Renee McGregor Support

Lockdown Stories


Life is hard right now; the lockdown continues. While there have been some relaxing of the rules, social distancing is very much here to stay for the foreseeable future. While we have been told to “be alert”, the threat from the invisible prey, Covid-19, is still very much present with still no real light at the end of the tunnel and a shift towards a “new norm” that none of us can really get our heads around. 

2020 will always go down as the year that we all look back on and remind ourselves to be grateful for our freedom. 

All around the world people are suffering; those who are ill, those who are working on the frontline, those who are delivering the avalanche of parcels being ordered as all non-essential shops remain closed. Those working in supermarkets, teachers who are trying to educate from a distance while also supporting parents having to take on the primary role of a teacher. Then there are those who have lost their jobs, those who are living in fearful relationships or abusive households and those who are homeless. Very few homes are harmonious right now.

From my small corner of the country, running my clinic from my kitchen table over a laptop, in my cottage, I hear and see the pain in those I work with. 

While understandably, we have been focusing on reducing the infection rate and following the motto to “stay home and stay safe”, little thought has been given to the long term implications of all these strategies on mental health, let alone to those who are in the midst of an illness.

We are all living our own story and in these unprecedented times, it can probably feel like, “survival of the fittest” or maybe even, “ I’m staying at home, so I’m doing my bit” with little thought to those that are experiencing this pandemic with heightened anxiety. 

Eating disorders and/or exercise dependency, are misunderstood at the best of times, but the lack of empathy and concern I am witnessing during this global pandemic has truly saddened me. 

An eating disorder is a coping mechanism; it is a method of denying difficult and uncomfortable emotions. A way of maintaining order when life feels chaotic. Food and exercise become the medium by which they express their discomfort, while at the same time a method of creating order; where the pursuit of achieving body image “ideals” is a way to try to attain approval and a sense of worth, when they can’t get this from anywhere else in their life. 

It is important to appreciate that most people with an eating disorder have low self-esteem. 

We are all born with self assurance but we can lose it through our experiences and interpretations at the different stages of development we go through. 

Eating disorders are very ritualistic, even those like binge eating disorders as there is often careful planning that goes into creating the space and environment to binge. Remember they provide order when life feels far from it. These rituals become a learnt behaviour, that then becomes the norm so that the individual can’t separate from the fact it feeds into their low self worth. The real problem with creating such rigid rules is that change becomes hard because the anxious mind becomes catastrophic. This is one of the reasons why so many of the people I have worked with have found the lockdown so difficult. Literally overnight, our lives changed. Those who have to live by strict routines, thrown into a complete sense of chaos. This heightened anxiety drives the need for “order” further which is why so many of the individuals I have worked with have found themselves becoming even more extreme in their behaviours around food and exercise. 

Another big challenge I have had to work through during this lockdown with many clients is social comparison. In general, if you think about the types of accounts you tend to follow on social media, they will probably all follow a similar theme. So, to a certain degree, your social media acts as an echo chamber for the messages you probably already believe in. This is particularly true for those with low self worth and disordered behaviours around food and exercise; it is a method to seek out the accounts that validate and maintain their behaviours. 

In addition, these same Individuals are continually upwardly comparing themselves with everyone else. We are living during a time where we have extra opportunity to scroll through social media, and with so many people posting about what training they are doing, as well as the ample provision of online workouts, it feeds into their self critical mindset. 

“I am not enough, I am not doing enough, I must do more” with no thought to the fact that their poor bodies are already being punished more than enough or that what is being posted is only a snapshot of that individual’s day. This is the key issue with so many with an eating disorder, they cannot see that their constant pursuit for “happiness, completeness, success” is unrealistic because life is not linear, it is more like a scatter diagram. They have never learnt how to deal with difficult emotions and so they continually run from them, not appreciating that it’s the lack of self acceptance that is fundamentally their cause of disease. 

For the most part, these last few months in clinic have been no different, providing a space for clients where there is no judgement and helping to manage their anxieties about food, exercise and body image. However at the same time, it has been a real opportunity to also help them explore their issues with uncertainty – that constant need to know, and get it right because what better way to teach than during a time when we really have no actual experience of answers of what lies ahead.  

It has also been about helping them to see that they are not defined by their past. Life happens to them but it doesn’t have to become them or their fate. 

It’s been about demonstrating that life is unpredictable; it almost comes at you like waves. The ideal scenario is that with each receding wave, we should let a little more go. A life free of regret and grudges is definitely simpler and less painful than one where you hold onto them but letting go is also easier said than done. 

