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+- [Andrew Huberman] Welcome
+to the Huberman Lab Podcast,
+where we discuss science
+and science-based tools for everyday life.
+- I'm Andrew Huberman.
+And I'm a Professor of
+Neurobiology and Ophthalmology
+at Stanford School of Medicine.
+Today, we are going to
+talk all about healthy
+and disordered eating.
+And indeed, we are going to talk
+about clinical eating disorders,
+such as anorexia, bulimia,
+and binge eating disorder,
+as well as some other
+related eating disorders.
+However, before we get into this material,
+I want to emphasize that
+today's discussion will include
+what it is to have a healthy
+relationship with food.
+We're going to talk about metabolism.
+We're going to talk about
+how eating frequency
+and what one eats influences
+things like appetite
+and satiety, as well as whether
+or not we have a healthy,
+psychological relationship
+to food and our body weight
+and so-called body composition,
+the ratio of muscle to fat,
+to bone, et cetera.
+So, as we march into this conversation,
+I'd like to share with
+you some interesting
+and what I believe are
+important findings in the realm
+of nutrition and human behavior.
+I know these days,
+many people are excited about or curious
+about so-called intermittent fasting,
+intermittent fasting
+is as the name implies,
+simply restricting one's feeding behavior,
+eating to a particular
+phase of the 24 hour
+or so-called circadian cycle.
+Other forms of intermittent
+fasting involve not eating
+for extended periods of
+time for an entire days,
+or some people will extend to two days
+or three days typically.
+And hopefully they will drink
+water during those times,
+sometimes referred to as water fasting,
+which means that they
+are ingesting fluids.
+And hopefully they are ingesting
+electrolytes such as salt,
+potassium and magnesium as well,
+because well one can
+survive for some period
+of time without ingesting calories,
+it is extremely important
+to continue to ingest plenty
+of fluids and electrolytes.
+And the reason for that is
+that the neurons of your brain
+and body that control your
+movements, your thoughts,
+clarity of thinking in general, et cetera,
+is critically dependent on the
+presence of adequate levels
+of sodium, potassium and
+magnesium, the electrolytes.
+And that's because neurons can
+only be electrically active
+by way of movement of particular ions,
+which include things like
+sodium potassium and magnesium.
+So, without those,
+you can't think, you can't
+function and it actually
+can be quite dangerous.
+So, why all the excitement
+about intermittent fasting?
+Well, a lot of the excitement
+relates to work that was done
+by a former colleague of mine,
+down at the Salk Institute
+for Biological Studies
+in San Diego, named Satchin Panda,
+Satchin's lab identified
+some very important
+and impactful health
+benefits of restricting
+one's feeding window to particular
+within the 24 hour cycle,
+or even to having extended
+fasts that go for a day
+or two days, or maybe even three days.
+What they saw was an improvement
+in liver enzymes and improvement
+in insulin sensitivity,
+which is something that is good.
+It means that you can utilize the calories
+and the blood sugar
+that you happen to have,
+being insulin insensitive is not good,
+and is actually a form of diabetes.
+What Satchin's lab and
+subsequently other labs showed,
+was that restricting one's
+feeding window to anywhere
+from four to eight or even 12 hours
+during each 24 hour cycle
+was beneficial in mice.
+And some studies in humans have also shown
+that it can be beneficial for
+various health parameters.
+However, the excitement about
+intermittent fasting seems
+to be related to the foundational
+truth about metabolism
+and weight loss and weight
+maintenance and weight gain,
+which is that regardless of
+whether or not you intermittent
+fast or whether or not you
+eat small meals all day long,
+or you eat one meal in the
+evening and snack up until then,
+it really doesn't matter in
+the sense that the calories
+that you ingest from whatever source,
+are going to be filtered through
+the calories that you burn,
+by way of exercise, basal metabolic rate,
+which is just the calories
+that you happen to burn,
+just being alive and
+thinking and breathing
+and your heart beating, et cetera.
+And the reason why many people
+will prefer intermittent
+fasting to other forms of let's
+just call it what it is diet
+or nutritional framework is
+that many people find it easier
+to not eat, then to
+limit their portion size.
+And here I'm not talking
+necessarily about eating disorders.
+I'm talking about the general population.
+So, I think that's one reason
+why there's so much excitement
+about intermittent fasting.
+Now, within the context
+of intermittent fasting
+on a circadian timescale,
+once every 24 hours,
+you generally find two
+categories of people,
+people who prefer to
+not eat in the morning,
+either because they are
+not hungry in the morning,
+or because they find it
+relatively straightforward
+to just drink things like
+coffee or water, et cetera,
+and push their feeding window
+out to noon or 2:00 P.M.
+or 3:00 P.M. and then they'll eat between,
+say 1:00 P.M. and 8:00 P.M. or 9:00 P.M..
+It depends on the individual.
+Other groups of people find
+that they are very hungry
+when they wake up in the morning,
+they don't feel well if
+they don't eat breakfast.
+And so they prefer to
+eat early in the day,
+but then they limit their
+feeding window such that they cut
+off their food intake or
+stop ingesting any calories
+of any kind, somewhere around 5:00 P.M.
+or 6:00 P.M., et cetera.
+So, the duration of the feeding window
+has not been broken down
+into the kind of nuanced type
+of information that one would really want.
+At least not in human studies saying,
+well, a six hour feeding window
+or an eight hour feeding window is ideal.
+It really is going to
+vary based on lifestyle
+and circumstances, for instance,
+some families really want
+to eat dinner together every night.
+So, do you want to be
+the person that's sitting
+there watching everybody eat?
+Because you're fasting
+from 5:00 P.M. onwards?
+I don't know.
+That's an individual difference.
+What you can start to identify, however,
+is that people tend to fall
+into either one category.
+The other people who prefer
+to skip eating in the morning
+or people that prefer to,
+or managed to skip eating in the evening.
+And there has been no evidence thus far,
+that one is better or worse,
+at least in terms of weight loss
+or overall health parameters.
+Now, you can imagine that some people
+might eat breakfast and dinner.
+And indeed I have several many colleagues
+in fact who just choose to skip lunch,
+because they're busy during the day,
+they eat breakfast and dinner,
+that doesn't afford the long,
+fast associated with sleep.
+What do I mean by that?
+Well, if you went to sleep at 11:00 P.M.
+and you wake up at 6:00 A.M.
+by extending your fast until
+1:00 P.M. in the afternoon,
+you get quite a long period
+of no ingesting any calories.
+Whereas when you don't eat
+during the middle of the day,
+you are getting a fasting period.
+That's probably anywhere
+from four to seven hours,
+but it's not linked to
+the longer fasting period
+of not eating while you
+are asleep, because most,
+all people and I want to emphasize most,
+do not eat while they are asleep.
+But we are going to talk
+about any new disorder
+that does exist, where people
+actually eat in their sleep.
+I know it sounds pretty
+wild, but indeed it,
+that eating disorder does exist.
+And it has a very interesting
+underlying mechanism.
+So, why are we talking about this?
+And in particular, why are
+we talking about this during
+an episode that includes a discussion
+about eating disorders?
+The reason is, nobody not the
+government, no nutritionists,
+no individual, no matter how knowledgeable
+they are about food and
+nutrition and food intake,
+can define the best plan for
+eating for any one individual.
+I'm going to repeat that.
+Nobody knows what truly healthy eating is.
+We only know the measurements
+we can take, liver enzymes,
+blood lipid profiles, body
+weight, athletic performance,
+mental performance, whether
+or not you're cranky all day,
+whether or not you're feeling relaxed,
+nobody knows how to define these.
+And these have strong
+cultural and familial
+and socio-societal influence.
+So, if you hang out with people
+that intermittent fast all
+day, that will seem normal.
+If you spend time with
+people that have never heard
+of intermittent fasting,
+intermittent fasting is
+going to seem very abnormal.
+Now we are going to talk
+about eating disorders
+that really fall into the category
+of clinically diagnosable
+eating disorders,
+for which there's actually
+serious health hazards
+and even the serious risk of death,
+we will get to that topic.
+But for the time being,
+I want to emphasize a new set of findings
+that I think many people
+will find interesting.
+And at least we'll want
+to consider in light
+of their current nutritional
+plan or pattern of eating,
+whether or not you're
+intermittent fasting or not.
+And I want to cue up
+an important framework
+for the rest of the
+conversation on healthy
+and disordered eating,
+which includes an understanding
+of thinking, decision-making
+and what we call homeostatic processes,
+meaning regulation of things
+that are going on in our brain
+and body and reward mechanisms.
+So, I'm going to return
+to that in a moment,
+but first I want to share
+with you these new findings
+that were just published in
+the Journal Cell Reports,
+a Cell Press Journal, excellent journal.
+This was a study that was
+performed both in mice
+and it included a crossover
+study with a human population.
+The human population was women,
+but it relates to a previous
+study that was also carried
+out in men.
+I'm going to simplify this study.
+We will provide a link to the
+full study so you can explore
+it in more detail.
+And if you're really
+excited about the results,
+I would encourage you to
+explore some of the references
+within that paper as well.
+What was the study?
+The study looked at giving
+mice or humans, two meals.
+And explored whether or not
+putting those meals early
+in the day or late in the day,
+had an impact on muscle hypertrophy,
+muscle growth and overall
+protein synthesis of muscle.
+So, when we eat, the amino
+acids from various foods
+are broken down and synthesized
+into different types of tissues.
+They can be utilized for energy,
+burned up for moving about
+and thinking et cetera,
+or it can be synthesize.
+Those amino acids can be
+synthesized into skeletal muscle.
+The sorts of skeletal
+muscles that allow you
+to move your limbs.
+This study explored how protein intake,
+which included what are called
+branch chain amino acids,
+and amino acids, like leucine,
+which are important for
+muscle protein synthesis.
+Explored whether or not emphasizing
+or skewing the protein
+intake toward early day
+or late day was better in
+terms of muscle hypertrophy.
+And they also looked at
+some parameters of strength,
+like grip strength.
+Now mice are nocturnal.
+So, before you say wait,
+mice are nocturnal,
+how did they look during the day?
+And it's completely,
+it doesn't apply because it's in mice.
+Of course they knew that.
+And they looked during
+the mice's active phase
+of their circadian cycle,
+which corresponds to our day.
+And in humans, they looked
+at whether or not eating
+most of one's protein early in the day,
+was better than if the protein intake
+and the sprint chain amino acids
+were placed later in the day.
+And yes, they had the mice
+do resistance training.
+They did that by emphasizing
+overload to one limb
+of the mouse.
+And that actually generates hypertrophy.
+It's a form of resistance
+training in mice.
+So, they don't have them weight training.
+They weren't doing curls
+and dips and squats
+and things of that sort.
+They were moving their own body weight,
+but they skewed that
+distribution of body weight
+by restricting a limb and
+forcing them to use one limb
+that did indeed grow in response to that.
+And then in humans,
+there was an exploration of grip strength.
+And then with resistance
+training that was also carried
+out through a peripheral study.
+Basically the takeaway from
+this study was that mice
+and humans can utilize amino
+acids that are ingested early
+in the day,
+better than they can utilize
+amino acids ingested later
+in the day in particular
+toward muscle hypertrophy
+and growth or maintenance of muscle,
+which for those of you
+that aren't interested
+in much muscle hypertrophy
+that aren't trying
+to grow your muscles.
+I've talked before in the
+episode on building strength
+and hypertrophy, that maintaining muscle,
+regardless of one's athletic prowess,
+regardless of one's age
+is extremely important
+because loss of skeletal muscle
+is one of the major causes of injury.
+As we age.
+It's one of the major causes,
+believe it or not, of cognitive
+and metabolic deficits
+as we age.
+So, maintaining muscle is important.
+Building muscle might be
+important to some of you,
+but what they found was ingesting
+protein early in the day.
+And these amino acids early in the day,
+led to more muscle hypertrophy
+than if the majority
+of amino acids and proteins
+were ingested late in the day.
+So, this translates to
+intermittent fasting,
+such that if you are interested
+in muscle hypertrophy,
+you might, and I want to emphasize,
+might consider making sure
+that you're getting sufficient
+protein intake early in the day.
+What sources of protein you use,
+is going to be highly individual.
+Some of you are meat eaters.
+Some of you don't eat red meat.
+Some of you eat chicken and fish and eggs.
+Some of you don't, some of you are vegans.
+It has been shown that the
+amino acid leucine is vital
+for the cell growth process,
+including muscle growth,
+because of its relationship
+to the so-called mTOR pathway,
+mammalian target of rapamycin.
+We can talk about that more if
+you like in a future episode,
+this means that if you're
+somebody who wants to maintain
+or increase the amount of
+muscle mass that you have,
+ingesting a high protein
+meal early in the day ought
+to be beneficial for that.
+Does it mean that you
+should not eat protein
+in the afternoon and evening?
+No.
+I think a lot of people might've
+misinterpreted this study
+and I don't want that to happen.
+This is only pointing out the fact
+that ingesting sufficient
+quality amino acids,
+including leucine, early in
+the day can be beneficial
+for maintenance and
+growth of muscle tissue.
+It does not say that you
+should avoid protein later
+in the day.
+Now for you intermittent
+fasters, this could be relevant.
+I, for instance,
+with somebody who for a very
+long time skipped breakfast,
+my first meal of the day would
+be in the early afternoon,
+mostly protein and salad,
+in my case, animal protein.
+'Cause that's in alignment with my values.
+Then in the evening I would eat pasta,
+vegetables, et cetera.
+I might have some protein,
+some small piece of fish or
+chicken or something like that,
+but I didn't really emphasize that.
+On the basis of these results.
+I am experimenting with.
+I want to emphasize experimenting with,
+I haven't completely
+tossed out my old protocol,
+but I'm experimenting with
+eating proteins early in the day
+and eating lunch.
+And then dinner might be
+light supper of some sort,
+but not so much protein
+later in the evening.
+Again, if you want to eat six meals a day,
+you want to eat round the clock.
+I'm not going to stop you.
+I'm not telling anybody what to do.
+As I mentioned earlier,
+nobody knows exactly how to
+eat for one's particular goals.
+But this study was really interesting,
+because it really did
+show that we can utilize
+the proteins that are
+ingested early in the day,
+better than we can utilize
+the proteins that are ingested
+later in the day.
+And of course there will be
+factors that can shift that.
+For instance, if you work out very hard
+with resistance training later in the day,
+resistance training is known
+to increase protein synthesis.
+So, it stands to reason
+that ingesting amino acids
+after that training would be beneficial.
+However, in this study,
+it did not seem to matter when
+the resistance training fell
+within the 24 hour schedule.
+The morning ingestion
+or early day ingestion
+of amino acids seemed to be beneficial.
+How early?
+Between the hours of about 5:00 A.M.
+and 10:00 A.M. for humans.
+Now just a bit of mechanism
+to explain why this happens.
+So, why would it be that
+ingesting protein early in the day
+would lead to more synthesis of muscle
+than ingesting protein later in the day?
+And the reason it turns out is related
+to the circadian clock mechanism
+that is present in all cells,
+including muscle cells.
+So, muscles have fibers.
