Reversing the damage
Correcting body composition is clearly an ultimate objective of nutritional treatment, but can only take place if there is competent cellular function. In the severely malnourished patient, two separate but linked processes occur. First, inadequate food consumption leads to wasting and functional changes in all tissues. Second, the general metabolic response to infection, trauma or other stress results in further specific nutrient losses and cellular damage. Ultimately the objective of treatment must be to return body composition to normal, but this requires competent metabolic machinery. Therefore, the first step has to be to repair the machinery, with tissue repletion being a secondary consideration during the early phase of treatment. The nutritional management of severe anorexia nervosa may be considered in terms of three consecutive phases: resuscitation, repair and repletion.
Resuscitation
Severe malnutrition is a medical emergency, and there is an urgent need to correct hypothermia, hypoglycaemia and electrolyte disturbance. Dehydration should be corrected cautiously and cardiovascular function stabilised as far as possible. Infections (some of which may not be clinically obvious) should be identified and treated.
Repair
Tissue function cannot be restored unless the cellular machinery has been repaired. This requires the correction of multiple specific nutrient deficiencies, which may not be detected by standard biochemical tests.
Repletion
Abnormal body composition can only be corrected safely when the cellular machinery has been adequately repaired. Aggressive attempts to drive weight gain at an early stage of treatment are therefore potentially dangerous. A simplistic approach to the correction of abnormal blood biochemistry is also hazardous, for example treating a low plasma albumin level with a high-protein diet or treating anaemia with supplemental iron.
The physical damage of restriction
A person will die from hunger when one of two things happen; either half of the body’s protein is used up, or all of their body fat. The internal systems become severely weakened and the organs/muscles (including the heart) are susceptible to atrophy as it starves. I remember walking like an old woman when I was at my worst- holding onto walls because the muscles on my legs were eating themselves. The nurses later told me that I was walking like the typical person with atrophy. It could have gotten worse though, and I was lucky to get early medical intervention. I have witnessed countless patients who have had this illness longer or who have undergone chronic energy depletion to the extent that they require a wheelchair. These patients typically are unable to walk as their legs simply do not have enough muscle attached to the bones to make movements. This explains why people with AN are asked to complete a sit/squat test and a sit up test. The healthy individual should be able to squat without falling and should be able to sit up completely from a flat laying down position.
Think about it- your body is not only converting its reserve fuel (body fat) into usable energy, it’s also breaking down muscles for the glucose and protein it cannot get from body fat alone. Eventually, the damage to your organs and heart from your body cannibalising itself is what finally kills you. I have heard people with anorexia tell me their heart muscle has been eaten and even one person told me their brain was starting to cannibalise itself. I have also met people who no longer have control over their bowel movements as the long intestines can shrink in the digestive track and lack of blood flow and nourishment can cause the intestines to shrivel.
A lack of sufficient protein to the heart causes the heart muscles to breakdown which causes murmurs and arrhythmias until the heart stops beating completely. Without a heart to keep pumping blood and oxygen to your brain, you slip into unconsciousness and die. If you have access to water but no food, then the entire process will take between 2 to 8 weeks depending on how much body fat is stored up. For obese individuals, this estimate can swing wildly but we’ll talk more about that at the bottom of the article.
Amino group (nitrogen and hydrogen) and an organic acid group (COOH). Proteins also have some sulfur because both amino acids cysteine and methionine contain sulfur.
Deoxyribonucleic acid (DNA), ribonucleic acid (RNA), adenosine triphosphate (ATP, responsible for providing cells with energy), and the phospholipid layer that protects your cells, all have phosphorus as a critical component .
MINERAL METABOLISM
Beyond the chemical elements, our entire mineral metabolism maintains our health on a cellular level.
The electrolytes: sodium, potassium, calcium, magnesium, chloride, hydrogen phosphate and hydrogen carbonate. The minerals within these electrolytic solutions are not electrolytes in their mineral state, but when dissolved in water they become electrically charged and that charge allows things to flow through the cell wall barrier.
The entire system of moving things back and forth across the cell wall is always in a state of flux but things go horribly wrong pretty fast when overall input and output do not match.The kidneys are the dominant organs maintaining this overall electrolytic balance, but the digestive, respiratory and cardiovascular systems are all critically involved as well. An average, unrestricted diet allows us to take in all the minerals and fluid necessary to create electrolytes to keep everything flowing in its usual homeodynamic state.Dehydration is often synonymous with elevated sodium in the blood: hypernatremia. Usually, any slight build-up in sodium in the cells triggers thirst— a way for the body to balance the sodium to water levels. Severe hypernatremia occurs when someone is unable to obtain water to correct the imbalance. The initial symptoms of dehydration include sluggishness, irritability, twitchiness (neuromuscular excitability) and swelling. Unchecked, it will lead to seizures and coma. On occasion the depletion of water in the body will outstrip the ability of someone to replenish the water.
