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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
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-Our first sponsor is Belcampo,
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-breakfast or for lunch.
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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.
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