In reality when we talk about “letting go” we are talking about becoming more forgiving and generally directing that forgiveness towards ourselves. It is a regular conversation I have with my clients…

“Next time you find yourself berating yourself, change your response and be more forgiving.”

We discuss how life is not permanent and we all have the power to change our narrative to one that involves self acceptance and compassion. However, more importantly, to really move forwards in the process of recovery, we have to embrace the fact that,

“Discomfort is the price of admission to a meaningful life”

-Susan David.  

ED and the Brain

 

Research has found that disrupted eating behaviours such as anorexia, bulimia, binge eating and orthorexia can reduce the volume of gray and white matter in a patient’s brain. This can cause issues such as increasing the likelihood of developing neurological symptoms, difficulties thinking and setting priorities, and also affecting emotional centers of the brain. As we review more research, it is increasingly apparent that hormonal restoration as well as nutritional rehabilitation are vital for recovery.

The Research

One study by Roberto and colleagues (2010) used MRI techniques to compare the brains of anorexia nervosa sufferers before and after their treatment, to women without the disorder. Their results showed that : “The correlation between BMI and volume changes suggests that starvation plays a central role in brain deficits among patients with AN, although the mechanism through which starvation impacts brain volume remains unclear.”

Another by Wagner and colleagues in 2005 looked at 40 women’s recovery from both anorexia and bulimia, over a longer term. The length of recovery ranged from 29 to 40 months, and showed that after weight restoration and nutritional rehabilitation, the brain structures of the recovered women were at the same volume as the control subjects.

The University of RWTH Aachen conducted a study in 2016 comparing the differences in grey and white matter loss between adolescents and adults suffering from AN. Researchers used meta-analysis to review 849 MRI studies. The results showed that adolescents with anorexia had a significantly greater reduction in grey matter than adults. These results have found a much higher risk of disruption in adolescents, as much of the brain’s growth occurs at this age, and disturbance has a greater negative effect. There was not enough data from adolescents to determine if long term recovery can be as complete as it is within adults, so we must remain cautious in this area.

 

Finally, a study from Chui and colleagues (2008) used cognitive tests as well as MRI scans to gather data from 66 adult women who had experienced AN in their adolescence, compared with 42 control subjects. Again, they showed that participants that had remained underweight had abnormal MRI scans. The participants who had AN from adolescence also reported more symptoms of OCD and depression, and exhibited high cortisol levels. Crucially, when the cognitive tests were run, they showed the relationship between the absent or irregular menstrual function and cognitive function. Patients who had recovered gray matter but were absent menses were still exhibiting lower than healthy patients in verbal ability, cognitive efficiency, broad reading, broad math, and verbal recall.

 

Fig. 02 taken from the Chui study.

The influence of menstrual function on cognitive performance is also a feature in research on the menopause, although the mechanisms of the effect are unclear. It is possible that estrogens ability to increase blood flow in the brain makes this difference, as it has been documented that cerebral blood circulation increases in women receiving estrogen replacement therapy.

Recovering the Brain

 

As we can see from the research above, there is a complex relationship between hormonal health, weight and brain structure as well as function. The studies have established that long term recovery can range depending on the duration and severity of the disorder, but the type of disorder does not seem to affect the amount of damage incurred, or the recovery attainable. Following that, menstrual restoration, if maintained, seems to lead to full cognitive function after at least six months. Menses may begin to be seen as a more important marker for brain healing in the future, but there is much more we need to know. Males are woefully underrepresented in eating disorder research at present, although there is precedent to suggest testosterone restoration will have a similar effect in recovery. There is also not enough data from eating disorder sufferers in the older population, and with over 65’s in the UK unable to access some NHS clinics (as reported in the BBC recently) it is obvious that strides need to be made in these areas.

