Swedish scientists say that eating disorders should be considered just that – eating disorders, rather than mental disorders. The proof, they say, is in the eating.
‘Anorexic patients can learn to eat at a normal rate by adjusting food intake to feedback from a smartphone app,’ says Per Södersten, Professor at the Karolinska Institute and lead author of an article in Frontiers in Neuroscience defending his pioneering method. ‘And in contrast to failing standard treatments, most regain a normal body weight, their health improves, and few relapse.’
The approach is based on the theory that slow eating and excessive physical exertion, both hallmarks of anorexia, are evolutionarily conserved responses to short food supply that can be triggered by dieting – and reversed by practising normal eating.
Which came first: the diet or the anorexia?
Attempts to treat anorexia as a mental illness have largely failed, claim the authors.
‘The standard treatment worldwide, cognitive behavioural therapy (CBT), targets cognitive processes thought to maintain the disorder,’ explains Södersten. ‘The rate of remission from eating disorders is at most 25% one year after CBT, with unknown outcomes in the long-term. Psychoactive drugs have proven even less effective.’
Instead, they say, we need to flip our perspective: to target eating behaviours that maintain dysfunctional cognitive processes.
‘This new perspective is not so new: nearly 40 years ago, it was realised that the conspicuous high physical activity of anorexia is a normal, evolutionarily conserved response – for example, foraging for food when it is in short supply – that can be triggered by dietary restriction.
‘In striking similarity to human anorexics, rats and mice given food only once a day begin to increase their running activity and decrease their food intake further to the point at which they lose a great deal of body weight and can eventually die.’
More recently, the theory has been elaborated and validated by studies of brain function.
‘We find that chemical signalising in the starved brain supports the search for food, rather than eating itself,’ reports Södersten.
How to eat
To prove that the evolutionary perspective works in practice, Södersten and his team have put their money where their (patient’s) mouth is. Their private clinics – which reinvest 100% of profits into research and development – are now the largest provider of eating disorders services in Sweden.
‘We first proposed teaching anorexics to eat back in 1996. At the time, it was thought that this was misplaced and even dangerous; today, no one can treat patients with eating disorders in Stockholm without a programme for restoring their eating behaviour.’
‘Subjects eat food from a plate that sits on a scale connected to their smartphone. The scale records the weight loss of the plate during the meal, and via an app creates a curve of food intake, meal duration and rate of eating,’ explains Södersten. ‘At regular intervals, a rating scale appears on the screen and the subject is asked to rate their feeling of fullness.’
‘A reference curve for eating rate and a reference curve for the feeling of fullness are also displayed on the screen of the smartphone. The subject can thus adapt their own curves in real time to the reference curves, which are based on eating behaviour recorded in healthy controls.’
Through this feedback, patients learn to visualise what normal portions of food look like and how to eat at a normal rate.
The method has now been used to treat over 1,500 patients to remission by practising eating.
‘The rate of remission is 75% on average of one year of treatment, the rate of relapse is 10% over five years of follow-up and no patient has died.’
This appears to be a vast improvement compared to the current best standard treatment of CBT. All the more so, considering that overall Södersten’s patients started off sicker than average.
‘The difference in outcome is so big that, according to our medical statistician, a randomised control trial [RCT] is now redundant. Nevertheless, we invite a head-to-head RCT by independent researchers – so far, there are no takers.’