Let’s talk about neurotransmitters.  Specifically, dopamine and serotonin, the “reward” and “feel good” chemicals in the brain that are inextricably intertwined with our perception of appetite.  Appetite is about so much more than just hunger or our need to fuel our bodies.  Appetite is emotional regulation, stimulated by powerful emotions and our baseline psychological state.  Appetite is also a product of social intercourse.  Stress initiates the release of cortisol, which also stimulates appetite, and so we quickly reach for a sugary snack like a donut to calm our nerves and sedate us, sometimes fragmenting into common eating disorders such as bulimia and anorexia nervosa.

During my employment as a Clinical Nutritionist at a medical weight loss clinic for just over a year, I quickly learned that most folks whom I was counseling did not primarily struggle with hormonal or metabolic derangement, they suffered from psychiatric disorders connected with food.  They did not really need my help to tell them what to eat. They already knew that the foods they were eating were bad for them.  Their appetite was driven by depression and anxiety, not hunger or a caloric energy deficit.  Most of them were also obese, which is etiologically driven by the underlying comorbidities of Metabolic Syndrome, further exacerbated by insulin and leptin resistance resulting in dysregulation of grehlin and leptin signaling.  These individuals facing psychosocial obstacles to healthy eating required interventional treatment by a qualified psychiatric professional in close collaboration with myself and the Functional Medicine physician who was my employer at the time.

Personally, whenever I feel hungry, aka a “healthy appetite”, the first question I always ask myself is simply:  “Am I truly hungry or just bored and depressed?”  Or maybe I’m just confusing hunger with thirst (another often overlooked factor).  “Appetite” is a loaded word.  Take for example the French tradition of the aperitif, which I clinically define as choosing to become slightly inebriated and spike one’s blood glucose in an effort to artificially stimulate appetite prior to a meal.  I’m pretty sure that our hunter-gatherer ancestors did not enjoy the luxury of consuming an aperitif before they went on a hunt for bison.  We can ramble on and on about advanced concepts of nutrition and metabolism as science, but the reality is that there is much more to appetite than biochemistry!  When we reach for a bag of potato chips or a tub of ice cream, we are motivated by our reptilian brain, not our higher brain functions that know full well how bad those substances are for us.  It’s about “comfort foods” and instant gratification, gluttony and sloth, a salve on our emotional wounds.  I therefore unashamedly propose a politically incorrect hypothesis, i.e. that most obese unhealthy people don’t need a nutritionist.  What they really need is a good psychiatrist!  I wonder if it’s too late for me to get a dual Masters in Nutrition and Psychology?


Ready for a change?

I wish to posit that any realistic change talk needs to be implemented contextually within the linear framework of the ‘Stages of Change Model’ of health behavior change.  If there is anything of any value that I have gleaned from my forays into nutrition counseling, it is that different clients react differently to elicitations for change within change talk modalities, depending upon where they are personally positioned in their stages of change at any given point in time.

A classic example of this principle was a client of mine a few years back who had just started working at his “dream job”, following a long period of unemployment that had lasted over a year, during which time I was able to help facilitate his transition from a sedentary junk-food lifestyle to an active healthy way of living and eating, in the process of which he had lost about 35 pounds of body fat, acquired greater energy, and was feeling better about himself in general, which may have been a contributing factor in successfully getting back onto his career path.  However, due to the pressures and time constraints imposed on him by his new job, he had slipped back into old ways and was starting to regain the weight that he had lost.  I would postulate that he had, within the expanded context of the Stages of Change model, relapsed from the ‘Action Stage’ back to the ‘Preparation Stage’, thus altering his linear relationship to the Stages of Change model.  But it also occurred to me that, when I first started working with him, I was not yet educated on the psychological counseling strategies of Motivational Interviewing (MI), which I later learned about during my grad school studies.  What I had done with this client was basically akin to well-meaning directing and bullying him into making changes in diet and lifestyle that did not originate from his own internal desire to change, hence any weight loss and improvements in his health were merely a temporary elusive accomplishment at best.

The aforementioned client was a great guy with tons of good intentions, but equipped with little in the way of concrete time-bound commitments to change.  I ran into him recently at a Costco and he told me that he is “genuinely happy now” and that he no longer sees much value in going back to the “Spartan diet and lifestyle” (as he calls it) that he had adopted when I was counseling him, known in Motivational Interviewing as ‘Sustain Talk’, not to be confused with ‘Change Talk’.  He acknowledged to me the value of weight loss and improved health, but he now questions his ability to change and can only seem to think of one good reason to change, i.e. “to get my wife off my back”, as he told me, and he realizes that he needs to change, because he understands that if he loses his health, he will also lose the new job that he loves so much, as well as respect and admiration from his wife.  Nevertheless, he has managed to rationalize his regression into unhealthy habits by stating that “this is just not a good time for me to get back on the program” (more Sustain Talk).

The greatest challenge for me, as a Nutrition Counselor, is to effectively elicit, via empathy and compassion, the three key components of Change Talk implementation: Commitment, i.e. “I will make changes”, Activation, i.e. “I am ready and fully prepared for change”, and Taking Steps, i.e. “I am taking specific actions to change right now”.  We know that we are truly ready for change when we do it because it is what we want, instead of a behavior that a clever counselor manipulated us into doing.  So before you try to talk someone that you care for (including yourself) into adopting a healthier diet and lifestyle, first make sure to accurately pinpoint their current location on the Stages of Change model.  Change is analog, not digital!


Do you hate some part of your body or know someone who does?

Body dysmorphia is a common psychiatric disorder that is the underlying cause of numerous medical conditions consistent with but distinct from eating disorders such as anorexia nervosa and bulimia.  The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) defines Body Dysmorphic Disorder (BDD) asa mental disorder characterized by the obsessive idea that some aspect of one’s own appearance is severely flawed and warrants exceptional measures to hide or fix it.”  It is distinguishable from the self-perception aberration of anorexia nervosa in that anorexics perceive themselves as fat overall, even when they are extremely skinny, whereas dysmorphic disorder involves a repetitive focus on a specific perceived flaw in your physical appearance, such as your nose or the shape of your hips.

An interesting example of this psychiatric problem can be illustrated anecdotally through the story of a personal training client of mine a few years back who was absolutely convinced that no matter how much mass he added to his biceps and triceps, he saw his upper arms as never being “big enough”.  Eventually, his arms got up to over 20″ in diameter, which was glaringly disproportionate with the rest of his body (he had skinny legs).  The worst part of this is that he was taking large doses of anabolic steroids to fuel his dysmorphic obsession, which eventually resulted in liver cirrhosis.  Sadly, I heard recently from a former colleague that he is now on a liver transplant wait list.  As you can see from my story, what we see in the mirror versus what others see when they look at us, can have devastating health implications, even the lesser-discussed conditions such as body dysmorphia.

If you think that maybe you think too much about a specific part of your body, please don’t go down the ‘Michael Jackson rabbit hole’.  Seek out the help of a mental health professional, without the slightest hint of shame or hesitation.  Trust me when I say that all of us have some psychiatric issue that we’re dealing with, whether we recognize it or not, whether we admit it or not.  In a crazy world, it’s perfectly normal to go just a little bit crazy, as long as your craziness doesn’t end up damaging your health!