Transcriber: Ildikó Zana Reviewer: Abed Shurrab
Food is as fundamental [to life as breathing],
and the most fundamental source of energy.
It is the source of energy for us
to have our strength in daily living,
and it is the centerpiece around which we establish a sense of joy,
communication, celebration.
It's the way we socialize.
We socialize around food.
But then, what about those who might have a reaction to food?
And then, there are those, for example, with type one diabetes.
With type one diabetes, a person cannot eat sugar
in the same way as those who don't.
The pancreas literally breaks down,
and cannot accompany the sugar into the cells,
and so the body starves.
So, when you think of diabetes,
how do you think of diabetes:
as a social illness, say, psychological illness?
Or a biological illness?
How many would say biological?
That's the way the majority of us think of it,
because we know that's the predominant cause of the illness.
But when you think of eating disorders,
do you think of eating disorders
as a social, psychological, or biological, illness?
It's that eating disorders maybe psychological and social as well,
but there is a serious biological basis to this illness,
and it's a brain basis.
Instead of the pancreas breaking down,
what we are now knowing is that there are pathways in the brain
that are not functioning in the same way
as those who don't have an eating disorder.
I'm going to focus today on anorexia and what we know from the inside out.
And what I want you to know
from all the areas of eating disorders,
there are about ten million persons in the United States
with anorexia and bulimia,
according to the National Eating Disorders Association,
and millions more with binge eating disorder
and other variations of those disorders.
We know that eating disorders
have the highest death rate of all mental illnesses.
So, it's not something that we can just think lightly about.
And it's very difficult to treat.
So, let's just start with you.
Let's just start with the sense that hopefully,
all of you had breakfast this morning.
And, with that breakfast,
you got some energy to start and enjoy this day, here at TEDx.
So, a person without an eating disorder
enjoys their toast, has a little more jam,
feels pleasure from what they're eating
and enjoys the taste and gets on with it.
And on you go.
But a person with an eating disorder,
such as anorexia,
when they eat, they experience high anxiety,
extreme thought disturbance,
and noise.
I want to give you an idea
of what that noise sounds like.
(Loud chattering voices)
And so the person who has an eating disorder
and has had her breakfast,
she's now trying to go to work,
she's trying to go to class.
And the noise and the disturbance
is acute.
She's trying to hear her professor through the noise.
She's trying to hear her employer talk to her,
and have an interaction with her.
And she's trying to focus, through the noise.
So, how in the world,
if she's going to have breakfast, and then she's supposed to have lunch,
and she's supposed to have dinner too,
and the noise continues to be acute,
"How can I function, how can I work,
how can I have a decent interaction,
and a clear focused interaction,
and get this project done?
How?
(Sound of voices stop)
Simply by not eating.
Because if I don't eat, Dr Hill,
I can then think more clearly.
If I don't eat, Dr Hill,
Please just don't have me eat breakfast, then I can get this assignment done.
Then I'll eat something, so then I can go ahead and get something,
because you say you're needing it,
but don't ask me to take that test and eat breakfast too,
Because, if I do,
I have to take the test
and think through the noise.
I have to finish the assignment and think through the noise.
So, what do we do
to be able to help a person with anorexia,
whose mental noise is so disturbed,
yet, they need food?
(Voices stop)
So, let's explore what's going on in the inside of the brain,
so that we can better understand what that looks like.
As we are looking at this research, we are seeing how the brain fires,
through FMRI studies.
Now, those are 3D studies, and it's not just looking at a picture.
The "f "means "functional".
So, they would give the patient a task,
while they're watching what goes on in the brain
and watching the oxygen blood flow.
So, when you're eating,
and it comes up from the gut and the signals get into the brain,
the signal moves through the thalamus right into the insula.
And the insula is the part of your brain
that gives the indication of hunger or fullness,
"I think I'm a little hungry; I better have some breakfast."
"Ah, that toast, that tasted good."
The taste and the degree of hunger comes out of the insula.
Right next to the insula is your amygdala,
and that's your alarm system that says,
"Anything wrong with the toast? Okay, then I'll stay calm, I'll be quiet."
"Anything wrong with...? Nope, I'm just alright."
So, amygdala just stays quiet.
And then it moves to the bottom of the striatum,
and you're going into the pleasure circuit.
The pleasure circuit, that dopamine, goes to a little high angle.
"Woo! That was nice; I'll have another, hmm, yes!"
And so, whenever you make a decision and you get pleasure from it,
you have a little dopamine spike.