+I think most people are aware of that,
+that your muscles are not
+just one big blob of tissue.
+A lot of these little
+fibers that contract.
+Within those fibers, however,
+there are cells with nuclei.
+Those nuclei contained DNA.
+DNA is transcribed into RNA.
+RNA is translated into proteins.
+The DNA of your cells,
+including these muscle cells
+are under strong circadian regulation.
+Each one has a pattern of gene
+expression that is different
+at different times
+during the 24 hour cycle,
+this is an unescapable reality
+of all cells in your body,
+right from your hair
+cells to your brain cells,
+to your retinal cells,
+to your toe on both feet.
+These cells make a gene
+called, BMAL, BMAL, B-M-A-L
+is a clock gene.
+And the expression of
+this clock gene varies
+across the 24 hour cycle,
+and proteins that are downstream
+of this BMAL gene influence
+protein synthesis.
+The circadian regulation
+of this BMAL gene turns
+out to be vitally important
+for this protein synthesis mechanism.
+How do we know that?
+Well, in this particular study,
+because they had a mouse that lacked BMAL,
+the gene was knocked out,
+they had bunch of these mice.
+They were able to explore
+whether or not this early day
+feeding effect was present or absent
+in these mice that lack the gene BMAL.
+And indeed it was absent.
+In other words,
+the effect of increased protein
+synthesis early in the day
+was eliminated in the
+absence of the BMAL gene.
+So, what this means is that
+when you wake up in the morning,
+assuming you're following
+a standard schedule
+of being asleep at night
+and awake during the day,
+your muscle cells are primed
+to incorporate amino acids
+and synthesize muscle,
+regardless of whether or
+not you weight trained
+the night before 8:00 P.M.,
+or you don't weight train at all,
+or you weight train afterwards or before.
+I said five to 10:00 P.M.
+is the sort of critical
+window for this increased
+protein synthesis.
+All this means is that if you
+are interested in maintaining
+or enhancing muscle tissue volume,
+that you might want to
+consider eating quality,
+protein and amino acids early in the day,
+you could train first.
+You could train after,
+you can not train at all.
+That's entirely different discussion.
+What is quality protein,
+well quality protein is
+going to be a protein
+that includes most of the
+essential amino acids.
+And in particular leucine.
+Now, there's a lot of debate as to whether
+or not you can get all
+the essential amino acids
+from a purely plant based diet
+or whether or not you need
+to ingest animal-based foods or not.
+The term quality protein
+has no strict scientific definition.
+Some people define quality
+protein as a protein
+that has a high essential
+amino acid to caloric ratio.
+Now, what that means is,
+a small piece of chicken
+or steak or eggs for instance,
+will have many essential amino acids
+with a low caloric content
+relative to say beans
+or plant-based food that can also get
+you essential amino acids,
+but it requires more calories to access
+those essential amino acids.
+Now that's that has many
+exceptions and nuances.
+And I for one, and perfectly
+respectful of the folks
+that just want to ingest
+plant-based foods in order to get
+their high quality protein.
+I think that actually can be done.
+One has to be careful and
+thoughtful in their choices
+about how to do that.
+So, this really isn't about animal based
+versus non-animal based foods.
+This is about getting quality
+amino acids early in the day
+from whatever foods are in
+alignment with your particular
+values in your particular eating plan.
+So, that's a lot of information,
+but the key takeaways are
+every cell in your muscles
+has a clock gene.
+The clock genes vary such
+that protein synthesis
+is greater early in the day
+than it is later in the day,
+such that in both mice and in humans,
+ingestion of quality proteins
+early in the day will be more
+so incorporated into muscle.
+Than the proteins that are
+ingested late in the day.
+And of course there are the
+caveats of if you're training
+hard late in the day,
+if you're adjusting your hormone status
+through whatever mechanism et cetera,
+protein synthesis can also
+be high later in the day.
+But for most people it's
+going to taper off due
+to this circadian BMAL
+gene related mechanism.
+Again, we will provide a link to the study
+and the other key takeaways
+were that nobody knows.
+Nobody can tell you what
+healthy feeding windows are,
+what the best feeding windows are.
+There's absolutely no
+information in that context,
+you talk to 10 nutritionists
+or academics or trainers
+or individuals about
+what healthy eating is,
+and you are going to get
+vastly different answers.
+And that's one of the
+reasons why I believe
+that the internet in
+particular social media,
+are so filled with contradictory opinions,
+but the calories in versus
+calories burned formula,
+is that more or less holy
+foundation of all things
+about nutrition, eating and weight.
+And as we transition
+today into the discussion
+about eating disorders,
+I'd like you to keep this in
+mind because for the treatment
+of eating disorders,
+it doesn't matter what psychological
+or early trauma based effects
+led to the eating disorder.
+If the person isn't adjusting
+their feeding behavior
+in a way that is going to
+ameliorate the symptoms
+of that disorder, which
+is ultimately the goal.
+Before we begin, I'd like to
+emphasize that this podcast
+is separate from my teaching
+and research roles at Stanford.
+It is however, part of
+my desire and effort
+to bring zero cost to consumer
+information about science
+and science related tools
+to the general public.
+In keeping with that theme,
+I'd like to thank the
+sponsors of today's podcast.
+Our first sponsor is Belcampo,
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+I don't eat a lot of meat, but
+I eat meat about once a day.
+That means a small piece of
+steak or chicken, et cetera,
+and usually a salad.
+I usually do that for
+breakfast or for lunch.
+And then in the evening
+I tend to follow a more
+or less vegetarian diet.
+I tend to eat pastas and
+vegetables and things of that sort.
+Well I don't eat a lot of meat.
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+is supported by probiotics.
+And for me,
+Athletic Greens is the best
+way to get those probiotics.
+I also ingest some fermented foods,
+but by ingesting Athletic Greens,
+I'm certain to get all the things I need.
+And also, I just feel
+better when I drink it.
+I genuinely feel like I have more energy
+and I just feel better.
+And I happen to really
+like the way it tastes.
+I mix mine with some water
+and some lemon juice.
+And in doing that, I'm certain
+to get all my nutritional
+basis covered and the probiotics support
+a healthy gut microbiome,
+which is important for mood,
+regulating inflammation and so on.
+If you want to try Athletic Greens,
+you can go to athleticgreens.com/huberman.
+And if you do that, you
+can claim a special offer.
+They'll give you five free travel packs.
+In addition to your Athletic Greens order,
+those travel packs make it really easy
+to mix up Athletic Greens
+while you're on the road,
+in the car, on the plane, et cetera.
+And they will give you a year supply
+of vitamin D3, K2,
+vitamin D3 and K2 have
+been shown to be important
+for blood lipid profiles for
+metabolism and a whole bunch
+of other metabolic and neural processes.
+So, go to athleticgreens.com/huberman
+to get the Athletic Greens,
+the five free travel
+packs and the year supply
+of D3 and K2.
+So, let's talk about eating disorders.
+And as we do that, I
+want to emphasize again,
+that nobody can really define
+what healthy eating is,
+with a single protocol.
+However, there is some general agreement
+about what unhealthy and
+disordered eating is.
+There are clear criteria
+in the psychiatric
+and psychological communities
+to define things like anorexia
+bulimia, binge eating disorder,
+all of which we will talk about,
+but as we have that discussion,
+I want to emphasize that self-diagnosis
+can be both a terrific, but
+also a very precarious thing.
+We talked about this a
+little bit in the episode
+about depression, there's always
+a temptation as one learns
+about the symptomology
+of a given disorder.
+It doesn't really matter
+what the disorder is,
+to ask the question.
+Well, do I have that?
+Does so-and-so that I know have that, ah,
+I see this sort of behavior
+or that pattern of thinking.
+In that individual, it's
+tempting to diagnose them
+and or ourselves as either having or not
+having a particular disorder.
+However, diagnoses really need
+to be carried out by people
+who are trained in that particular field,
+and that have deep
+expertise in recognizing
+the symptomology, including some
+of the more subtle symptomology
+of eating disorders.
+So, if any of the symptoms
+resonate with you,
+by way of you thinking
+that you have this particular
+disorder or someone that,
+you know, has this disorder,
+I would take that seriously,
+but I would take that information
+to a qualified healthcare
+professional that could diagnose
+or rule out any of these
+possible disorders.
+I say that not to protect us,
+but to protect you, because
+information is valuable.
+And I do believe that
+knowledge of knowledge
+can be very valuable
+in navigating any topic
+and improving our thoughts and
+behaviors around that topic.
+But one doesn't want to, or I should say,
+one, shouldn't start to
+self-diagnose simply on the basis
+of information without running
+that through the filter
+of a qualified professional.
+So, what is an eating disorder?
+Well, we have to take a step back,
+and confess to the fact that
+every society, every culture,
+every family, and every individual
+has a different relationship to food,
+eating disorders, however,
+have particular criteria
+that allow us to define them and to think
+about different modes of treatment.
+As it relates to the particular
+symptoms and particular,
+the psychological and biological symptoms
+of those disorders.
+Now that's a mouthful, no pun intended.
+What are the major eating disorders?
+Anorexia nervosa, most commonly
+referred to as anorexia
+is perhaps the most prevalent
+and the most dangerous
+of all eating disorders.
+In fact, anorexia is the most
+dangerous psychiatric disorder
+of all, even more than depression.
+The probability of death
+for untreated anorexia
+is very high, and sadly the prevalence
+of anorexia is very high.
+So, what is anorexia
+and how prevalent is it?
+Anorexia, if you look
+it up online or you talk
+to a qualified professional,
+is essentially a failure
+to eat enough, to
+maintain a healthy weight.
+You can see all sorts of very
+troubling symptoms of somebody
+who's been anorexic for
+some period of time,
+a general loss of muscle mass
+because they're ingesting
+fewer calories than they burn.
+Muscle is very metabolically active.
+They tend to lose a lot of muscle mass.
+They will have a low heart rate.
+This is the body and brain's
+attempt to lower energy output.
+They will have low blood pressure.
+They'll sometimes have
+symptoms like fainting.
+They will have sometimes
+even hair growth on the face,
+something called lanugo,
+which is essentially the body's attempt
+to insulate the body because
+of loss of body heat.
+When you're that thin.
+Loss of bone density,
+osteoporosis, loss of
+periods in girls and women,
+and all sorts of disrupted
+gut and immune functions.
+So, there are just tons
+of terrible symptoms
+of anorexia that really
+placed the anorexic
+into a very risky state,
+which is why mortality
+from anorexia gone
+untreated is extremely high.
+Now, one of the
+misconceptions about anorexia,
+is that it stems from an
+overemphasis on perfectionism,
+or that because of all
+the images in social media
+and in advertising of
+extremely thin and fit
+or muscular people that
+individuals are looking
+at themselves and comparing
+themselves to those images
+and thinking that they don't match up
+and developing anorexia,
+that turns out to not be the case.
+If you look at the prevalence
+or the rates of anorexia,
+in the last 10 years or 20 years,
+and you compare that to when
+anorexia was first identified,
+which was in the 1600s,
+and perhaps even earlier,
+what you find is that rates
+of anorexia are not going up.
+So, this idea that the images
+that we're being bombarded
+with are causing anorexia
+doesn't seem to be true.
+Now, that is not to say that the images
+that we in particular young
+people are being bombarded
+with are healthy for the
+psychological state of mind.
+But classically define anorexia
+has existed at essentially
+the same prevalence for the last 100, 200,
+300 and 400 years,
+which is incredible and really
+speaks to the likelihood
+that there's a strong
+biological contribution
+to what we call anorexia nervosa.
+Anorexia nervosa is extremely common.
+It's anywhere from one to 2% of women.
+And the typical onset is in
+adolescence close to puberty,
+but it can show up later in life as well.
+In fact, the identification
+and diagnosis of anorexia tends
+to be in the early '20s.
+But if you look back at the
+history of those individuals,
+there were typically signs
+of anorexia that back
+into their early teens.
+Or maybe even before that.
+Now, of course, men can
+be anorexic as well,
+but anorexia nervosa does seem
+to occur at 10 times the rate
+in women and young girls,
+than it does in men and young boys.
+So, while there does seem to be more
+of a prevalence of anorexia
+in boys and young men,
+these days, that's probably
+due to better diagnosis
+and detection than it is to some sort
+of societal shift related
+to imagery, et cetera.
+Later, we will talk about body dysmorphia
+and some of the images
+that are present in media
+and social media and how those
+are impacting other forms
+of eating disorders.
+But when you look at anorexia nervosa,
+this failure to maintain weight,
+even to healthy levels
+and often drops in weight
+that are very dangerous or even deadly,
+that has existed for a very long time,
+and seems to be somewhat
+hardwired into the biology
+of individuals that suffer from it.
+Now, when I say hard wired,
+that doesn't mean that it
+can't be treated or cured,
+and indeed it can.
+Bulimia which is defined as
+binge eating or overeating.
+Let me explain what that is.
+Binge eating is consuming
+vast amounts of calories
+in a short period of time.
+Overeating can be ingesting
+more calories than one needs,
+but over an extended period of time,
+both can exist of course, but
+bulimia is also very common.
+It's more common in young girls
+and in women that it is
+in young boys and in men,
+but it is present in both sexes.
+Bulimia and rates of
+bulimia might be increasing.
+That's sort of an interesting finding.
+It's not quite clear
+whether or not it's existed
+in its same form for a long period of time
+or within other new forms that
+are evolving or showing up,
+we're going to drill into bulimia
+and what it actually is
+and what it represents.
+But one thing I want to be clear about,
+just as the perfectionist
+mindset has been associated
+with anorexia, and it turns
+out that's not the case.
+It can be, but it's not always
+associated with anorexia.
+There was the idea that
+bulimia is associated
+with early trauma in childhood,
+in particular sexual trauma.
+And while that can be the case,
+there's no direct
+correlation between the two.
+Now, obviously psychological
+phenomena and trauma
+can have a profound impact on the way
+that the brain wires up and the way
+that people approach food
+and other types of behaviors.
+But the sort of classic
+idea was that all anorexics
+are perfectionists, they
+want to perform well.
+It's all about control and autonomy.
+And bulimics are kind of
+dysregulated and acting
+out against some early sexual trauma,
+those stereotypes of the
+psychological framework
+of anorexics and
+bulimics, doesn't hold up.
+When you look at the data, many,
+many meta analysis have been done.
+It just simply is not the case.
+And in both instances,
+both anorexia and bulimia,
+there are clear biological underpinnings,
+to what's driving the
+under-eating or the overeating.
+So, we're going to talk about
+the biology of under eating
+and overeating and
+appropriate levels of eating.
+And by doing that,
+we will start to identify
+some of the mechanisms
+that serve as entry
+points for the treatment
+of both anorexia and bulimia.
+And as some of you are probably aware,
+anorexia and bulimia can be comorbid,
+they can exist with one another.
+There are anorexics who
+will binge and then purge
+in order to maintain that
+unhealthily low weight.
+There are bulimics
+who fit the psychological
+criteria of anorexia.
+And so there's a lot of overlap
+between those two categories.
+Now let's talk about the
+categorization for a second and why
+the categorization has led to now a bunch
+of other eating disorders as defined
+by the psychiatric community.
