, by feeling a throbbing, excited heart in the chest, or sometimes by hearing one's own or someone else's heartbeat)
-The rhythm of breathing (regular and soft in a calm state, rapid or erratic in anxious or excited states, irregular in various particular ways as a person is crying or sobbing; or when a person is dying, e.g. Cheyne Stokes respiration)
-The chirping of crickets or the croaking of frogs (these rhythms being affected by human proximity)
-The rhythm of work tasks (e.g. preparing some kind of meal or building some kind of structure would involve repetitively pounding, picking, or working with a material, and if this was a monotonous, laborious task, a rhythm would naturally form to help the person "get into it")
-The rhythm of human footsteps (steady and strong when feeling confident and certain, rapid or timid when frightened, stomping when angry)
-The rhythms of the human voice. Before the development of languages over 50 000 years ago, probably a great deal of communicative content between humans would have been based on "non-verbal" vocalizations, which would have emphasized tonal quality but also rhythm. Today vocal rhythms are most obviously part of the expressive content in poetry and song.
-Part of rhythm includes silence. It is the "empty space" between sounds. There was a lot more silence in pre-modern cultures.

Upon the development of human culture, starting perhaps 50 000 years ago, rhythms would have been generated spontaneously as a part of creative expression, as celebration, or as ritual.

In modern culture, perhaps a lot of the ancient, prehistoric aspects of rhythmic perception have been "drowned out". In urban environments, we have a lot of cacophonic, industrial sounds, or multiple sources of sounds all coming at us at the same time. There may not be very much silence at all. I suspect that this cacophony is a contributing factor to life stress, and one of the variables increasing the rate of mental illness (there are certainly many studies showing increased prevalence of various mental illnesses in urban environments). As a corollary, I believe that spending time developing one's musical and rhythmic experiences is beneficial to mental health.

As a therapeutic modality, drumming could help people in various ways:
1) as a form of meditative focus
2) it involves physical action: it is a form of exercise as well as a form of tactile stimulation
3) it helps to focus attention: it is a form of mental exercise, as well as a means to distract mental energy away from anxiety or other negative emotions
4) it can be an endless source of intellectual stimulation, with hearing or producing increasingly complex rhythms and cross-rhythms. This can evolve to become a source of esthetic enjoyment, also leading to appreciating rhythm in other aspects of life and music more richly.
5) it can be a social activity, in which other members of the group can be guides or teachers: in drum circles, individuals need not be skilled in drumming or in generating complex rhythms--exposure to the group permits a social learning experience
6) similarly, a drum circle could be a good setting to deal with performance anxiety or social anxiety, in the comfort of an encouraging and accepting group
7) it can simply be a healthy, enjoyable form of stress management
8) drum circles can be a means to build community: the experience combines elements having to do with conformity (maintaining the same rhythm together) and with individuality (each person may have a separate or special rhythmic role or task) -- both such elements are required to have healthy community life

In Vancouver, I know of one regular drum circle group, which has been open to anyone interested. The leader of this group, Lyle Povah, has done interesting work with drum circles as part of an inpatient eating disorders treatment program. Here's his website:
http://lylepovah.com/

There may be similar groups in other communities across the world, and I encourage people to research this, and to consider checking one out.

Friday, January 30, 2009

Narrative Therapy & the "Guru Effect"

This is another interesting therapy style, pioneered by the Australian social worker Michael White (1948-2008).

Here is my condensed account of narrative therapy: the main idea that I appreciate in this style is the application of a "story metaphor" to a person's life and problems. The patient becomes an author. Problems in the person's life (such as depression or eating disorders) become characters, and each of these characters gets a name. These characters are understood to have voices in the narrative, and to influence the story. The ways in which the different characters exert influence upon the story are examined, by the patient and by others. The role of the character--its purpose in the plot, so to speak--is considered. The question is considered of whether the story requires the character in some way, whether the character needs to be present, or what the story would be like without the character at all. The next step is to creatively "re-author" the story, addressing the problems externally as characters to deal with. The motives could be considered about why the different characters are behaving as they do. Elements which empower or weaken the character are considered. Important messages the characters might have to communicate could be considered or validated. The different "antics" of the characters (problems) could be anticipated, "spoken back to", or thwarted, through a creative act of "re-authoring".

The idea is really quite similar to cognitive-behavioural therapy, but perhaps with a more imaginative infusion of literary theory.

I find much of the written theory about this style incredibly cumbersome and laden with unnecessary jargon. Also I think this style, like many others, tended to see the founder as a sort of guru. There is a phenomenon I call the "guru effect" in which people with complex problems report significant change when they encounter some wise, charismatic figure, often in a public setting (I guess we can see this on certain types of TV shows these days).

I don't mean to be too critical of the "guru effect" because I acknowledge that there are some people who can share their charisma and wisdom very effectively, in a way that can be dramatically helpful. The word "guru" itself, and its origins, ought to be treated with respect, and the existence of this phenomenon can be appreciated as a gift to the world.

However, the "guru effect" can sometimes lead to a lot of dogma and a type of religious fervour that can foster overvalued ideas about what it is that is actually helping. This is especially problematic, in my opinion, if the adherents to a particular style begin to reject or criticize other styles or ideas, in ways that are not founded upon good evidence.

In any case, I think there are some imaginative and helpful ideas in narrative therapy--I'm always on the lookout for variations of cognitive-behavioural therapy or other therapies that are a little bit more imaginative, creative, or even fun (therapy isn't always fun, but humour, enjoyment, creativity, and playfulness can be immensely important elements at times).