For people who are high achieving and successful, patience is typically not one of their long suits, especially when “patience” involves rest and restraint.
It’s not enough that our patients are often self-driven high achievers, but as this temperament trait is also highly heritable, many of our parents are as well. It is not unusual for our kids to be valedictorians, salutatorians, the lead in the school play, talented musicians, or competitive dancers or athletes, whose efforts have received recognition and acclaim. And which parent is not proud of this?
Healing interventions, whether in the realm of eating disorders or orthopedics, cancer or heart disease, take time. Like baking bread and letting it rise, time is an actual and essential ingredient. We just don’t like it, because many of us like to move at top speed.
“OK, so now she’s weight restored, when can she play soccer?”
The hateful answer is “that depends”-- not on her psychology so much as on her physiology.
Kartini Clinic’s Weight Restoration 2.0, about which I have written and Dr Moshtael lectured, is an advance in weight/health restoration that involves examining a patient’s own biological parameters to help time their return to full activity, and even to set weight gain goals. We look at nutritional/fueling parameters such as C3 and Total T3, we look at leptin and various sex hormones, we look at the thyroid and more.
Many insights about physiological restoration in eating disorders come to us from the research on obesity and dieting. There are many, many physiological similarities between our patients who have lost weight because of anorexia nervosa and those who have dieted because of obesity. Metabolic derangements due to low food intake are very rapid. Compensatory responses from the brain take place, perhaps even within hours. This “rapid response” is necessary under conditions of famine in order to “turn down” the metabolic fires to conserve energy and keep the person alive long enough to seek food. And, as we have discussed in other blogs, and as Ancel Keys so elegantly documented, hormones and neuropeptides that promote appetite go into hyper-drive: ghrelin, PYY and others; and the gut is slowed down in order to hang on to food longer (constipation and bloating anyone?).
When food once again becomes available, the person’s biochemistry returns to normal---but here’s the catch: slowly. The brain is deeply suspicious about environmental food security and cares little about our aesthetic concerns (what do I look like? Am I too fat around the middle?) Middle, schmiddle, it just wants you to stay alive.
Here’s an interesting and relevant article from the New England Journal of Medicine which I urge you to read. Plough through the technical bits, about every other sentence appears to be in common English and that is enough to make it understandable. Although the authors were principally interested in why people gained weight so readily after “successful” dieting (answer: it’s their physiology not their lack of moral fiber), their observations are relevant to our patients. They found that metabolism does not return to baseline for 12 months or more, as is also true for many of the reactive hormones such as leptin.
This is important for our patients as we advise no return to full exercise until the leptin is normalized, something that often lags behind weight restoration as such. Exercise will further suppress leptin.
Many parents who seem to accept that anorexia nervosa, for example, is a serious illness, a neurobiological disorder with profound effects on health, with a mortality of 10% (!), and unknown permanent effects on cognition, growth, development and reproduction, still scream “whaaat??!!!” when it is implied that their child may not be advised to return to their sport for about a year. “But [insert sport or favorite activity here] is the source of his/her social life! It’s where s/he feels most competent and it helps with mood. And s/he will be devastated if s/he has to wait.”
Unfortunately that may be quite possible. But here’s where being an adult parent comes in: we must take the long view. Ultimately, full healing and resumption of growth and development, both cognitive and somatic, must take place. Our children and teens cannot be expected to think like a 40 year old, to take the long view of their lives and while swallowing the bitter pill of “waiting” for full healing to take place. That would be our job, and a hard job it is. But remember that 10%?
That hard-to-swallow “tincture of time” prescribed by physicians for healing of bones, applies to us here as well. Let’s bend our efforts as adults, as parents, towards helping a child explore their full range of talents and interests while we wait, and not be trapped in the space of crushed short-term expectations.
In short, let’s lead by example.