+One of the classic symptoms of anorexia
+is a loss of menstrual
+cycles, loss of periods.
+And the reason for that is when
+the body is undernourished,
+the body fat stores,
+send signals to the brain
+to inform that the body is undernourished,
+or they turn off the
+signals that say, look,
+there are enough body fat cells out here
+to support healthy metabolism.
+And therefore let's shut down ovulation,
+literally signal sent
+from the fat and muscle
+to the brain and the brain,
+the hypothalamus and pituitary
+will send signals down
+to the ovaries,
+or they will turn off the
+signals heading to the ovaries
+to deploy eggs,
+to maturation of eggs in
+the follicle, et cetera.
+So, there are instances in
+which people have anorexia
+or have bulimia,
+but are still maintaining
+healthy menstrual cycles
+or at least menstrual cycles.
+And that has led to a whole
+set of other categorizations
+of eating disorders, like
+binge eating disorder,
+where there tends to
+be a lot of overeating,
+but not the purging or
+categorizations of anorexia,
+in which people are under feeding,
+but they are not losing their periods.
+And so these have a number of
+different names and acronyms.
+Some of them include things like, EDNOS,
+EDNOS is eating disorder,
+not otherwise specified.
+So, that's a sub categorization or OSFEDs.
+So, OSFEDs is or specified
+feeding or eating disorder.
+So, right now,
+if you were to look
+online or you're looking
+to the psychiatric and
+psychological textbooks,
+what you would find is that
+there's a huge constellation
+of eating disorders today.
+We're mainly going to talk about anorexia,
+bulimia, binge eating
+disorder and body dysmorphia.
+You can even find eating
+disorders like pica,
+where people actually ingest
+things like dirt or rocks
+or metal because they
+have a genuine appetite
+for those things.
+I certainly do not recommend sampling any
+of those non food items.
+As foods, is incredibly dangerous.
+People often poisoned themselves.
+They often can cause structural blockages
+some people have died from
+those sorts of things.
+But nonetheless, there
+are aspects of our brain
+and biology that when disrupted can lead
+to very bizarre types of eating behavior,
+sometimes pica is caused by
+malnutrition, but not always.
+And so today we're going to focus
+on the most prevalent eating disorders,
+but we are going to build
+up toward that understanding
+by looking at what healthy
+metabolism and eating
+and satiety and hunger looks like.
+Because one, I realized that not everyone
+out there has an eating disorder.
+And two, I want people to
+understand this relationship
+between how they think,
+the decisions they take
+about what they eat
+and how the body and the
+brain at subconscious levels
+are driving some of these
+behaviors healthy or otherwise.
+Because I do think that
+it can lead us to a better
+understanding of what healthy
+eating is for most of us,
+and to increase compassion and hopefully
+even increased improvement in
+treatment of eating disorders
+for those that are suffering from them.
+So, what is hunger and what is satiety?
+Satiety, of course being sated
+or feeling like we've had enough food.
+I want to remind people
+of the basic mechanisms
+by which the brain and body communicate.
+This is vitally important,
+not just for this discussion,
+but for any discussion, about
+how we think, how we behave,
+how we feel, the body is
+communicating two types
+of information to the
+brain on a regular basis,
+but in particular around
+feeding, and those two types
+of information are mechanical information,
+and chemical information.
+What do I mean by mechanical information?
+Well, if you take a deep breath, oh,
+and you hold your breath,
+what you'll find is that
+you can hold your breath
+a lot longer than if
+you exhale all your air
+and you hold your breath with lungs empty.
+And the reason is not because
+when your lungs are full,
+you have enough oxygen
+and therefore you can hold your breath.
+It's because when your lungs are full,
+a particular class of
+neurons called baroreceptors,
+send information to the brain and say,
+there's pressure in the lungs.
+And that means that there's
+probably oxygen in here.
+And so the trigger to breathe
+is actually suppressed,
+when your lungs are empty.
+Even if you have plenty
+of oxygen in your system,
+those baroreceptors send a
+different signal to the brain,
+which is there's no oxygen in
+here and you should breathe.
+And so the impulse to
+breathe comes earlier.
+Likewise, when your stomach is full,
+it sends signals to your
+brain that are purely based
+on this mechanical fullness,
+has nothing to do with
+nutrients, that says I'm full.
+And therefore don't be as hungry.
+Don't motivate to find or ingest food.
+Whereas when our gut is empty,
+even if we have plenty of nutrients
+or plenty of body fat stores,
+we tend to focus on food a bit more.
+So, volume and mechanical
+influences have a profound effect
+on how we think.
+And what consider doing or not doing,
+likewise chemical effects.
+When we ingest food,
+our so-called blood sugar or
+blood glucose levels go up.
+That information is signaled to the brain
+via neuronal pathways
+and hormonal pathways.
+And in particular, there
+are neurons within our gut,
+that signal to areas of our
+brain stem that are involved
+in satiety in our sense of having enough
+that there's food in our system.
+So, that's chemical information.
+So, how our hunger and
+feeding and satiety regulated
+by way of mechanical
+and chemical signaling.
+You have, I have,
+we all have neurons in our
+hypothalamus that trigger eating
+and neurons that trigger
+cessation or stopping of eating.
+We have an accelerator on
+eating and we have a break.
+And I covered all of this in
+a lot of detail in the episode
+on feeding and metabolism and hunger.
+So, if you want a lot more
+detail, see that episode,
+but right now,
+I'm just going to give you the top contour
+of how all that works.
+Your hypothalamus is an
+area of your forebrain,
+which tells you it's in the front,
+but it's at the base of your
+forebrain sits more or less
+above the roof of your mouth.
+The hypothalamus contains
+lots of different kinds
+of neurons, including neurons
+that stimulate sexual activity
+and desire, regulate your body temperature
+and control appetite and
+ceasing of eating and appetite.
+There are two types of neurons
+within a particular area
+of your hypothalamus
+that are relevant here.
+There are the so-called
+POMC neurons, okay?
+Pro-opiomelanocortin neurons
+that tend to act as more
+of a break on appetite,
+by way of another hormone
+called melanocytes stimulating hormone.
+And not so incidentally
+when you're getting
+a lot of sunlight and you're
+viewing a lot of sunlight,
+that system is ramped up.
+This is why appetite is
+lower in the summer months
+than it is in the winter months.
+This is true in animals.
+And this is true in humans.
+And you have a class of neurons
+called the AgRP neurons.
+The AgRP neurons are the
+ones that stimulate feeding,
+and they create a sort of
+anxiety or excitement about food,
+can be positive anxiety, or
+it can be negative anxiety.
+What do I mean by that?
+Well, if you ever seen kids
+heading in to get ice cream,
+they're absolutely excited.
+You see people getting raised,
+sit down and eat a big meal.
+They're excited to eat.
+Sometimes that's due to social factors,
+but they have an increase
+in overall levels
+of autonomic arousal.
+And depending on the context,
+they can feel excited or anxious,
+but it is a ramping up of energy.
+These AgRP neurons are what caused that,
+in fact so much so that if you eliminate
+or kill these neurons, which has been done
+in experimental mouse
+models in the laboratory,
+but also there are
+humans that have lesions
+or neurotoxic effects
+on these AgRP neurons.
+And what you find is that
+they don't want to eat.
+They essentially become anorexic,
+meaning they don't want to ingest food.
+They have no appetite for food whatsoever.
+Now that's not exactly what anorexia is,
+but these AgRP neurons
+are like an accelerator
+on wanting to eat.
+Whereas if you stimulate
+these AgRP neurons
+or in humans that have
+say a small tumor near
+these AgRP neurons,
+they become hyperphagic.
+They will eat to the point of bursting,
+both animals and humans
+that have elevated levels
+of these AgRP neurons are anxious.
+They want to eat,
+and they will ingest food to
+the point where they override
+those mechanical and
+chemical signals in the body.
+And I know it sounds
+horrible, and it is horrible.
+They will eat until the
+point that they burst.
+Now, there are signals
+coming back from the body
+to inform the brain about presence
+of different levels of nutrients.
+And that generally comes
+from three sources.
+First of all, is body fat.
+The more body fat we have,
+the more we secrete a hormone
+called leptin, L-E-P-T-I-N,
+leptin from body fat,
+leptin goes to the brain
+and suppresses appetite.
+This is a body to brain signaling
+mechanism that says, look,
+I've had enough,
+not incidentally, leptin
+signaling is disrupted
+in people that have bulimia and obesity
+and certain forms of
+binge eating disorder.
+So, that system has disrupted
+they have had enough signal
+or there's enough body fat
+here such that you don't need
+to eat more right here,
+I'm sort of in the voice
+of the body fat, trying to
+talk to the brain, that signal,
+that dialogue is mixed up or messed up.
+In some cases it's absent entirely.
+So, the body fat is signaling to the brain
+about how much reserve you have.
+It's sort of like a
+savings account for energy,
+'cause that's what body fat is.
+You've got lipids in there
+and through lipolysis,
+that can be metabolized.
+If you're interested in that process,
+both how to increase it.
+And just generally how it works.
+You can see the episode on
+the science of fat loss.
+The body fat is doing something
+else really interesting
+that relates to anorexia,
+when they're sufficient levels of body fat
+and leptin circulating in the blood.
+And that leptin signal gets to the brain,
+the hypothalamus and the pituitary gland
+register that signal.
+And in a completely subconscious way,
+trigger the deployment of eggs
+in females and the production
+of sperm in males.
+So, when body fat stores are very low,
+the reason why periods shut
+off or sperm production
+is reduced or even shut off
+is because there's not enough
+leptin getting to the
+hypothalamus and to the pituitary.
+And they shut off the
+signals, the hormones,
+things like
+gonadotropin-releasing hormone,
+luteinizing hormone,
+follicle-stimulating hormone,
+all these hormones.
+So, you don't have to remember the names
+of if you don't want to
+that travel to the ovary
+or to the testes and
+cause the ovary and testes
+to ovulate or to produce more sperm.
+So, the reason why anorexic
+stopped having periods,
+while they stopped cycling,
+is because there isn't sufficient
+leptin in the bloodstream.
+Now there have been attempts
+to give leptin to anorexics
+because leptin has been
+sequenced and the peptide
+has been synthesized.
+And so you can inject leptin into people.
+There are studies where they've done that,
+when that happens, it
+does not tend to alleviate
+the anorexia, does not cause
+people to start eating again.
+And that actually makes sense
+because leptin is also a way
+of shutting off the hunger signals saying,
+it's the body fats way of saying, hey,
+there's a lot of body fat here,
+or there is sufficient body fat.
+There doesn't even have
+to be a lot, but it has,
+in some cases been shown
+to rescue the menstrual,
+cycling in some anorexics, okay?
+So, body fat is signaling to the brain.
+The gut is signaling to the brain.
+There are neurons in your gut
+that are primarily responding
+to meaning they fire electrical signals.
+When there are sufficient
+fatty acids coming
+from fats you ingest, amino acids coming
+from proteins you ingest and sugars coming
+from carbohydrates and sugars.
+Things like fructose, glucose, et cetera.
+Those signals are being sent
+from the fat and from the gut
+up to the brain.
+And therefore your body
+has multiple signals
+of directing you toward
+eating more or eating less.
+So, you've got two categories of neurons.
+One that acts as an accelerator,
+the AgRP neuron saying,
+eat, eat, and get you excited to eat.
+And then you have a category of neurons.
+The POMC neurons that
+are suppressing hunger.
+They're acting like a break,
+and the body is informing
+the brain all the time about the status
+of the body and whether or
+not it needs more food or not.
+So, you might ask why is it
+that people who are overweight
+and have a lot of body fat,
+why they would continue to eat a lot,
+well past a certain
+threshold of body fat that's
+when you start getting
+into these so-called metabolic disorders,
+where blood glucose
+metabolism is disrupted,
+leptin signaling is disrupted
+and there are all sorts
+of changes on both the
+brain side and the body end
+of things, such that they're hungry,
+despite the fact that the body has plenty
+of energy on reserve.
+Okay, that I think is
+sufficient to explain the basics
+of hunger and satiety are kind
+of a biological mechanism.
+And the important thing again,
+to remember is that they're
+mechanical and chemical signals
+that come from fullness
+or absence of fullness
+that come in the presence
+of glucose in the blood
+or the absence of glucose in the blood.
+When you haven't eaten for a long time,
+glucagon levels go up, for instance,
+GLP1 levels go up and those will drive you
+to seek out food and want food.
+And then there are the signals
+that are coming from body fat
+and from neurons in the gut.
+So, there's a lot of convergence,
+in a lot of pathways.
+I don't offer you all those
+pathways to confuse you.
+I offer you those pathways
+to clarify the extent
+to which something as simple
+as eating or the decision
+to not eat is complicated.
+We've perhaps heard,
+or I've certainly heard
+that, oh, you know,
+it takes about 20 minutes
+for satiety to set in,
+so you should eat slowly that
+you won't realize that you're
+full until about 20 minutes.
+That's actually not true.
+I don't know where that got started,
+but we should probably
+all chew our food better
+and eat more slowly,
+be more mindful of what
+we're eating, et cetera.
+So, in anticipation of this episode,
+I consulted extensively with a colleague
+of mine at Stanford,
+who sadly for us is going off
+to University of Pennsylvania.
+So, our losses University
+of Pennsylvania's win.
+His name is Dr. Casey Halpern.
+He's a MD, Medical
+Doctor and Neurosurgeon,
+and a PhD who studies
+binge-eating disorder
+and other types of eating
+disorders and how they arise
+in the brain.
+And he's developed some
+really pioneering treatments for them.
+We'll talk more about his
+work a little bit later
+in the episode, but we
+got to the discussion
+of why a body that has
+sufficient energy levels
+would desire to eat more at all.
+And this is not just the case
+for binge eating disorder
+for bulimia, but why
+that would be the case.
+You know, this is primitive biology
+that evolved over many tens.
+If not hundreds of thousands
+of years, you see it in mice,
+you see it in humans,
+very similar types of
+pathways and effects.
+How is it that human
+beings who have plenty
+of fat on reserve and plenty of glycogen
+in their liver, et cetera.
+In other words, plenty of
+energy, why they would be hungry,
+why they would eat at all.
+It seems like that just shouldn't happen.
+And he had a very important,
+and I think clear and intuitive way
+of framing up all this stuff around eating
+and motivated behaviors
+and how they can go awry,
+not just in eating
+disorders, but in all of us.
+Basically what he said was,
+from an evolutionary standpoint,
+it makes sense that we should
+eat as often as we can,
+as much as we can, and as fast as we can.
+Well, that sounds crazy.
+I've was told to eat not
+too often, not too much,
+and to eat slowly and chew my food.
+But as Dr. Halpern pointed out,
+there are circuits in the
+brain to reward eating
+often eating fast and
+cramming as much food
+into you as possible.
+Because from a purely
+evolutionary standpoint,
+food was scarce, and
+seeking food was dangerous,
+whether or not it was from
+animal sources or not.
+And it's always been competitive,
+for those of you that grew
+up in families with a lot of siblings.
+This may resonate with you.