"So, shall I put jam on it?"
I taste it, "Hmm, that was good, I'll have some more."
So you get these little pleasure surges in the dopamine.
It's your brains way, gut sensation, that says, "Yeah, yum!"
And so, then, the front of the brain begins to start interpreting it:
"Well, if you liked it, and the amygdala is not showing any alarm,
let's move it forward and let's have some more."
And then the cortex starts weighing "Is this good/bad?"
And so, "Oh, it tasted good, I liked the toast.
I'm hungry, then I'll go ahead and eat it", says the ACC.
Then on we go to the dorsolateral prefrontal cortex,
which is where Carly Simon sings about anticipation.
Only I'm thinking about anticipation with food, not other areas.
So, when we look at anticipation for the next bite,
"I think I could have another one!
That's fine, I'll have another bite."
And parietal then takes in, a sense of the brain that looks at,
"How am I in relation to those around me?"
So, "Oh, I look okay."
So then, you have another bite.
"Hmm, that was good"
Alright, then have some more.
I'll have another bite, I still look okay.
Take a third bite.
So, as you're eating your toast with your jam,
and you're looking around, you're saying, "Isn't this good?
Why can't she just eat?
Why can't she just enjoy her food?
Look, I'll fix this for you, I know you'll like it, It's really good."
Now, for the person with anorexia.
Same brain, same stations.
So, we've got the insula,
but, when that person takes the bite of the toast,
with anorexia, we actually get no signal.
None.
It's so flat, there's no signal for hunger in the insula.
There's no system or signal for the sense
that the hunger is getting a little worse.
So, while their body is starving,
and it's sending signals up,
the insula is not getting it.
It's just letting that serotonin pass right on by,
and the serotonin is not registering.
So, they can look at you and go,
"Oh, no, I'm not hungry; you go ahead."
"How could you not be hungry?"
"I'm not hungry", and they have no signal.
They take a bite of toast to accommodate you,
so they're not feeling like somebody's focusing too much on them.
They may eat the toast, and, with that, they may feel the taste.
But what we're finding is the flatness of the taste.
So, it tastes like cardboard.
That doesn't taste so good.
So now they're starting to eat, but they're not hungry.
They've eaten something and it's a bit flat.
So, amygdala's getting a little worried and it's going,
"Well, that causes me a little concern.
If you're not hungry, or you don't get any taste from it,
how do I know if it's not something of concern?"
So, the amygdala begins to, literally,
start to rev up and get more and more fearful,
a little more panicky.
And so, then, we head to that dopamine area,
and will they get any sense of pleasure?
No; dopamine is flat as well.
So, the whole gut sensation is not registering.
I get no flavor, I get no sense of hunger
and no pleasure from that bite of toast,
even with jam.
So then, the front of the brain is trying to interpret that.
"Wait a minute; she didn't like it? It was yucky? She's got no flavor?
So woe, woe!
I don't know if I should eat another bite, just hold back there."
So, the brain is trying to now figure out and make sense of those lack of signals.
So that cortex starts going,
"Is it good or bad? Maybe this is bad,
maybe this is just bad toast, maybe this is bad jam.
Maybe I shouldn't just eat it.
So okay, I'll just decide I won't eat it."
And so now, my dorsal lateral prefrontal cortex has no idea.
"Well, then what am I supposed to eat?
Oooh, I don't know what I'd do, what I'd do?"
The clients tell me over and over:
"I don’t know what to do about the next bite, Dr Hill,
I don’t know if I should eat it,
I’m literally eating blind because I do not know
what works and what doesn’t work."
And then sitting right back in that parietal area,
where they see a sense of their own sense of self,
we see disturbance that is off the chart.
They see themselves,
as that food translates into their brain,
they see themselves growing and magnifying.
The delusional impact is acute.
So, with anorexia there is increased [thought disturbance].
The moment we start refeeding to help that person who's starving,
we used to say,
"Just eat and you’ll start to feel better."
I don’t say that anymore.
I now say, "You're going to eat, and it’s going to be painful.
When you eat, it’s not going to feel good or think good.
Because as we try to help refeed you,
you’re going to have increased disturbed thoughts,
while your weight is restoring.
And it’s going to be miserable.
You’re going to have increased disturbed thoughts,
even when you restore your weight,
and you may have that for a good period of time,
and for some, that volume of noise never comes down,
and in other cases the volume comes down."
