Answers to Anorexia - 2nd Edition
If you or a loved one is living with anorexia, or if you are a clinician who cares for people with anorexia, Dr. James Greenblatt’s new book Answers to Anorexia, may prove a useful read. Dr. Greenblatt is the medical director of Walden Behavioral Care, a consortium of eating disorder treatment centers. He is also a functional psychiatrist and one of the original pioneers in the field of orthomolecular psychiatry, which seeks to correct biochemical imbalances using nutritional supplements. He has poured his three decades of experience working with thousands of people with anorexia into this book, resulting in a thorough and accessible guide for patients, families, and professionals.
Anorexia is one of the most vexing conditions we psychiatrists face in our clinical work—and one of the deadliest. Disordered eating behavior is just one of the many facets of this extraordinarily complex condition, which is often accompanied by intense anxiety, delusional thinking, severe depression, and suicidal ideation. In my 20 years of clinical experience as a general psychiatrist, including 13 years in college mental health, I know firsthand how challenging this condition is to treat. People suffering from anorexia rarely seek care for their condition on their own, as poor insight into the illness and resistance to treatment are hallmarks of this disease. These symptoms are often misinterpreted as defiance, which can foster feelings of hopelessness, helplessness, and even anger in those who are trying to help.
Conventional treatment models seek to increase food intake and achieve a normal body weight, but since the defining characteristic of anorexia nervosa is the refusal—or inability—to eat enough food to maintain healthy bodily functions, increasing food intake is no easy task.
Dr. Greenblatt views the signs and symptoms of anorexia as the predictable consequences of starvation. When the brain and body lack the fundamental ingredients they need to function properly, a whole host of behavioral, cognitive, emotional, and physiological problems will naturally ensue. Dr. Greenblatt works to address their root causes using innovative strategies so logical it is surprising they aren’t more widely used.
One of these strategies is to address the underlying malnourishment with supplements including essential nutrients such as amino acids, vitamins, and fatty acids, which patients are more likely to accept and tolerate at first than dietary expansion. When patients say they can’t eat because food hurts their stomach, he believes them and prescribes digestive enzymes and other supportive supplements, explaining that malnourishment will naturally reduce the body’s ability to produce the molecules required to process food in the gastrointestinal tract.
In his experience, he has found that correcting nutrient deficiencies can help improve cognition, mood, and gastrointestinal symptoms, paving the way for food-based strategies and other personalized therapeutic options, including psychotherapy and medication.
One fascinating example of an intervention he has found helpful in his work is nutritional lithium therapy, a topic to which he devotes an entire chapter. He argues that lithium, a trace element naturally found in water and soil, is an essential mineral critical to neurological health, and he believes that many people are deficient in this mineral. He has found “micro-doses” of only two milligrams per day to be safe and beneficial to many of his patients by stabilizing mood, tempering impulsivity, and reducing suicidal thinking. This is far lower than the lowest pharmaceutical dose of lithium prescribed as a mood stabilizer in general psychiatric practice, which is 150 mg.
It has always baffled me that nutritional quality is rarely considered important in anorexia nervosa. The prevailing wisdom is that people with anorexia need simply to eat an unrestricted diet that contains enough calories to restore normal body weight. One of the most frustrating practices I see in this field is that patients admitted to hospitals are typically required to eat all of the food served to them on the unit, as refusing any item is viewed as noncompliant eating-disordered behavior. Unfortunately, these hospital diets include many foods with little to no nutritional value and contain ingredients that work against optimal nutrition and brain health such as cookies, juice, and processed cereal products. Wisely, Dr. Greenblatt focuses on nutrition first. “It’s not the weight, it’s the nutrition," he writes, "If you get the nutrition right, the weight takes care of itself.”
This brings me to a viewpoint expressed in the book with which I disagree. Dr. Greenblatt writes that following special diets which exclude certain foods or food groups, including vegan, vegetarian, and gluten-free diets, can be a warning sign of emerging anorexia. He therefore recommends against the elimination of or removal of any food groups in his work (except in documented cases of Celiac disease, which require a gluten-free diet). I am convinced that wheat does not belong in the human diet and jeopardizes optimal brain nutrition and mental health. I encourage all of my patients to use the paleo diet (which excludes all grains, legumes, dairy, and modern processed foods) as the first step towards their recovery from any mental health issue. [read my article "Six Reasons to Go Paleo for Mental Health" for more information.]
That aside, I learned a great deal from reading this book that has expanded my thinking about anorexia and will inform and improve my clinical practice. While there is unfortunately too little formal clinical trial research to understand how many people may accept, tolerate, and benefit from Greenblatt's recommended strategies, it stands to reason that the risk-benefit calculation would make them a valuable tool for patients and clinicians seeking new ways forward—particularly given that there are no medications shown to be effective in treating anorexia.
Answers to Anorexia is scientifically well-referenced and includes descriptions of the latest research studies, recommendations about laboratory testing, supplements, and medications, plenty of real-world case examples, as well as helpful summaries at the end of each chapter. Dr. Greenblatt's supplement recommendations are refreshingly descriptive rather than commercial, as he neither endorses nor sells specific brands of supplements in his book. This important guide is a welcome roadmap to revolutionizing the care of this complicated condition. His hopeful conclusion is that real and lasting recovery is possible when anorexia is treated first and foremost as a disease of malnutrition.