+I just one sibling,
+we were competitive about certain things,
+but typically not competitive about food,
+but I had friends that
+had a lot of siblings.
+It was really interesting to
+see how food was served up
+and how it was taken in those households.
+It was like food would hit
+the table and it was just
+an absolute war for
+portions and who got what
+and how much and who got
+a slightly bigger piece
+of cake, et cetera,
+turned out to be a frequent
+happening in these meals
+and that these birthday parties,
+whereas the only children
+perhaps were used
+to having more food presented
+to them without having
+to compete with other
+members of the species.
+Every animal, including
+humans has a hardwired circuit
+that we were born with that pays attention
+to how much food is available,
+how much we are getting now
+and how much we are likely
+to get in the future.
+And without going down the rabbit hole
+of arcuate nucleus
+biology, in two sentences,
+you have a hypothalamic area
+called the arcuate nucleus.
+It's a fascinating area.
+It's actually the area that houses,
+these PMOC neurons and
+these other types of neurons
+that regulate hunger and satiety.
+And these neurons
+in the arcuate nucleus
+start getting active.
+When we see food and think about food,
+they drive hunger, and they drive hunger
+in a way that's responsive
+to what the food looks like,
+what it smells like,
+but also our prior history of
+interactions with that food.
+And it takes into account social context,
+whether or not we are going
+to get the whole pizza
+to ourselves or whether or not
+there are going to be others
+that we are going to have to compete with.
+So, there are a lot of signals
+that this arcuate nucleus
+in your brain are paying attention to.
+So, Dr. Halpern pointed
+out that you actually
+have an accelerator that
+increases your level of awareness
+and anxiety and sort
+of constricts your field of
+view and all your senses.
+Anytime you interact
+with food and is driving
+a primitive reflex to ingest
+as much food as you can,
+as quickly as you can,
+and then move on from there,
+and presumably to do the same elsewhere.
+So, that changed the way that
+I think about eating behavior
+and eating disorders.
+In fact, we could think about
+eating disorders like bulimia
+as an unmasking of that mechanism
+without the so-called top-down control,
+without the mechanisms that we
+use to regulate our behavior.
+And indeed bulimia and
+binge-eating disorder
+are closely associated with impulsivity
+and with impulsive
+behaviors of other kinds,
+something that we also will discuss more.
+What's the pathway?
+How does this work?
+What is Dr. Halpern and his
+colleagues doing in order
+to try and treat things
+like binge eating disorder?
+Well, you can frame all of behavior,
+good decision making
+and bad decision-making.
+In a pretty simple box diagram model.
+And I realized that many of
+you are listening to this,
+not watching this.
+There is no diagram to look at.
+I'll just explain it so
+that you can conceptualize
+it in your mind.
+We have knowledge of what we
+should do, in one box, okay?
+We should eat that.
+We shouldn't eat that.
+We should wait for dinner.
+We shouldn't wait for dinner.
+And then we have what we
+actually do in another box, okay?
+Now this is true for all behaviors,
+we should say something or
+we want to say something,
+but we don't, we shouldn't say
+something, but we do anyway.
+That's the knowledge that
+kind of looping in your head.
+I should do my homework.
+I should go for a run.
+I shouldn't do this right now.
+I shouldn't be on social media,
+all those kinds of shoulds and shouldn'ts
+that are circulating your head.
+That's one box.
+Then there's what you actually do.
+The behavior, whether or not
+you suppress the behavior,
+you turn off your phone and
+you go read a book or you go
+to sleep or whether or
+not you stay up all night,
+or you stay up for another
+hour, even five minutes.
+In between those two boxes
+are two intervening forces.
+And those intervening forces
+are critically important.
+Those intervening forces
+are homeostatic processes,
+called by some processes, same thing,
+homeostatic processes,
+that regulate the balance
+of different systems in
+your body, hot and cold,
+awake or asleep, dopamine and
+the desire to pursue things,
+serotonin and the desire
+to just relax and chill.
+So, homeostatic processes
+and reward systems.
+And as we now move into
+discussion about anorexia,
+and bulimia specifically,
+what you'll see is that
+anorexia and bulimia
+are not a breaking of the
+mindset of what one should do
+or shouldn't do.
+It's a disruption of these
+homeostatic and reward processes,
+such that decision-making
+is completely disrupted.
+And in many cases is not available
+to the anorexic or bulimic.
+Now, I don't want to be abstract here.
+What I'm saying is that the
+person who starves themselves
+to the point where they
+might die and in some cases,
+sadly do die.
+They can know perfectly well
+that their behavior is leading
+to bad outcomes and possibly even death.
+And yet they are not
+able to intervene unless
+they get particular clinical help,
+because the homeostatic processes,
+the signals from the body
+and brain that say, you need food.
+Those aren't registering in the same way
+that they are for other individuals.
+and for the bulimic or
+the person that suffers
+from binge eating disorder.
+They don't necessarily
+want to eat that food.
+They simply cannot help it.
+It's like a reflex for them,
+because the homeostatic processes
+and the reward processes
+associated with food,
+are such that they can't intervene
+between the should do X, Y, or Z,
+or shouldn't do X, Y, or Z.
+And what their actual behavior is.
+Now, this isn't just a biological
+mechanistic explanation
+for what could have been
+summarized in two sentences.
+What this is,
+is a roadmap of where interventions
+can really make a difference.
+So, as we talk about different
+drug based interventions
+or behavioral interventions
+or social interventions,
+I'd like you to think
+about whether or not those
+interventions are breaking into,
+or tapping into this box of the thinking,
+the sort of pattern of
+thinking around food,
+whether or not it's the behavior,
+the actual ingestion or
+the restriction of food,
+or whether or not it's tapping
+into the homeostatic process,
+the balance of energy systems
+and kind of getting enough,
+but not too much, or it's
+tapping into the reward system.
+And just as a little teaser
+of where we're headed,
+what you'll find based on the
+data clinical data experiments
+done very carefully and very
+well by excellent groups.
+What you'll find is the
+anorexics have a sort
+of switch that's been flipped,
+such that their decision-making
+is actually pretty darn good.
+It might even be better
+than yours in terms
+of evaluating food, nutritional content,
+but their habits are disrupted.
+So, they're not even
+consciously aware of the fact
+that they're making terrible.
+And in some cases, very
+dangerous food choices,
+and turns out that habits.
+And the way that we build and
+break and rebuild new habits
+is one of the most effective
+treatments for anorexia.
+So, now let's talk about anorexia,
+this failure to consume enough energy,
+such that the individuals
+at risk of death,
+and if not death, then
+severe metabolic disorders,
+lack of bone density, et cetera.
+As I mentioned earlier,
+anorexia and things that
+almost certainly were,
+and are anorexia have
+been described as early
+as the 1600s.
+And maybe even earlier,
+there are some records from the saints,
+from the 1400s of people
+that refuse to ingest food.
+Another common myth is that
+anorexia is only the sort
+of thing that you see in rich societies.
+These are spoiled
+children with so much food
+that they decide they're
+only going to focus
+on how slim they are,
+how they look in bathing
+suits, et cetera, not true.
+A careful analysis through
+medical epidemiology has shown
+that you find anorexia even in cultures
+and societies where food is scarce.
+So, that really speaks
+to biological mechanism.
+Now it's hard to unveil in
+societies where food is scarce,
+because a lot of people
+are starving and hungry,
+but there are individuals that
+choose still to avoid food
+and seem to have some sort of
+reward mechanism that rewards
+them, where makes them feel
+better if they don't eat,
+despite the fact that their body
+is severely depleted of nutrients.
+So, that's very interesting
+and points again
+to some disruption in
+some biological mechanism.
+Now, I want to make sure
+that I'm emphasizing
+that I'm not in favor of people,
+in particular young children, adolescents,
+and teenagers being bombarded
+with unrealistic imagery about bodies.
+But the idea that that's the cause of,
+or is amplifying anorexia,
+the data just don't seem
+to support that, anorexia
+in its classic sense,
+requires that there be an endocrine,
+meaning a hormonal disruption,
+menstrual abnormalities,
+lack of sperm production,
+or low testosterone in
+males, in order to meet
+the classification for anorexia.
+But as I mentioned earlier,
+there are now nuanced and new
+classifications of anorexia
+that even for individuals
+that still menstruate
+or that maintain a sperm
+production anorexia,
+can still be considered
+a clinically diagnosable disorder.
+Now, typically anorexia
+starts in adolescence,
+right around puberty.
+Let's take a look at what puberty is.
+Puberty at a very broad
+level is the most significant
+and dramatic developmental step.
+Anyone goes through in their lifespan.
+The body changes, the
+brain changes, perceptions,
+change, one's own self
+perception, changes.
+And most of those changes are
+driven by changes in circuitry
+within the hypothalamus.
+So, neurons that are
+controlling the production
+of the so-called sex steroid hormones,
+things like testosterone,
+estrogen, and related
+hormones, prolactin, et cetera.
+Those are all changing
+at very rapid rates.
+Anorexia tends to show up
+around this time in a subset
+of individuals who on the
+face of it seem to find food,
+aversive, now the purely
+psychological theory
+of this is that they are
+fighting for autonomy.
+They want control.
+Puberty is also a time in
+which children and parents
+are in a tug of war over control.
+You were once a small child
+being told when to go to bed
+sent to your room.
+Now you're a child that
+can talk back and say,
+I don't want to, or I refuse to.
+And that happens a lot
+in various households,
+as I'm sure you're familiar with.
+Adolescence and puberty
+is also when girls start
+menstruating typically,
+or boys develop deeper voice,
+they start producing sperm, et cetera.
+So, there are a lot of bodily changes
+that also drive perceptual
+changes and perceptual changes
+that drive bodily changes.
+And it is a dramatic
+shift for a young girl
+or boy that doesn't nourish
+themselves sufficiently.
+During that period,
+there are a number of
+downstream negative effects.
+I'll list out some of them,
+these are just a subset of
+the effects, hypogonadism.
+That's the lack of sperm production
+or healthy egg production.
+There is amenorrhea,
+which is the lack of
+menstrual cycling, okay?
+So, a failure to have a menstrual cycle.
+Reduced insulin secretion,
+insulin is this hormone
+that's released in order
+to help shuttle glucose
+into various tissues
+for energy utilization.
+That's down because energy
+levels are down so much.
+One of the symptoms that's
+a little more cryptic,
+and that has actually
+interesting implications
+for sake of the cholesterol
+hypothesis is that anorexics
+who ingest very little
+food often have cosmically
+high levels of cholesterol, including LDL,
+low density, lipoprotein cholesterol.
+You say, well, how could that possibly be?
+We were all told and continue to be told
+from many sources that
+ingestion of dietary cholesterol
+is what drives high levels
+of bodily cholesterol.
+Cholesterol is manufactured
+by the liver and in anorexics
+who consume very little food.
+They often have cosmically
+high levels of cholesterol,
+which is one of the kind of wrinkles
+in the so-called dietary
+cholesterol hypothesis
+that all of our cholesterol
+that we see on a blood panel
+is due to what we eat.
+But the explanation for it
+is that under conditions
+where there's not sufficient cholesterol
+to synthesize the sex steroid hormones,
+things like testosterone and estrogen,
+which are required in
+both males and females,
+those are made from
+cholesterol that the body,
+the liver will start
+generating its own cholesterol
+will often overshoot the
+mark to a dramatic degree.
+So, the blood lipid profiles and anorexics
+are often very unhealthy despite the fact
+that they're eating very little food.
+In addition, they tend
+to have elevated levels
+of things like vasopressin,
+which are hormones that
+regulate body temperature
+and salt and blood volume.
+They tend to have low blood pressure.
+They can pass out.
+I mentioned some of the
+other symptoms earlier.
+In other words, there are a huge number
+of terrible things happening.
+Thyroid levels are down.
+Heart rates are down, if
+I'm painting a very bleak
+picture here is indeed a bleak picture.
+So, we have to ask
+ourselves what can be done
+for the anorexic, right?
+Let's say it's a failure
+of the AgRP neurons
+to stimulate appetite and feeding.
+Let's say it's too much
+anxiety around food.
+Let's say it's because of
+the way that food restriction
+was used for reward in
+the household, right?
+I'm making this up,
+but you can imagine a
+hypothetical scenario
+where let's just say the mother
+of a particular individual
+is very vocal about her avoidance of food.
+We've seen this before, right?
+You've probably seen
+somebody who loves to cook
+and prepare food, but then sits down
+and doesn't seem to eat.
+And they always seem to in
+air quotes have eaten earlier.
+I ate while I cooked, I
+ate while I cooked, right?
+These people that you
+never actually see eating,
+we all know people like
+this, are they anorexic?
+Possibly, we don't know.
+A child observes that kind of behavior.
+Maybe that individual is
+being always being told how
+beautiful they look or how
+wonderful or fit they look,
+what incredible meals they produce.
+And you could imagine a purely
+psychosocial set of events
+that could lead a child to be anorexic.
+That doesn't seem to be the case,
+at least not in terms of driving classic,
+anorexia, a really extreme
+deprivation of oneself from food.
+However, there is a strong
+genetic component for anorexia.
+So, you could imagine a mild
+form of anorexia in a parent
+that is supported or
+exacerbated by praise,
+so that the person feels
+good from the praise
+they're getting, that they
+want to be a low body weight
+for whatever reason,
+for aesthetic reasons or for
+whatever reasons that happened
+to appeal to them.
+And the child has a genetic
+predisposition, right?
+We never think about genes in
+terms of controlling behavior,
+genes, bias, probabilities
+for behavior, okay?
+So, you can have a gene for
+depression of schizophrenia,
+but it's not deterministic,
+in the same way
+that there are genes that
+determine your eye color,
+or your skin color or
+your hair color, okay?
+So, there's a genetic
+predisposition there.
+And that genetic predisposition
+could exist such that if one
+is rewarded enough times
+for a particular behavior,
+that behavior can start to ratchet in
+to our neural circuitry,
+because behavior drives neural changes,
+so called neuroplasticity.
+And you could imagine that
+that child could develop
+a full-blown case of anorexia.
+And this is why I raised at the
+beginning that no one really
+knows how to define healthy eating.
+And so therefore we have to
+rely on just identification
+of unhealthy behaviors,
+but what do we point people to in terms
+of what healthy replacement
+behaviors would be.
+So, rather than just look
+at anorexics and say,
+they're not eating enough.
+And there's this huge
+array of terrible things
+that they're doing to their
+body, and they need to eat more.
+We need to rescue them from themselves.
+Let's look under the hood.
+Let's look at, what's known
+about the neural circuitry
+and the sorts of perceptions and behaviors
+of the neural circuitry is driving,
+in order to understand what
+they are truly suffering from,
+at the level of cause ,not just symptoms,
+it's clear what they're
+suffering from at the level
+of symptoms, symptoms are how we diagnose.
+I listed off a number of those things,
+but let's look under the
+hood and try and identify
+where one could intervene in theory,
+in order to try and rescue the anorexic
+or help the anorexic rescue themselves.
+Because it turns out that
+the answer or at least one
+of the answers of how to do
+that is not intuitive at all.
+At least to me was very surprising.
