I was recently sent an article from which I will be quoting extensively here (it’s also included in this newsletter - ed.). The article is by Heidi Mills, writing for Outside magazine and features the work of Dr. Emily Cooper of Seattle Performance Medicine. Dr. Cooper has consulted with Kartini Clinic on metabolic health and weight balancing for some time.  Originally, we worked together to try and solve the conundrum of patients with AN who appear to be weight restored but who don’t resume regular menstruation.  We concluded this persistent amenorrhea (lack of menstruation) has to do with a failure to properly restore leptin. In other words, with convincing the brain that “the famine” is over and that it can therefore allow normal hormonal functioning again (e.g. menstruation).

The gist of this article is that many athletes are puzzled by the counterintuitive effects of heavy training and low caloric intake on their weight.  Put bluntly, they expect their weight to go down with such interventions, but it creeps up instead.  Further caloric restriction does not help.

“But,” our patients might say, “I restricted and exercised and I did lose weight.”  That’s right.  That is indeed what happens in most people, at first.  But keep that behavior up and it becomes more and more difficult to “achieve” the same degree of weight loss, until eventually you may begin to gain weight, despite your “efforts”.  And, of course, those “efforts” lead to low mood, poor socialization, hair loss, menstrual disruption, bone loss, etc. etc. even if you are still doing your homework and getting straight A’s.  The brain is very well defended against starvation, and it will get it’s revenge!

Paraphrasing Dr Cooper Mills writes: “The scientific process that happens with under-fueled sports activity works like this: A workout session increases ghrelin, a hunger hormone that jacks up the appetite, slows the metabolism, and tells the brain the body is hungry. Athletes can mitigate the production of ghrelin by eating before and during exercise.

At the same time that ghrelin rises, the hormone leptin drops. Leptin reassures the brain that body weight is not too low, so without enough, metabolism drops and the body tries to hold on to fat. Endurance training is known to suppress leptin, especially in women.

The rise in ghrelin and drop in leptin becomes pronounced when athletes don’t take in enough food to support their exercise. Sometimes, they’re consciously restricting calories, as was the case with Scott [an athlete Cooper treated]. At one point, she drank only protein shakes because she wanted to be sure she wasn’t consuming any extra calories.”

Sound familiar?

This experience may resonate with people whose weight falls in the “obese” category , many of whom have spent a lifetime of dieting, adhering to one restricted program after another, while their weight creeps up and no one believes that they are not over-eating. It equally may resonate with the patient who has had an eating disorder for years: I have had more than one older teen patient tell me that, as it became harder and harder to lose weight with just restricting and exercising, they began purging. That’s a counter-productive and self-perpetuating behavior we would certainly wish to avoid.  Those with binge eating disorder know the pain of a food-demanding brain that they cannot turn off even when that food-seeking is physically painful and deeply unsatisfying.

Cooper’s recipe for success is very like what we do for patients with eating disorders: ordered, planful eating (note: not “intuitive” but in fact “mechanical”), rest and temporary cessation of training and exercise until balance is achieved.

As Cooper states, “since exercise endorphins suppress appetite in some people, anyone training for endurance events can’t rely on hunger alone... Athletes need to eat mechanically and not by appetite.”  

It’s interesting that “eating mechanically” to resist under-fueling and metabolic disruption is advice so easily accepted when discussing athletic performance, but when suggested in recovery from an eating disorder (as we do with the Kartini Meal Plan), we are accused of “rigidity” and of promoting food intake that is “not normal”.  We weave a tangled web of resistance and anxiety when it comes to anything that has to do with weight, even those of us who do not have eating disorders ourselves.

The hard news is that many will have to stop exercising at all - at least for a while - in order to recover metabolic functioning.  And when they do resume, will need to carefully fuel their activity and get plenty of rest.

If you think this advice is easy to hear, think again.  I call this “hard news” because not only are many of our patients with AN appalled to hear this, their parents resist it as well.  For almost no one out there seems to believe that exercise can be anything except a panacea for all ills.  And while exercise (hateful term! I prefer “physical activity” or “play”) is important to health in general, like water itself, which can be essential to functioning, but in excess can also destroy us.

A final word from Dr Cooper: “Some athletes can alter their nutrition and training plans and see immediate results, while others may need longer to recover”.

Recovery from the metabolic devastation caused by starvation takes time.  Your child can recover from an eating disorder, but healing takes time, and adequate rest for the injured part(s) will be needed.