So the person with anorexia thinks and feels worse
when they’re at a normal weight.
They hit the normal weight,
and all your friends are coming around, going,
"Oh, you look so good, you look well!"
And they are literally living in the noise
and the disturbance and the pain
of a normal healthy-sized body.
So, it makes sense
why relapse has been so high.
Because by not eating,
I can deaden that pain, and get back to work.
If you start re-framing food, for you, food is socializing, joy, pleasure.
But for a person with anorexia,
it’s like the insulin to the diabetes:
it's medicine.
Just, "I need to take my medicine, and I've got some side-effects from it.
I have to eat my food."
So we have been testing and working in collaboration,
and exploring new research in the sense of:
can we bring the volume down of that noise?
So maybe we need to pre-plan the food,
pre-dose it,
and prescribe it,
so that they know exactly what they’re going to eat into.
So when you’re going somewhere with a friend who has anorexia you say,
just like with a person with diabetes,
"Do you have your insulin? Do you have your food?
Do you have a plan? Do you have your food?"
And so if they know what they’re taking,
and they know the amount,
and they know and potentially practiced eating some of that food over and over,
the clients report that the noise comes down.
It may not go away,
but then I can hear and function
and interact and get through it.
"So I am realizing that using the same meal plan
is not part of the disease",
one of the clients said.
"It's actually part of the cure."
One father got it.
He got it beautifully.
He said, "Okay, Dr Hill, spontaneity is out, planning is in."
I said, "Exactly."
And so they planned,
because there was going to be a big holiday gathering
and they were going to go to a restaurant together.
And the client worked with the eating disorder dietitian,
she went,
she knew exactly what she was going to order,
the amount she was going to order,
but she also decided, just in case, she would take her lunchbox
with her backup meal-plan,
just like you take your insulin, when you need to take it along as well.
Mom, dad - everybody knew - aunts, uncles.
She was so nervous,
she didn’t want people focusing and watching her,
she was just trying to be like everybody else
and be at this gathering at the restaurant.
So the waitress is going around, and she said, "What would you like?"
And the father leaned back to let his daughter order,
and she had it all down, and she said, "I’d like this and this."
The waitress said, "Oh I’m sorry, honey, we’re all out of that."
She froze.
Wasn’t sure what to do, she hadn't plannned
The father looked up and said, "You know, would you give us a minute, please?"
"Oh, okay!"
So the waitress went away and he said, "Alright, you can’t eat that,
this isn't here, so, do you have your lunch?"
"Yeah, Dad, but I don’t want to make a big scene."
"It’s all right, just get out your lunch."
And he called the waitress over and goes,
"You know, my daughter has a reaction to some of the foods on this menu.
She’s brought some things she’s going to eat.
We’re all going go continue to order."
(Sigh of relief)
The whole family ordered, they all had fun,
they all interacted,
and her noise could stay low enough as she ate her meal-plan
in order to enjoy the interaction as much as she could.
So, when we look at the prognosis,
what’s going to happen as the future is revealed in the sense of science,
and what direction we’re going with anorexia and eating disorders?
And with anorexia, some may be able to stabilize, and hold onto that.
We’re seeing that especially when it’s adolescents,
and that brain wires forward,
and the longer they hold to that meal-plan and get it stabilized,
the noise can actually wire out,
calm goes,
and as long as they stay within those safe boundaries,
a person can move on in recovery.
So, there are some with anorexia that will recover,
and some that will learn to manage.
And there is a sub-part that will remain accurately ill.
This is a visual replication of what I think of with anorexia.
The title of it is,
"Three kinds of lines, in a continuance."
We got your carbs, your proteins, your fats,
and very specific dose levels,
over and over and over and over.
Or is this art?
An Italian renaissance piece with multiple kinds of lines,
clear image of what the image is.
So is a meal only a meal
unless it is drawn out, filled with variety,
and has all kinds of fresh and different types of foods?
Or can a meal for some be something to get you through
to get on to enjoy life?
Now when I was getting ready to prepare for this,
something that I experienced was a great deal of anxiety,
and I told my patients that I was very nervous.
And they said to me,
"Dr Hill, if you go up and you share with them our voices,
and you tell them what it’s like for us,
we’re going to be here standing on the stage with you,
and let you know that we’re here with you."
So, they’re here with me.
And together while we struggle through the meal,
let’s help them get on with the act of living.
As Helen Keller said it,
"The world is full of struggling and it’s full of overcoming it.”
Thank you.
(Applause)