+I would be remiss if I didn't
+start with the obvious,
+which is, is there a chemical defect?
+Meaning is there some
+disruption in one of the major
+chemical systems in the brain
+that makes anorexics anorexic
+and therefore, can we
+replace that chemical?
+Or can we reduce some chemical
+and essentially eliminate anorexia?
+And the answer is not
+really sort of maybe no,
+here's why, there are a
+lot of different chemicals
+in the brain and body,
+but there are a category of
+chemicals that are particularly
+important that if you've
+listened to this podcast before,
+even if you haven't are
+going to come up again
+and again and again,
+and that is the category
+of chemicals in the brain
+and body called the neuromodulators,
+neuromodulators are different
+than neuro-transmitters
+in the sense that
+neuromodulators modulator
+or change the activity of
+brain areas in neural circuits,
+you can think of them as
+microphones that are held
+between particular sets of
+connections in the brain
+that make those connections in the brain,
+more likely to be active
+relative to others, okay?
+They make them louder so to speak,
+there are many neuromodulators,
+but the ones that are important for sake
+of today's discussion
+are the classic ones,
+dopamine, acetylcholine,
+or epinephrin and serotonin.
+Let's focus on serotonin.
+Serotonin is a neuromodulator
+that tends to increase
+the activity of certain neural circuits,
+including within the hypothalamus,
+but also within the body that
+trigger a sense of satiety,
+of having enough, enough
+food, enough warmth,
+enough social connection,
+enough of any motivated goal
+or drive or any type of thing
+or behavior that one would want more of,
+serotonin tends to make
+those circuits quiet down.
+Now, there are many categories
+of drugs that emphasize
+the serotonergic circuitry,
+meaning they cause the release
+of, or the efficiency of
+serotonin in the brain and body.
+Things like Prozac, Zoloft,
+Paxil, things of that variety.
+Those drugs have been used
+to some degree of success.
+Although not much to treat
+things like anorexia nervosa.
+That should make sense,
+because if these drugs increase
+serotonin, if their general
+effect is to increase serotonin,
+it will be to lower anxiety.
+That sounds like a great thing.
+A lot of anorexics are
+really anxious around food.
+We'll talk about why, lowering
+anxiety you might think
+would lead to ingestion of more food,
+but that's not often what
+happens, increasing serotonin,
+by way of some drug regimen will tend
+to make one less hungry,
+because with heightened levels
+of serotonin in the blood and brain,
+there isn't the desire
+to go seek out the things
+that will raise serotonin on their own.
+Now, some anorexics do well or benefit
+from these serotonergic drugs,
+these drugs that increase the
+activity of these circuits
+that leads to satiety.
+But if you think about
+the major goal of treating
+an anorexic it's to get them
+to have more hunger, more appetite.
+So, now I want to focus on some
+of the work that's been done
+around the habits and
+behaviors of anorexics,
+because those turned
+out to be ideal places for intervention.
+The work I'm about to describe was done
+by Dr. Joanna Steinglass and colleagues
+at Columbia University in New York.
+And there are other groups as well.
+Of course, they're
+doing this type of work,
+but they did what I think
+are really some beautiful
+experiments and some
+beautiful explorations
+of potential treatments for anorexics.
+That seemed to have a quite high degree
+of effectiveness when they
+are applied correctly.
+First of all, there's a
+challenge in studying anorexia
+because in anorexia,
+what you're essentially
+studying is the absence
+of a behavior.
+It's very hard to study
+the absence of a behavior,
+as opposed to a behavior.
+So, they did some
+experiments with anorexics,
+giving them a gallery of
+pictures of different foods,
+and allowing those anorexia patients
+to arrange those foods,
+according to preference
+about what they would select,
+about food, nutrient content
+about caloric content.
+They essentially asked these
+anorexics to evaluate food,
+and in doing so,
+they were able to identify
+something that's very unique
+to anorexics at the level
+of their perception of food.
+What they found is the anorexics,
+rather than being anxious
+in the presence of food,
+and that anxiety driving
+and avoidance of food.
+What they found is that
+anorexics have a hyper acuity,
+a hyper awareness of the
+fat content of foods,
+almost to the point of being
+sort of fat content savant.
+Now they don't necessarily
+know that they're doing this.
+They're not looking at an
+avocado and thinking, okay,
+that's X number of grams of fat rather,
+or looking at an apple and
+saying, okay, that has no fat.
+They start to do this
+more or less reflexively.
+Now it's a well-known symptom of anorexia,
+especially young anorexics
+that they have kind
+of an obsession with
+food, caloric contents,
+macronutrient ratios, meaning fat protein
+and carbohydrate ratios.
+They know caloric numbers,
+but then they sort of
+pass that information
+into a memory system in
+their brain that allows
+their interactions with
+food, to be very reflexive
+in a way that they are actively
+avoiding high-fat content,
+foods, calorie rich foods,
+and defaulting towards
+very low calorie foods.
+If they have to eat.
+Now, this might seem like
+an almost trivial result
+on the face of it, you think, okay,
+they don't like to eat when they do eat.
+They eat low calorie, low fat foods, duh,
+but it's the way in which they
+are doing this subconsciously
+that they learn this
+information and then they pass
+it off to a reflexive habit.
+And that's very important
+because what that means
+is that we need to look at
+what processes in the brain,
+what brain areas,
+what chemicals drive
+decision-making and knowledge.
+And we also need to look
+at the areas of the brain
+that drive habit formation
+and habit execution,
+because for any of you that have habits.
+And that means all of you,
+the hallmark feature of a
+habit is that it's reflexive.
+You have a mosquito bite on
+your leg, you scratch it.
+You didn't necessarily even think, oh,
+I'm going to scratch that.
+In fact, just to take a little
+bit of a moment of respites
+and talk about habits in general,
+there's a beautiful
+study that was done out
+of Caltech University,
+looking at the parking
+lot of where people park
+in the morning, without
+designated parking spots,
+and the trajectories that they
+use to walk to their offices
+in the morning.
+So, they put cameras up
+on the roof of Caltech,
+is the kind of thing that
+the nerdy kids at Caltech do.
+I think at Caltech,
+if you call someone a nerdy
+is I think it's a compliment.
+So, my apologies to the
+non nerds at Caltech,
+I think there's one or two
+of you and for the nerdy ones
+of you at Caltech, you're welcome.
+They videotaped the
+behaviors of these faculty
+and students and staff.
+And what they found, is that
+people follow trajectories
+from their car that are
+remarkably stereotype.
+First of all, they tend to
+park always in the same spot.
+If they can, they tend
+to get out of their car.
+Of course, 'cause they're
+on the driver's side
+or passenger side in the same place.
+They turn and pivot their
+body at approximately
+the same rate every day.
+They close the door,
+they've put their bag on their shoulder
+or across their chest,
+or however it is that
+they carry their briefcase
+or whatever it is.
+And they follow trajectories onto campus
+that are so stereotyped.
+That you'd wonder if you just trace line,
+after line after line.
+What you'd find is that every
+day is almost exactly the same
+and you do this too.
+You don't realize it because
+if you're being videotaped
+in this kind of behavior, it's
+not being released to you,
+but your behaviors are so
+stereotyped to the point
+where if you were to see them
+laid out in front of you,
+in kind of diagrammatic
+format of the lines
+and the trajectories that you
+follow throughout the day,
+the lifting of your mug and how frequently
+you drink each hour,
+you would be amazed and
+probably a little bit scared
+by how much of a robot we all are.
+Now that robotic aspect of
+our neurocircuitry is vital,
+because it's what allows us
+to think about other things
+and do other things, and
+drive other behaviors.
+But the work of Dr. Steinglass
+and colleagues showed
+that in the case of the anorexic,
+those habits are exactly
+the place where things start
+to go awry.
+And that drive this very
+dysfunctional under-eating behavior
+that sadly often leads to death
+or certainly bad medical outcomes.
+And it turns out that the
+brain areas associated
+with habit formation and execution
+are the best point of intervention.
+So, what Dr. Steinglass
+and colleagues did,
+is they took anorexics and they
+of course had control groups
+and they put them in an FMRI scanner,
+which are these brain scanners
+that allow you to evaluate
+which brain areas are active,
+during particular tasks.
+And because when you're
+in one of those scanners,
+you actually, you know,
+I've actually been in one of these things.
+You're biting down on a
+bite bar and you're most
+of the time and most all of
+these scanners you're immobile.
+So, you're looking at
+things on a TV screen.
+Sometimes you can press
+buttons to select choices
+and so forth, but you can't
+really eat within those things.
+What they found was that
+reward based decision-making,
+the drive to pursue a
+particular food or the drive
+to perform a particular task,
+which is a lot of what
+we do throughout our day,
+that was controlled by a brain area called
+the ventromedial prefrontal cortex.
+Let me simplify a little bit of this,
+but I'm going to simplify it
+by giving you a little detail,
+because it's the Huberman Lab Podcast.
+And I believe in mechanism,
+mechanism is the way that
+you get true understanding
+and that you can then be
+very quick and give overviews
+of things, but you need the mechanism.
+So, you have reflexes and
+you have neural processes
+that include what are called duration path
+and outcome type processes,
+a duration path, outcome type process,
+we can shorten with DPO.
+DPO is for all types of
+goal related behaviors.
+So, for instance,
+if you want to get a
+particular grade on an exam,
+you want to learn something,
+you want to complete a workout.
+You want to go to the grocery
+store and pick some stuff up
+and then head home.
+You're going to think duration.
+How long do I have, okay,
+do I have 45 minutes to get to the store?
+How long does it take to
+get to the store path?
+Which way am I going to drive there?
+Which way am I going to navigate
+through the grocery store,
+outcome, was able to get
+in and get the items I need
+and get home in time, okay?
+DPO, duration path outcome.
+It's a very conscious process.
+You tend to take into account
+different criteria related
+to what's preventing
+you from accomplishing
+what you want to do
+and what's helping you or assisting you.
+So, of course,
+as you get to the checkout
+line in the grocery store,
+you're going to select the
+shortest line for instance.
+So, that's all DPO stuff.
+It requires decision-making
+and it's reward-based,
+you use these DPO type
+processes in the short term
+to pick up groceries and pick
+a line at the grocery store
+and decide which trajectory to take home.
+And you use them for navigating
+long extended processes
+in life, trying to get a
+degree or raise children
+or get through a particularly
+challenging year, et cetera.
+So, duration path outcome,
+and that entire process
+relies on your fore brain.
+This prefrontal cortex,
+the prefrontal cortex is what allows you
+to take information from memory,
+combine it with information
+about what's happening
+in the present context, and
+then to direct your behavior,
+your speech, et cetera,
+toward particular outcomes.
+And if all that sounds
+like a mouthful, it is,
+and it's very metabolically demanding,
+decision-making is
+metabolically demanding.
+It takes effort, okay?
+Reflexes on the other hand,
+don't involve the prefrontal
+cortex in the same way,
+habits and reflexes.
+Like once you know how to
+walk, you get up and you walk,
+you don't have to think
+about right foot, left foot,
+right foot, left foot.
+You just do it.
+That doesn't rely on prefrontal cortex.
+It's subconscious as
+it's sometimes called,
+but basically you don't have
+to use the parts of the brain
+that are involved in duration path
+and outcome type analysis.
+Okay, so, in this particular study,
+they examined brain activity in anorexics
+who are selecting different foods.
+And as I mentioned earlier,
+they have a hyper acuity or
+awareness of which foods contain
+more or less calories than other foods
+and what the fat content
+of particular foods is,
+in particular, et cetera,
+they're doing all this while in a scanner.
+And then they look at
+what sorts of brain areas
+are active after that task is done.
+And what they found
+was really interesting,
+what they found was that the
+dorsal lateral prefrontal
+cortex not surprisingly is
+involved in the decision-making
+and the evaluation of this food,
+which foods are going to be
+best to eat in this context,
+which foods are going to
+be appropriate for at least
+that anorexics framework
+about what's okay to eat
+and what's not okay to eat and how much.
+However, there are areas of the
+brain that were active after
+that decision-making process.
+And those are the brain
+areas that turn out to drive
+the habit of avoiding particular foods
+and approaching other foods.
+And in that case,
+it wasn't the dorsolateral
+prefrontal cortex.
+It was an area of the brain called
+the dorsal lateral striatum.
+Now the striatum is a
+big area in the brain.
+It's involved in a lot
+of different things.
+It includes areas like
+the caudate and putamen.
+And I just want to mention, as
+I throw out all these names,
+you do not need to remember the names
+of these different structures.
+They're just there,
+if you are interested
+in that level of detail,
+but basically you have a
+brain area and anorexics
+have a brain area that's
+involved in evaluating
+and decision-making around food.
+And then another brain
+area that's involved
+in the reflexive consumption
+of particular foods
+and the reflexive
+avoidance of other foods.
+If you remember way back at
+the beginning of the episode,
+I feel like that was a long time ago now.
+When we talked about how you
+have these sorts of processes
+in the brain,
+but there are always homeostatic
+and reward systems influencing
+this kind of thing.
+Well, in the brain of the anorexic,
+it turns out that the reward
+systems have been attached
+to the execution of habits
+in a way that is unhealthy
+for body weight,
+but at least from a purely
+neural circuit perspective,
+the reward is now given this
+chemical reward in the brain,
+is given for avoiding particular
+foods and only approaching
+these very low calorie, low fat foods.
+So, there really does seem
+to be a flip in the switch,
+in the anorexic brain that
+rewards them internally.
+They feel good when
+they avoid certain foods
+and they approach others.
+So, it's not a deprivation based model
+where they are flagellating
+themselves or masochistic
+or actively avoiding food in
+order to punish themselves,
+which is interesting because a
+lot of psychological theories
+support that idea.
+Rather, once this transitions
+into a set of habits,
+they are actually getting
+a sense of reward.
+They feel good, presumably
+from the release
+of a different neuromodulator
+called dopamine,
+by approaching foods that are
+low fat, low calorie content.
+And so their whole brain circuitry
+is skewed toward avoiding
+particular things.
+And they actually are rewarded
+for that, and they feel good.
+They feel better than if they were eating
+in a healthy weight supporting way.
+Now the dorsolateral
+striatum is a structure
+that we should think about
+in a little bit more depth.
+It's part of a set of
+circuits that are involved
+in what are called go no-go tasks.
+And I don't want to go into this in a lot
+of detail right now,
+because it would take us too far down
+the rabbit hole of neurocircuitry.
+But basically in terms of behaviors,
+we both have DPO type behaviors.
+So, decision-making,
+reward based behaviors.
+And we have habits that
+we learn and we acquire.
+And then we just start to
+reflexively, things like walking,
+things like yawning when we're tired,
+things like taking a particular route
+through the parking lot, right?
+We learned that the first time
+we go to a given parking lot
+and walk into a building.
+But after that, we tend to follow
+the exact same trajectory
+becomes very automatized.
+It's just like, we just
+do it without thinking.
+Well, the go no-go
+circuitry is another aspect
+of our behavior,
+where we both have to
+select behaviors to perform.
+And we have to select
+behaviors to suppress.