Those with restrictive eating disorders often generate hypernatremia through purging, diuretic and laxative abuse (mimicking a stomach flu in effect). The opposite of hypernatremia is, of course, hyponatremia. Those with restrictive eating disorders are just as likely to suffer hypernatremia and hyponatremia. Why? In an effort to try to stave off severe dehydration, patients will drink a lot of water. They quickly find that “water loading” is also a way to take the edge off of hunger. Excessive water intake can also lower optimal electrolyte levels and that, too, is life threatening. And of course, insufficient intake of food rich in all these minerals will create hyponatremia as well. Symptoms of hyponatremia include nausea, vomiting, headache, confusion and, as with hypernatremia, eventually seizures and coma. Many with intractable eating disorders will attempt to manage mineral metabolism in the absence of eating enough food. Sadly, the body is the best arbiter of mineral metabolism, and often patients attempting to keep mineral and water levels at an optimal state, in the absence of real food, are constantly overshooting in one direction or another. The damage associated with mineral metabolism imbalances primarily impacts the kidneys.
TRACE MINERALS
“Trace minerals do not exist by themselves but in relationship to one another. Too much of one trace element can lead to imbalances in others...Most trace elements need to be in ionic form to be well absorbed in the intestine.”
[AG Schauss, Minerals, Trace Elements and Human Health, BioSocial Publications, Tacoma, WA, 1995].
The devil is in the details, and Alexander Schauss, quoted above, has spent a good amount of time investigating the impacts of trace mineral imbalances and behavioral problems.
There are nine accepted trace minerals relevant to human health: iron (Fe), zinc (Zn), copper (Cu), iodine (I), selenium (Se), manganese (Mn), fluorine (F), chromium (Cr) and molybdenum (Mo) [Learning Seed, 2009].
Of course, there are likely hundreds of trace minerals and their isotopes that are equally critical to human health (found in our omnivore diets) but as yet to be identified when it comes to particular biological function and value.
It turns out that dirt is key to our health and survival. Soil is critical in providing bioavailable trace minerals in both the plants and animals that we eat. And, unfortunately, the shift to chemical-based applications for both the growing of plants and animals since the Second World War (see above) has actually depleted much of these trace elements in soil and hence their depletion in our food sources as well.
With all the usual caveats that the following book parrots the dogma associated with ‘obesity’, Farmacology, by Dr. Daphne Miller, provides a very readable and pleasant romp through the inter-relationships between human health and soil.
But for the purpose of this post and more scientifically stated:
“The transfer of trace elements within the soil–plant chain is a part of the biochemical cycling of chemical elements—it is an element flow from nonliving to the living compartments of the biosphere. Several factors control the processes of mobility and availability of elements; in general, they are of geochemical, climatic, biological, as well as of anthropogenic origin.” [A. Kabata-Pendias, 2004]
What does any of this have to do with damage from restrictive eating or the potential for the reversal of that damage? Everything.
As with electrolytes, trace minerals are not easy to manipulate for optimal health within a lone individual outside of the soil-to-food-to-energy cycles that connect that individual to the entire planetary biosphere.
The critical takeaway from this entire discussion on chemical constituents, minerals and health is that it is the inter-relationship of these items, and not their mere presence, that determines health. Sodium levels are only relevant in relation to water levels and in relation to environmental conditions both within and outside the body as a whole.
MEDICAL DILEMMAS AND THE RECOVERY PROCESS
“Wait and see” is not a standard of care within the medical community. For a host of understandable reasons, doctors get in there with stabilizing interventions at the earliest possible opportunity.
First and foremost among the drive to intervene is liability. If a doctor believes she has a life-saving intervention at hand and she knowingly withholds the intervention in the interests of waiting and seeing how the condition will progress, then she is merely a walking lawsuit waiting to happen. And that is not cynical, that is practical—any physician who is not cognizant of that fact will soon be separated from his or her practice altogether.
Secondly, and no less compelling, are the ethical unknowns a physician, and her patient, must face. Imagine you discover a lump and it’s cancerous. But no one has any real way to determine whether the cancer will eventually be the cause of your death or whether you will live a long life with a very slow growing cancer that has no part to play in your eventual natural death from other causes.
And although I have not read this one (as yet) I have read another book by this author and I suspect this one will be a very interesting read: Antifragile: Things That Gain From Disorder, by Nicholas Nassim Taleb. And that is the issue at hand when it comes to the process of recovery: gaining from disorder. It is important, and yet exceedingly difficult, to work with a physician who is driven to ask: in what direction are the symptoms heading? The stability that we often see with patients who have endured years of restriction and its commensurate damage is often misidentified as a good thing. It is, instead, an insidiously fragile stability where almost literally a puff of wind will collapse the entire system. Taleb uses the term “antifragile” to denote that a system gets stronger with shocks, rather than remaining the same despite those shocks. You are building your own antifragile system from the inside out when you enter the recovery process, and it is a roiling, tectonic and intense process. While medical intervention may be an absolute necessity as you undergo the process of recovery— there is no way that pancreatitis is a wait-and-see crisis, as one example— keep asking questions about the risks of non-intervention and of taking that wait-and-see approach.
Remember my Mount St. Helen’s analogy in Phases of Recovery from a Restrictive Eating Disorder? Well, I have yet another image to add to these mounting analogies: Shiva: Destroyer (or Transformer) of Worlds (the image used at the beginning of this final section).