+And the anorexic brain
+seems to reward suppression
+of one set of behaviors,
+ingestion of high calorie
+foods, and to reward focus,
+or even hyper-focus and
+consumption of low fat,
+low calorie foods.
+So, this homeostatic process that we learn
+about from like high school onward,
+that, oh, everything in
+your body is designed
+to keep everything in balance.
+You stay awake for a
+certain amount of time.
+You want to sleep, you
+don't eat for a while.
+Then you want to eat to
+maintain weight, right?
+You eat too much.
+Then you want to eat less.
+Those systems are disrupted.
+And so what's so beautiful about this work
+from the Columbia group,
+is that what it says
+is the place to intervene
+has to be the habit.
+This stuff has already passed
+through all the learning,
+it's passed through
+all the reward systems.
+It's clearly not being overrun
+by the homeostatic processes
+of the body.
+There's very little body fat.
+There's no leptin,
+whatever neurons in the brain
+respond to leptin are starved
+for leptin, periods of
+shutdown, sperm production,
+and testosterone is lowered.
+Bone density is down.
+Clearly, this is overriding all
+those homeostatic processes,
+all the signals that
+would say eat, eat, eat.
+Those don't matter in the
+brain of the anorexic.
+In the brain of the anorexic
+is just performing habits
+and they're being rewarded for it.
+So, when you come along and say, look,
+you should really eat this
+whole pie or this whole pizza
+you'll feel better.
+That's how she aversive to them.
+So, since it appears to be a habit,
+a reflex that's perpetuating
+the anorexic phenotype.
+As we say, in science,
+it's perpetuating anorexia
+in this individual
+and telling them about
+all this terrible stuff
+that's happening in their body won't work,
+taking them away from all the images
+of thin people online, et cetera.
+That's not going to work.
+What's going to work.
+What's going to work is intervening
+in the neural circuitry.
+That's related to the habit itself.
+And it turns out that
+there are ways to do that.
+So, how do you break a habit?
+How do you rewire the brain circuitry
+that's literally causing a reflex?
+And in this case causing a reflex
+that is killing the individual,
+or at least leading to
+very bad health outcomes.
+The way that you do that is
+through a cognitive mechanism
+where you teach the individual,
+what is leading up to the habit?
+This is a little bit similar
+to the way that somebody
+who suffers from addiction starts to put
+in different constraint type behaviors,
+constraint type behaviors,
+are the sorts of things
+like where the alcoholic
+will call a hotel ahead
+of time and say, listen,
+I want the mini bar taken out of the room.
+I don't want a television
+in the room, et cetera,
+constraint type behaviors.
+Those are really ways of keeping oneself
+from the temptation.
+But with these habits,
+they work at such a subconscious level.
+That what seems to work best
+is a combination of teaching
+the individual about their internal state
+and how to register their internal state.
+What we call interoception this ability
+to perceive your internal state,
+so that they can start to learn,
+to associate the interactions
+with different types of food,
+with the sorts of cues that are
+occurring within their body,
+quickening of heart rate,
+hyper acuity of focus that
+we talked about earlier.
+Once they start to be able
+to notice that those things
+are happening, then they
+can start to intervene.
+So, let's talk about what
+those things are that lead
+into a habit,
+because those turn out to
+be the exact points of entry
+for changing and eliminating
+and rewiring habits,
+to a more healthy behaviors.
+And I should highlight that
+this isn't just about rewiring
+habits for sake of the anorexic.
+These are also the same types
+of mechanisms that one would
+want to incorporate in
+order to rewire any habit
+of any kind.
+There are two main features of thinking
+that go into the sorts of
+habits that anorexics execute.
+The first is something called
+weak central coherence.
+Weak central coherence is
+essentially an inability
+to see the forest through the trees.
+It's a hyper acuity and focus on details
+within a given environment.
+And there's actually an
+interesting probe test for anorexia
+that involves something akin
+to kind of a where's Waldo type
+of puzzle, where an image is put up.
+The one that I saw was one
+in which there is a big
+array of coffee beans.
+Actually, they're all brown coffee beans.
+And your job is to identify
+where in that array
+of coffee beans, there's a face.
+And indeed there's a
+face embedded in there.
+It looks a little bit like a coffee bean,
+but once you see it,
+you realize it's a face,
+not a coffee bean.
+And it becomes very hard to
+not notice the face after that.
+Anorexics, are very good
+at identifying the face.
+They find it much faster
+than do non-anorexics,
+which is really interesting, right?
+They somehow are able
+to hone in on details
+and find those details and
+fixate on those details.
+Now eventually, most, if not
+all people find the face,
+but once you do what you will
+find and what everyone finds
+is that you can't unfine
+the face, it just jumps out.
+So, what essentially
+you've lost is the ability
+to see the whole picture,
+because there's some
+detail within that picture
+that you're obsessed by.
+So, this has kind of elements
+of obsessive compulsive disorder,
+but it's not really obsessive
+compulsive disorder per se.
+So, we call that weak central coherence.
+It's a hyper acuity on
+one particular feature.
+You miss the big picture.
+The other is a challenge in set shifting
+that once you identify something
+that's of particular interest
+and that's driving some sort
+of reward, for the anorexic
+that would be identifying the
+high-fat foods or identifying
+the one food on the table that
+one could eat without anyone,
+hopefully noticing that they're
+eating just the green beans
+and not touching any of the other food.
+If you ever had a meal with an anorexic.
+You might be familiar with this.
+It's kind of uncomfortable to be around.
+Actually they go through a
+lot of elaborate procedures
+to kind of hide food too.
+They'll sometimes even chew food,
+hold it in their mouth and
+then go to the bathroom
+and discard it things, very elaborate,
+very troubling types of
+things to hear about,
+and to be around.
+But you'll notice that they push food
+around their plate a lot.
+They become masterful actually at trying
+to keep people's awareness
+away from what they're doing,
+which is to hone in on these
+low fat, low calorie foods.
+And they can't seem to set shift.
+They can't just relax and enjoy
+the meal, because the meal
+for them is essentially
+like this where's Waldo
+or find the face in the
+coffee being tasked.
+They're constantly monitoring
+how much people are observing
+them and trying to navigate this.
+What would otherwise be a
+really pleasant circumstance
+for most people they're trying to navigate
+through this because remember for them,
+the reward is in the
+avoidance of certain things
+and the acquiring of only the foods
+that their brain rewards them for,
+because those are the foods
+that have been preselected
+and are now habit.
+What's amazing.
+And frankly also important
+are these findings
+that once you teach anorexics,
+what's happening to them,
+that they're doing this,
+they are able to intervene.
+Now they need support, right?
+And another form of therapy
+that seems to work well
+for anorexics that ideally is combined
+with this habit rewiring,
+is a family-based model.
+Family-based models are
+starting to surface a lot now
+in various therapy settings,
+therapy based models
+in short are basically
+where the entire family is made aware
+of the individual's challenges
+with a particular eating
+disorder or other disorder.
+And in understanding some of
+the biology and psychology
+around it, they stopped
+condemning the individual.
+They start to support that
+individual through queuing them
+towards their own habits
+that they observe.
+They give them some autonomy.
+They realize that none of
+this changes overnight,
+but they're taught about
+things like neuroplasticity
+and the ability to change one's brain
+in response to experience.
+And so there's a whole
+internal support network.
+Now, for people that live alone,
+this isn't available to them.
+This isn't the kind of
+thing that you share
+with your coworkers.
+You might involve a
+close friend or a spouse,
+but it's not the sort of thing
+that people that don't live
+in a family context can
+really benefit from.
+All of these things
+fall under the umbrella
+of cognitive behavioral therapy.
+And I should mention that
+cognitive behavioral therapies
+are often done in conjunction
+with pharmacologic therapies.
+I think that there's this idea
+out there that it's either,
+or when often it's both.
+So, cognitive behavioral are
+often combined with this habit
+recognition and rewiring approach,
+which is starting to become
+more and more common.
+And I think the date on
+it looked really good
+that especially when it
+individuals are taught this early
+in adolescence, that there are
+positive outcomes over time,
+the relapse rate of
+anorexia is quite high.
+It's about 50% of individuals
+will relapse at some point
+often triggered by a
+stressful life circumstance.
+But the combination of
+cognitive behavioral therapy
+that includes this family model,
+or at least habit reformulation seems
+to be fairly effective.
+And at present might be the
+most effective treatment.
+Now there are additional
+treatments starting to surface,
+and that takes us into the realm
+of chemical treatments for anorexia.
+And I just want to mention
+that there are clinical trials,
+meaning legal clinical trials being done
+at Johns Hopkins School of
+Medicine by Matthew Johnson
+and others, exploring how drugs like MDMA,
+which increases dopamine and
+serotonin to very high levels
+or siliciden so-called magic mushrooms,
+which increases serotonin
+and other compounds
+to very high levels within the confines
+of a professionally supported
+therapeutic environment
+can help people rewire their brain,
+such that they can get
+relief from major depression
+and various forms of trauma.
+And now eating disorders
+are also being explored
+in the context of MDMA and
+siliciden clinical trials.
+I do want to emphasize that
+those are clinical trials,
+that those compounds are not yet legal.
+And in many cases, most
+cases they are still illegal.
+I do not think that
+they should be explored
+without a properly trained medical doctor,
+that the clinical trials are
+essential to complete before
+one explores those
+compounds in particular,
+because lately I get a lot of
+emails about these compounds.
+People telling me that they've
+had amazing experiences
+and relief from various things,
+not just eating disorders,
+but depression, et cetera.
+However, I get an equal number
+of emails from people saying
+that they worked with
+some self appointed guide.
+This would be outside the
+clinical trials I was referring
+to, and they are now experiencing
+chronic visual, snow.
+They're getting genuine
+visual field deficits.
+They are havering ticks that
+they have never had before,
+they have chronic insomnia.
+So, I'm not passing judgment
+on any of these compounds
+or the people that are
+doing this sort of thing.
+I just want to see the clinical data.
+And I do believe that we should
+wait until these clinical
+trials are done before people
+start approaching the stuff.
+And that's because they
+are serious compounds.
+They can open plasticity,
+but whether or not they work quote unquote
+for different types of eating disorders
+or depression and trauma, the
+data are looking promising,
+but that the clinical
+trials are still not done.
+And I know a number of people
+are going out of the U.S.
+and into other countries
+where this stuff is being done
+more regularly and there too.
+I've gotten reports back of people doing
+so-called ibogaine treatments.
+Some of you who are familiar
+with eating disorders
+will immediately be asking,
+well, what about ibogaine?
+Does it work?
+Does it work?
+Well, the clinical trials in
+this country are not complete.
+I've heard evidence direct.
+I've heard directly from
+people who have benefited
+from the sorts of things, for
+treatment of eating disorders.
+But I've also heard of people
+that have developed chronic
+seizure disorders from
+pursuing things like ibogaine
+for the treatment of eating disorders.
+So, again, I'm not passing judgment.
+I would just like to see more data.
+And it's very important
+that the safety aspects
+of safety be in place.
+So, this is definitely not
+something to get renegade about.
+So, it appears that once
+anorexia has established
+that habit breaking through self-awareness
+of what the habits are,
+is going to be a primary entry point.
+That might seem kind of trivial.
+You might say, well,
+could you have just told
+us that in one sentence,
+but I want to return us to this model
+about homeostatic processes,
+reward, processes, et cetera.
+That leads us to a place
+where the short answer is no,
+you can't simply say break the habit.
+An individual needs to be informed
+about where that habit comes from.
+And the fact that what currently seems
+like a rewarded habit should
+actually be a punished habit.
+Now, I don't mean by actual punishment,
+but what I mean is within the brain,
+there's been a switch
+and the anorexic needs
+to learn that there's been a
+switch such that what should
+be rewarding is now punished
+and what should be punished.
+Starvation is now rewarded.
+The beauty of being a human
+being is that knowledge
+of knowledge can allow you
+to make better decisions.
+I'll say that again,
+the beauty of being a human
+being is that knowledge
+of knowledge can allow you
+to make better decisions.
+Now, of course, when we are
+anxious, when we are tired,
+when we are intoxicated,
+we have less access to that
+ability to use knowledge
+of knowledge, to intervene.
+The anorexic will often do
+things that are in keeping
+with their habits, such as overexercising.
+This is a area that anyone
+who's treated anorexics
+or interacted with
+anorexics is well aware of,
+that they are constantly moving.
+They're constantly on the treadmill.
+They're constantly running.
+They always want to be
+moving and burning calories,
+so that they can feel
+okay about interacting
+with food or because they
+have the distorted body image.
+Well, does breaking a habit mean
+that they should stop moving
+around and exercising?
+No, not necessarily.
+There's some really
+interesting studies that show
+that shifting anorexics towards activities
+that for instance, build
+muscle resistance training
+and allow them to eat a bit more food
+without necessarily losing weight,
+but rather to put more
+muscle on their body
+can actually be beneficial.
+Now I'm not talking about
+anorexics becoming bodybuilders,
+has all body dysmorphia
+associated with bodybuilding,
+but certain forms of
+exercise are just catabolic.
+Meaning they break down
+the amount of muscle.
+They reduce body weight, overall,
+other types of exercises
+like resistance training
+or anabolic, they allow
+muscle to be put on.
+And there are some interesting
+studies, not a lot,
+but some interesting studies
+trying to encourage anorexics,
+not to stop exercising,
+but rather to stop exercising
+in this neurotic catabolic way
+of breaking oneself down,
+but rather getting them
+shifted toward breaking habits
+of only approaching low
+calorie, low fat foods,
+while also encouraging them to
+embark on resistance training
+and to start to learn and
+reward the relationship
+between exercise for sake
+of making one's body strong,
+including the bones, not just
+the muscles, but the bones,
+which is important,
+especially in anorexics.
+And then to see food as a
+way to nourish that process,
+to building a body that could
+be of the stable weight.
+Hopefully there, once the
+anorexic is of a healthy weight
+that they're maintaining that weight,
+but that they don't have to
+constantly be on this treadmill,
+no pun intended of balancing
+whatever food intake
+they have with activity.
+And along the lines of that.
+During the episode on fat
+loss and metabolism as well,
+I talked about this neat
+and non-exercise induced
+thermogenesis where people
+who tend to be thin,
+tend to bounce around a lot.
+They're kind of fidgety
+and that burns 1000
+of calories a day, anywhere
+from 800 to 2000 calories a day.
+Now that can be beneficial for
+the folks that are overweight
+and have a healthy mindset about food,
+but are trying to lose weight.
+And it turns out that by, you
+literally fidgeting and
+bouncing around, like,
+this is why I'm doing this.
+It looks ridiculous.
+You actually burn a lot
+of body fat and calories.
+That way provide you're
+in a caloric deficit,
+you'll burn body fat
+because body fat is not just
+a passive tissue.
+It actually receives input from neurons
+that release noradrenaline and adrenaline.
+And this neat.
+Has been described for
+several decades now.
+And it actually is a pretty terrific way
+to burn off more calories.
+So, with the anorexic,
+you actually want to encourage
+them to not constantly
+be trying to burn off calories.
+That can be very challenging.
+So, shifting them toward
+activities like weight bearing
+activities or resistance
+training that promote
+this more anabolic type of
+relationship to activity,
+as opposed to catabolic can be beneficial.
+Before we move on to talking
+about bulimia and some related
+disorders, I want to talk
+about an aspect of anorexia.
+That's very interesting,
+quite troubling in fact,
+but that has received a lot of attention
+and that's the distorted self image.
+Now, episode and depression,
+we talked about a very powerful
+aspect of major depression,
+which is this anti-self
+confabulation that people
+who are depressed seem
+to genuinely believe.
+And even confabulate about the fact
+that they are performing poorly in life
+and that they are no good or
+not, or worthless, et cetera.
+It's literally a lie that they
+believe and their statements
+and their feelings and
+their behaviors start
+to reflect that lie.
+They're not conscious of it.
+That's why we call it a confabulation.
+Anorexics often will see
+themselves as overweight
+or imperfect in ways that
+are of an obsession for them,
+they'll think, oh, you know,
+their arms are a little bit fat, you know,
+or, you know, the contour,
+their face makes they
+don't like the pictures
+of themselves or they.
+What I'm describing here is
+actually pretty typical behavior
+of a lot of people.
+I mean, how many people do
+you know that after you take
+a picture of them, they
+say, can I see the picture?
+And then they tell you that
+you have to throw it away.
+That doesn't necessarily
+mean they're anorexic
+or they're suffering from
+some sort of disorder.
+That just means that they're
+a human being that cares
+about how they appear in the world.
+We're not here to judge that
+in the case of the anorexic.
+The problem seems to be that
+they have a genuine distortion
+of their self image so much so
+that they don't actually see
+themselves accurately, their
+visual perceptions are off.
+And the reason we know this,
+it's because of some really important
+and beautiful studies that
+were done with my colleague,
+Jeremy Bailenson's lab at Stanford,
+he's in the department of communications,
+he's actually collaborated
+with a Dr. Halpern that
+I mentioned earlier.
+What's really interesting about
+these studies is they give
+us a window into the perceptual
+defect that anorexics have.
+I've actually done one
+of these experiments.
+I'm fortunate to not be anorexic,
+but I've done some work
+with the VR lab over there.
+And what you get to do is
+you get to adjust this avatar
+of yourself to the point
+where you think it's,
+as accurate as it could possibly be,
+and anorexics, really distort this avatar.
+In other words,
+they create this serious
+mismatch between their perception
+of themselves and the reality.
+So, indeed it does seem to be
+the case now what's relieving,
+or I should say what's encouraging
+about some of the therapies that we talked
+about before the family based model,
+the Connie behavioral treatments.
+Yes, and the drug treatments as well.
+But this habit intervention
+model is that as one starts
+to shift those things,
+it does appear that the
+perception of self seems
+to follow that the
+perception of self seems
+to shift along with the change in habits.
+And that's a relief,
+or at least I find that reassuring
+because changing one's
+perception is actually very hard,
+as somebody who's worked
+almost his entire career
+on visual perception and related things.
+The perceptual apparatus of
+the brain are not very amenable
+to neuroplasticity, meaning
+they don't change that easily.
+Whereas it appears that the circuitry
+that's related to habit
+formation, and decision-making
+and the reward, circuitry,
+that stuff can be rewired.
+And so anorexics as they progress
+out of their anorexic state into one,
+which they are intervening
+in their reflexes,
+gaining better habits
+around food, eating more,
+more accurately, assessing foods
+and environments that
+they're in related to food,
+as they change their behavior.
+And they start to put on healthy weight,
+maybe they're also doing the
+sorts of exercises that allow
+them to put on healthy
+weight and avoiding kind
+of extreme exercises of cannibalism
+and breaking themselves down.
+They also managed to somehow
+just as a consequence
+of all that rewire their
+perception of self.
+So, it doesn't seem that
+trying to tell someone,
+oh my gosh, you're so thin.
+You really need to eat.
+That doesn't seem to work.
+They just don't see
+themselves the same way
+that you see them.
+And so I offer that as a
+point of consideration,
+if you know someone that's anorexic,
+or if you look at an
+anorexic and you think,
+how is it that they are
+still critical of the small,
+even nonexistent amount of body fat
+on their triceps or something?
+How is that?
+Well, it's literally that their brain,
+as it relates to perceptions,
+visual perceptions in particular,
+they're completely off.
+And fortunately by changing habits,
+you rewire those circuits as well.
+Okay, so let's talk about bulimia,
+which is overeating and
+then purging typically
+by self-induced vomiting or by ingestion
+of laxatives, sometimes also in concert
+with people taking
+stimulants and fat burners,
+over ingestion of stimulus to
+try and burn off more energy.
+And then we'll also talk
+about binge eating disorder,
+which has a lot of the
+same features as bulimia,
+but typically no purging.
+I'm not going to list off
+all the clinical criteria
+that would allow someone
+to be diagnosed as bulimic
+or binge eating disorder.
+But the general features are
+that they ingest far more
+calories than they need,
+anywhere from 10 to 30 times,
+their daily caloric intake,
+oftentimes within a two hour period,
+which is just a staggering
+amount of food and nutrients
+in a short period of time.
+Oftentimes they're overriding
+those mechanical signals
+from the body that they're full.
+It's a really troubling
+thing to think about,
+but people are literally
+gorging themselves with food.
+This looks a lot like a laboratory animal
+that has these AgRP neurons stimulated,
+these neurons that will eat
+until they almost burst or burst.
+So, you wonder is that these
+AgRP neurons that are active
+almost certainly yes.
+That they're involved.
+Although I don't think that that's going
+to be the major point of intervention,
+but we're going to talk about
+other types of interventions.
+There are a number of clinical criteria.
+For instance, if somebody
+has one of these binges
+once a year, does that make them bulimic?
+Technically, no, but I certainly
+don't recommend people do this.
+If you are one of these people
+who has so-called cheat days, right?
+Some of you may be
+familiar with cheat days.
+I think they're a little less common now,
+but the idea is you eat clean for six days
+or five days a week or two weeks.
+And then you have a so-called
+cheat day where you just kind
+of go wild and eat whatever
+you want and whatever volumes
+is that bulimia.
+And it has some of the contour of bulimia.
+If you're vomiting afterwards
+or binge eating disorder,
+if you're not,
+does it constitute full blown bulimia
+or binge eating disorder?
+And it's pretty hard to say,
+the criteria that were described
+to me is that if somebody
+is doing this at least once
+a month, over a period of
+anywhere from two to three months,
+then it likely would qualify.
+And I certainly know people
+who do these cheat days
+and by those criteria,
+they have something like
+binge eating disorder.
+But in general,
+one of the hallmark features
+of bulimia binge eating
+disorder is that people are
+unable to control their eating.
+They're just simply,
+they're not making the
+decision to have a cheat day.
+They're not making the
+decision to overeat.
+They are simply driven from
+the inside without question
+by way of neurocircuitry.
+They are driven from the
+inside to ingest far more food
+than they need.
+And in some cases than
+they would want to eat.
+So, it's a lot like the habit
+that we described for anorexia,
+it's almost like it's
+turned into a reflux once
+they get going, all
+the homeostatic signals
+are being overridden, all
+the signals from the body,
+the leptin, the insulin, the glucose,
+all that stuff has cosmically sky high.
+And yet they're just what we,
+the nerds call hyperphagic,
+they're just eating like crazy.
+So, what's going on there?
+Well, there've been a lot of ideas,
+about why this arises.
+There's the so-called
+thyroid hormone hypothesis.
+That one's a tricky one.
+It turns out that cortisol
+and thyroid hormone
+concentrations vary according
+to when the binge purge happened.
+So, there were some studies that looked
+at thyroid hormone levels
+and they found elevated
+thyroid hormone levels.
+Thyroid hormone is involved in metabolism
+and not just the burning of energy,
+but the use of energy in
+converting it to different tissues
+of the body, cartilage bone,
+fat, and muscle, et cetera,
+did a whole episode on
+thyroid and growth hormone.
+By the way,
+if you're interested in learning
+more about thyroid hormone,
+but thyroid hormone can also
+be depleted at other phases
+of the binge purge cycle.
+Now, without listing off
+all the terrible things
+that happen with this binge purge cycle,
+there are a number of things
+that are really worth pointing out.
+One is that the vomiting itself,
+the use of laxatives that
+can cause severe disruption
+to the mucosal lining the mucus lining
+of the digestive tract
+can severely disrupt
+the gut microbiome.
+It can cause all sorts of even
+a ulceration of the esophagus
+and just really terrible stuff.
+There's a lot of shame
+associated with bulimia,
+oftentimes because people are
+vomiting and it's hard to hide
+that vomiting behavior,
+people are aware of it.
+There's some social isolation.
+So, you recall from the beginning,
+it does not appear that sexual trauma
+is a prerequisite for bulimia.
+Although sometimes it can
+occur the hallmark feature
+of bulimia that distinguishes
+it from anorexia,
+aside from the fact that
+it's overeating as opposed
+to under-eating is a lack
+of what they call inhibitory control.
+And that might come as no surprise.
+But first of all, the bulimic,
+unlike the anorexic is hyper
+impulsive and oftentimes
+has other types of impulse behaviors.
+They might have a little bit of alcohol
+and then start to eat like crazy.
+Whereas normally they're very restrictive.
+That's a common feature of bulimia,
+sometimes they over ingest
+alcohol during these binges.
+Sometimes they are sexually
+promiscuous, not always,
+but it's a general issue with satiety
+once they start eating and
+with impulse control generally.
+And for that reason,
+many of the treatments
+that you see for bulimia
+and binge eating disorder
+are the sorts of treatments
+that don't seem to work so well,
+or at least most of the time for anorexia.
+So, the drugs that increase
+the neuromodulator serotonin,
+for instance, fluoxetine
+also called Prozac, Paxil, et cetera.
+Those things oftentimes can
+be effective in bulimia.
+Some of the drugs that are
+used to treat attention deficit
+hyperactivity disorder an
+ADD, a topic that we're going
+to talk about in depth
+here on the podcast soon,
+some of those same drugs like Adderall,
+Vyvanse and things of
+that sort can also be used
+to treat bulimia and
+binge eating disorder.
+Why would that work?
+Well now you are familiar
+with the prefrontal cortex.
+You probably know more
+about prefrontal cortex
+than you ever wanted to,
+just from this episode,
+prefrontal cortex is involved
+in this analysis of duration
+path and outcome.
+Duration path and outcome
+is how we avoid impulsivity.
+It's how we think.
+Okay, if this, then
+that, if that, then this,
+you can imagine how for
+the obsessive compulsive
+or for the anorexic, these are
+circuits that are overactive.
+For the bulimic this is
+the circuit that's going
+to essentially be underactive
+and is under conditions
+where they think, oh, you
+know, I shouldn't eat anything.
+I shouldn't eat anything.
+And then they just tear
+the refrigerator open
+and plow through that.
+And then at that point they're
+plowing through the cupboards
+and then they're ordering food.
+And then they're feeling
+horrible about themselves.
+There do tend to be these cycles
+of binge and purge followed
+by feelings of real shame
+because they just can't
+control their behavior.
+And what is more embarrassing
+than not being able to control
+one's behavior as an
+adult or as a young adult.
+So, really the polar opposite
+of what you see in anorexia.
+So, this lack of impulsivity implies
+a lack of prefrontal control.
+What we call top-down control.
+Why do we call it top-down?
+Because the prefrontal
+cortex is suppressing
+the activity of deeper limbic
+and hypothalamic circuitry,
+and things of that sort.
+Anytime you feel like
+you want to say something
+really offensive and you
+don't, that's top-down control.
+That's your prefrontal cortex.
+Anytime someone says something
+and you like grow your teeth.
+'Cause you'd know you
+shouldn't say anything,
+gritting your teeth is
+top-dow control, okay?
+When you explode or burst
+or say the wrong thing,
+or say the thing that you
+shouldn't say or do the thing
+you shouldn't do, that's
+lack of prefrontal control.
+And indeed people who have
+frontotemporal dementia
+due to aging or head injuries,
+see this a lot and people play sports get
+a lot frontal damage.
+They become more impulsive.
+So, bulimics have an
+issue with impulsivity,
+and therefore drugs that
+can increase serotonin.
+And sometimes these drugs
+that increase dopamine
+and adrenaline also called epinephrin,
+will increase the tone as we
+call it the dopaminergic tone
+or the, it's called adrenergic,
+but norepinephrine
+levels in the brain allow
+for more top-down control.
+And that's also why
+they're used to treat ADHD
+and attention deficit disorder.
+They tend to create a hyper-focus.
+They tend to push the brain into,
+these drugs tend to create a hyper-focus,
+and tend to push the brain
+and general motor processing
+into one in which you think
+if this, then that, if this,
+then that, so anticipating outcomes.
+And for that reason, drugs
+like Wellbutrin, bupropion,
+which is an antidepressant,
+which mainly increases
+the amount of dopamine
+and norepinephrine and less serotonin,
+that can also be effective
+for certain types
+of binge-eating disorder is actually used
+to treat smoking, for
+promoting smoking cessation
+and for depression, but
+also for certain forms
+of obesity related to
+binge eating disorder.
+And the data are pretty good.
+And there are timed release forms
+of this and non-time release forms.
+And I think you have to consult
+with a psychiatrist in order
+to get these prescribed because
+they are prescription drugs,
+but it's a very different
+constellation of neurochemicals
+and brain areas and
+approaches for bulimia.
+The treatment of binge eating
+disorder has been explored
+from a new standpoint recently.
+And that's the work of this now,
+sadly, former colleague of
+mine, Dr. Casey Halpern,
+who's at University of Pennsylvania
+that I mentioned earlier,
+they are using deep brain stimulation
+in order to treat binge-eating disorder.
+Now why deep brain stimulation?
+Well work from Dr.
+Halpern and others while
+at Stanford showed that
+there are particular patterns
+of brain activity in both
+the prefrontal cortex,
+but also in an area of the brain
+called the nucleus accumbens,
+very important and very
+relevant area of the brain
+in this context,
+and in any discussion
+about motivated behaviors
+of any kind, feeding,
+sex, drug relay behavior,
+people exercise compulsively,
+the nucleus accumbens
+is in a ongoing dialogue
+with the prefrontal cortex
+and the nucleus accumbens
+has no mind of its own,
+but it's associated
+with dopamine release.
+It's part of this
+so-called reward pathway.
+And what Dr. Halpern and
+colleagues discovered
+is that there are particular
+patterns of activity
+that ripple through the brain,
+through these prefrontal
+networks and through
+this nucleus accumbens area,
+those areas are connected.
+It's called Delta oscillations,
+Delta, just being a particular frequency
+of electrical activity for your aficionado
+as wonderful heart activity.
+But in any case,
+those Delta oscillations
+in the nucleus accumbens
+are associated with food
+reward in both mice and humans.
+Somehow this reverberatory
+activity creates a perception
+in the individual that
+food is hyper rewarding.
+And that's interesting,
+and has allowed them
+to use a targeted deep
+brain stimulation approach
+to treat binge-eating disorder.
+And this deep brain
+stimulation is appearing
+to be an effective treatment.
+There's still more studies
+that need to be done.
+Actually, if you think you
+have binge-eating disorder,
+you can find the criteria for that.
+And you could contact Dr. Halpern he's.
+As I mentioned, he's moving
+to University of Pennsylvania.
+They are recruiting patients
+for these studies all the time.
+The studies are fairly invasive.
+They involve a FDA approved
+approach of literally placing
+a wire down into an
+area of the brain that,
+and allows the individual to
+stimulate a particular brain
+area to offset some of
+these activity patterns
+that lead to a elevated
+sense of reward from food
+and binge eating.
+And the data looked really promising.
+Now I realize that's a
+very invasive approach.
+Not everybody is going to be willing
+to have this wire inserted into the brain,
+but for people that suffer
+from binge-eating disorder.
+This is a great and very
+exciting potential treatment.
+Because what I didn't tell
+you is that many people
+have binge eating disorder are obese
+to the point where their
+health is greatly risk.
+Now, obesity causes all sorts
+of shifts in the dialogue
+between the brain and body.
+Some of which you'll
+recognize from earlier
+in the discussion, for instance,
+leptin signaling is disrupted.
+So, the fat there's lots of body fat,
+but even though that
+body fat is secreting,
+this hormone leptin in that
+signal should shut down
+the desire to eat.
+The receptors to leptin in the
+brain are totally screwed up.
+And so the signal to eat is there,
+but the signal to stop
+eating is not there.
+So, again, you have an
+accelerator and a brake,
+and it's like, the accelerator
+has always pushed down.
+Some of these brain
+stimulation approaches seem
+to be able to bypass some of that,
+and of course there all
+the metabolic syndromes
+and the problems with having
+excess levels of body fat,
+things like insulin
+resistance, type two diabetes.
+I mean, as disturbing as is to here,
+there are many individuals, actually,
+I know some who are so obese
+that they start getting bodily sores.
+They're not just bedsores,
+but they have skin sores that
+are very disruptive to them.
+They don't like having these sores.
+And in addition to that,
+they can get peripheral neuropathies
+because of some of these metabolic issues.
+They're not getting enough utilization
+of the nutrients in the tissue,
+because the way that insulin
+has disrupted insulin singling,
+and they actually have
+to have certain portions
+of their limbs amputated, and
+yet they continue to overeat.
+So, this is not an issue of
+self-control that can easily
+be dealt with simply by
+telling the person, look,
+you have to stop eating
+or you're going to die,
+or you're going to have
+your legs amputated.
+Like with anorexia,
+there's a distortion in
+the relationship to food,
+but the homeostatic and the
+reward aspects are disrupted.
+So, unlike anorexia,
+where it seems to be a
+habit based mechanism
+with bulimia and binge eating disorder,
+something deep within the
+neural circuitry is causing food
+to be hyper attractive
+and the break is off.
+So, if you want to develop some empathy
+for what these people are dealing with,
+consider this, it's like driving a car,
+you get onto a grade, maybe
+a 10 or 15 degree grade,
+and you're heading down
+and you figure, well,
+you'll just pump the brakes a little bit,
+but there is no break, right?
+So, you start going faster
+and faster and faster.
+And your only choice is
+to use the accelerator
+just to coach through it.
+That's essentially what's happening
+to these neural circuits.
+So, the work of Dr. Halpern and others,
+I think is really exciting.
+And even though it's highly invasive,
+I think is going to lead
+to not just some relief
+for the patients that do get
+that deep brain stimulation,
+but also the identification
+of what sorts of receptors
+are present in those brain areas.
+That could help.
+What that means is that once
+we understand which brain areas
+are involved in disorder, and
+we understand what receptors,
+those brain areas express,
+then there can start to be
+additional interventions
+by way of non invasive treatments,
+things like drug treatments,
+do behavioral interventions
+work for bulimia?
+In some cases, yes,
+provided that those interventions
+are done early enough.
+Regardless, behavioral interventions,
+coupled with drug based interventions
+are always more effective
+than either one alone.
+Fortunately, there is a
+decent size kit of drugs
+that can help with bulimia.
+I mentioned some of them before things
+like bupropion, Welbutrin
+some of the serotonergic drugs
+and some of the drugs
+used to treat impulsivity.
+So, we have on the one hand anorexia,
+which seems to be a disruption
+in habit and a coupling
+of unhealthy habits in this case,
+food restriction to the reward pathway.
+And on the flip side,
+we have binge eating disorder and bulimia
+where a very unhealthy
+habit of gorging oneself
+with food sometimes followed by purging,
+is not necessarily coupled to reward.
+They feel terrible when
+they do that, right?
+The anorexic feels great about restricting
+their food intake.
+They feel like they're
+winning some sort of game.
+The circuitry is flipped somehow that way.
+With bulimia they feel
+horrible about the fact
+that they're bingeing,
+there's immense shame.
+They can't control themselves.
+The reward is set up before the behavior,
+the reward is set up
+in drawing them to food
+and in making food look like something
+that's incredibly appetizing
+and there's no impulse break.
+There's no way for them to
+stop that kind of behavior.
+So, really kind of troubling
+thing to think about.
+In either case,
+I think for those of
+us that know anorexics
+or have observed anorexia,
+it's so hard to see
+somebody starved themselves
+to near death or to death.
+What more could be disturbing?
+Well, equally disturbing is
+somebody who has an abundance
+of food and is gorging themselves,
+and then feels terrible about it.
+So, these are heavy topics.
+These are topics that
+frankly no one really wants
+to talk about unless they
+know someone who is suffering
+from them, or they
+themselves suffer from them.
+What I've tried to do today
+is try and give you a window
+into what really underlies these things
+that we call eating disorders.
+I hope I've done that at the level
+of biology neurocircuitry
+mechanism endocrinology,
+and some of the psychology,
+as with any episode of this podcast.
+But especially in this
+month where we're talking
+about mental health issues
+and mental health disorders,
+behavioral disorders, there's
+no way that I can exhaustively
+cover all the different
+forms of treatment.
+You have the modely approach,
+you've got all these different
+approaches to depression,
+into anorexia, et cetera.
+What I've tried to do
+is give you a framework.
+And in doing that,
+I've tried to give you a
+framework of understanding
+that also applies to this question.
+That's I think equally
+important and goes alongside
+the treatment of eating disorders
+is what in the world is healthy eating.
+What in the world is a
+healthy relationship to food.
+I like to think that I have a
+healthy relationship to food.
+I know the foods I like.
+I enjoy them.
+They're 10 or 15 foods in
+particular that I liked very much.
+I've mentioned a few of
+them on the podcast before,
+and I was sort of amused,
+surprised and perplexed as to why.
+For instance, I do enjoy eating
+butter, not in huge amounts,
+but I do like butter.
+So, that seemed to be pretty
+triggering for folks out there.
+A small selection of people
+decided that the ingestion
+of butter was a health concern.
+Look to me,
+ingesting butter in small
+quantities is something
+that I'm comfortable with.
+And my blood lipid profiles feel good.
+They look good to me.
+For other people that
+might not be the case.
+For some people.
+The idea of eating an
+animal-based food is probably
+so repulsive that it actually
+can make them feel physically sick.
+And I think that we should
+be aware that that kind
+of mental phenotype exists.
+I'm not calling it a pathology
+for other people like myself,
+things like butter and meat feel healthy.
+Now, what quantities?
+Well, I enjoy eating very much.
+I'm not shy about this.
+I've talked about on the
+podcast before, I enjoy eating.
+Some people have a very
+complicated relationship to food.
+They don't think of it as nourishment.
+They don't enjoy it socially.
+It's a stressful thing for them based
+on their personal history,
+or maybe just general anxiety around food.
+And I hope that in sharing
+this information about the fact
+that anytime we approach food,
+these neurons in our hype,
+in the arcuate area of our
+hypothalamus actually increase
+our levels of anxiety.
+This is related to that
+point that Dr. Halpern made,
+which was that from an
+evolutionary standpoint,
+it is advantageous to ingest as much food
+as often as possible,
+as quickly as possible.
+We now know that to not be
+healthy in this age of abundance,
+where calories are essentially everywhere.
+And yet a lot of people
+feel anxious in anticipation
+of a meal.
+What could be useful to them?
+Well, whether or not they have
+an eating disorder or not.
+It's very clear that developing
+methods to calm oneself
+in the presence of any anxiety
+or fear inducing stimulus
+can be beneficial.
+I've talked about some of these
+episodes related to stress,
+things like the physiological
+side to inhale through
+the nose and a long exhale,
+things like mindfulness
+meditation certainly can help.
+There are data, a lot of
+studies out there showing
+that meditation practice
+can help people deal
+with eating related anxiety and disorders.
+I think as a general rule,
+trying to avoid approaching
+a meal or sitting down
+to eat in an anxious state
+is probably a good idea,
+but let's be realistic.
+How often can we do that?
+I think most of us are
+going to have circumstances
+where we're rushing around
+trying to just eat before we head
+out or get to a meal.
+And then we sit down and
+we find ourselves eating.
+This is one of the first
+times in human evolution
+where we mostly eat out of
+a desire to consume food,
+not out of a need for food.
+Most everybody could
+go a fairly long period
+of time, just ingesting
+water and electrolytes.
+And not that I'm
+suggesting people do that,
+but let's face it.
+We largely eat nowadays
+because of a desire to eat,
+not a need to eat,
+and yet we need to eat on
+a fairly regular basis.
+And so no topic is more complicated
+and nuanced than food and nutrition.
+And in particular, as it
+relates to eating disorders.
+So, the major takeaways today are,
+we should all be asking the question,
+what is healthy eating for us?
+How do we develop a relationship
+to food that we can enjoy
+food, hopefully both socially
+and on our own, but
+that we are not neurotic
+and compulsive about it.
+For those of you that intermittent fast,
+this also applies, right?
+What, you know, God forbid,
+if you eat 30 minutes before
+your eating window starts,
+what does that mean?
+If it means something catastrophic,
+do you have an eating disorder?
+I don't know.
+Maybe you have an anxiety disorder,
+that's for you to explore.
+If you don't manage to
+eat five meals a day
+and that's your obsession.
+Well, then, you know,
+the same thing applies.
+These are questions that
+we can all ask ourselves.
+Today, we focus on the extremes
+of food related behaviors
+that really qualify as genuine disorders.
+They are in the psychiatric
+manuals and they are diagnosable
+and they are serious health concerns.
+They're not just mentally
+troubling and concerning
+for the people suffering from them
+and the people around them,
+but they are genuine health concerns,
+just want to reiterate,
+that interaction nervosa is
+the most deadly psychiatric
+disorder by a huge margin.
+And if you look
+statistically at the number
+of people with eating
+disorders and that die
+of eating disorders,
+it's not far off from the number of people
+that die from automobile accidents.
+I know that that sounds
+like a ridiculous number,
+but you can look this up.
+This is particularly true in
+certain countries, why that is,
+we don't know, but again,
+this is not a new phenomenon.
+This is not just related
+to body image issues
+that are created through social media.
+And as a final point on that,
+many of you are probably asking
+what about plastic surgery?
+What about all the steps that
+people are going through?
+Excuse me, to preen themselves
+and change themselves.
+Are people addicted to plastic surgery?
+Is that a form of body dysmorphia?
+And indeed it is.
+And so we will do an
+episode on exercise related
+and plastic surgery
+related body dysmorphia.
+I think there is very little
+question that those types
+of disorders are clearly
+related to what we're observing
+in social media and in media,
+that this shift of, for
+instance, action heroes.
+If you look at action heroes in the '80s,
+there were very few men
+that were very large.
+You had your terminate,
+you had your stallone's
+in your shorts and eggers
+and a few others, but the
+men in movies tended to be,
+if they were muscular,
+they were far more
+svelte than they are now.
+There's this kind of, there's a,
+literally a hypertrophy of the imagery.
+And likewise there's been hypertrophy
+of the female body shape.
+As it's portrayed in the media.
+There are body dysmorphia that are related
+to those types of things.
+And that relate to things
+like plastic surgery,
+steroid abuse, diet,
+drug abuse, and so on.
+Definitely important to
+think about and consider,
+and definitely deserving
+of its own episode.
+You've learned a lot
+of neuroscience today.
+I hope that was useful in
+thinking about these disorders
+and in thinking about
+other aspects of feeding
+and motivated behaviors,
+I would love for you
+to take away this model
+that was handed off to me,
+that I think is so powerful for thinking
+about all sorts of
+things, not just eating,
+but all kinds of behaviors and perceptions
+that you have one box for what you think,
+one box for what you do
+and what is intervening between those?
+Why is it that you can know
+better and not do better?
+Well it's because you also have to cope
+with the subconscious
+homeostatic processes
+and reward processes.
+And those oftentimes
+can be disrupted in ways
+that we find ourselves doing
+things that are not good
+for us or not good for other people.
+But fortunately, there is this great gift,
+which is that knowledge
+of knowledge can allow you
+to do better without question.
+And that knowledge of knowledge
+allowing you to do better
+over time leads to this
+incredible phenomenon
+called neuroplasticity, which
+essentially is translated
+into doing better over time.
+Even if difficult eventually
+makes doing better reflexive.
+If you're enjoying this
+podcast and learning from it,
+please subscribe to our YouTube channel.
+That's Huberman Lab on YouTube.
+And there, you can also leave
+us comments and feedback
+and suggestions for future
+topics and future guests
+for the Huberman Lab Podcast.
+As well we hope that you will subscribe
+on both Apple and Spotify and on Apple,
+you have the opportunity to
+leave us up to a five star
+review and to give us
+feedback there as well.
+Please also check out
+the sponsors mentioned
+at the beginning of the podcast,
+that's a terrific way
+to support the podcast.
+And if you'd like to
+support research on stress,
+human performance, sleep and so forth,
+you can go to a hubermanlab.stanford.edu.
+And there there's a
+tab that you can click.
+If you'd like to make a
+tax deductible donation
+to the laboratory,
+to explore the sorts of things that relate
+to neurocircuits stress,
+sleep and human performance.
+Not today, but oftentimes on this podcast,
+we discuss various
+compounds and supplements
+that people could possibly
+take in order to help deal
+with anxiety, improve gut microbiome,
+improve their sleep, et cetera.
+We didn't discuss those today,
+but for those of you
+interested in those compounds,
+if you want to see the ones that I take,
+you can go to Thorne that's T-H-O-R-N-E
+.com/the letter U/huberman.
+So, it's thorne.com/u/huberman.
+See all the supplements that I take,
+you get 20% off any of those supplements.
+And if you enter the Thorne
+site through that portal,
+you can get 20% off any of the
+supplements that Thorne makes
+we partnered with Thorne
+because they have the highest levels
+of stringency with respect to
+the quality of ingredients,
+the precision of the amounts
+of those ingredients.
+And while supplements are
+certainly not required
+or necessary for anything really,
+you can always use behavioral tools.
+Many people benefit
+from taking supplements
+of various kinds.
+And we do believe that getting supplements
+of the very highest quality
+is going to be important
+if that's the decision for you.
+And last but not least,
+I want to thank you for
+your time and attention.
+And thank you for your
+interest in science.
+[fast-paced music]
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