Jake Rollings

Renee Mcgregor Practice Manager

 

References:

 

Chui, H.T., Christensen, B.K., Zipursky, R.B., Richards, B.A., Hanratty, M.K., Kabani, N.J., Mikulis, D.J., Katzman, D.K., 2008. Cognitive function and brain structure in females with a history of adolescent-onset anorexia nervosa. Pediatrics 122, e426-437. https://doi.org/10.1542/peds.2008-0170

Roberto, C.A., Mayer, L.E.S., Brickman, A.M., Barnes, A., Muraskin, J., Yeung, L.-K., Steffener, J., Sy, M., Hirsch, J., Stern, Y., Walsh, B.T., 2011. Brain Tissue Volume Changes Following Weight Gain in Adults with Anorexia Nervosa. Int J Eat Disord 44. https://doi.org/10.1002/eat.20840

Seitz, J., Herpertz-Dahlmann, B., Konrad, K., 2016. Brain morphological changes in adolescent and adult patients with anorexia nervosa. J Neural Transm 123, 949–959. https://doi.org/10.1007/s00702-016-1567-9

Wagner, A., Greer, P., Bailer, U.F., Frank, G.K., Henry, S.E., Putnam, K., Meltzer, C.C., Ziolko, S.K., Hoge, J., McConaha, C., Kaye, W.H., 2006. Normal brain tissue volumes after long-term recovery in anorexia and bulimia nervosa. Biol. Psychiatry 59, 291–293. https://doi.org/10.1016/j.biopsych.2005.06.014

How eating disorders affect the neurobiology of the brain, 2015. . The Emily Program. URL https://emilyprogram.com/blog/how-eating-disorders-affect-the-neurobiology-of-the-brain/ (accessed 10.25.19).

RED-S research: bones and ballet

Suboptimal bone health with associated recurrent stress fractures can be career ending for athletes and dancers. Bone stress injuries, including stress fractures and other complications of suboptimal bone heath such as compression fractures are some of the most clinically significant sequalae of low energy availability described in the Relative Energy Deficiency in Sport (RED-S) clinical model[i].

Early identification of those with suboptimal bone health is crucial. In terms of identifying athletes/dancers at risk of developing bone health consequences due to RED-S, a sport specific questionnaire in male cyclists has been demonstrated to be effective[ii]. The purpose of identifying those at risk of suboptimal bone health is in order to put in place interventions, to prevent progression, and in some cases, improve bone health. Evidence for positive outcomes of these behavioural interventions are reported in male cyclists[iii].

Currently bone mineral density (BMD) is measured using Dual X ray Absorptiometry (DXA), which is low in dose and involves ionising radiation. This limits the frequency of measurement, even though bone is metabolically active and often one of first systems to change in response to low energy availability[iv]. The new technology of Radiofrequency Echographic Multi Spectrometry (R.E.M.S.) involves use of an ultrasound and provides information on bone microarchitecture. Currently assessment of bone microarchitecture is only possible with peripheral Quantitative Computerised Tomography (pQCT), which not only uses a high radiation dose, but is also limited to assessment of peripheral skeletal sites. Even though BMD is undoubtedly an important factor in determining bone health, bone strength and structure also plays an important part.

Given this, main objective of a forthcoming study[v] is to establish the effectiveness of identifying those at risk of suboptimal bone health with this new specialised ultrasound based technology and correlate with questionnaire and blood markers in both athletic and non athletic populations.

Ballet and other dance forms

RED-S is more prevalent in sports where having a low body weight confers a performance or aesthetic advantage. Although dance is not a sport, it is a type of activity which requires low body weight from both a performance and aesthetic point of view for both male and female dancers. Dance training often starts at a young age[vi] and as with early sport specialisation, there is an increased risk of developing low energy availability during this time of high-energy demand for growth and development[vii]. So much so, that this situation can have a negative impact on accumulation of peak bone mass and adverse potential long-term effects[viii].

Although there is a validated questionnaire LEAF-Q[ix] for assessing low energy availability in female athletes, this excludes half the population and is not sport specific. A questionnaire-based study amongst female athletes was found to be effective at identifying and quantifying the clinical consequences of low energy availability[x]. Our recent study of competitive male road cyclists found that a sport specific energy availability questionnaire combined with interview (SEAQ-I)[xi]was the measured factor most effective in indicating low BMD of the lumbar spine. BMD of the lumbar spine is a quantifiable measure of chronic low energy availability. Other objective measures of low energy availability include indicators of endocrine function. In women menstrual function and in men testosterone, which in turn are linked to the clinical outcome of impaired bone health and stress fracture in runners[xii]

To date, there is a dearth of sport specific questionnaires to assess low energy availability and none that are dance specific. Dance involves both male and female and is certainly a type of activity where individuals are at risk of low energy availability and the clinical consequences of RED-S. Therefore the aim of the current dance study is to use a dance specific energy availability questionnaire (DEAQ)[xiii]to asses awareness, risk factors and consequences of low energy availability and RED-S.

 

***

Dr. Nicky Keay (@nickyKfitnessBA, MA (Cantab), MB, BChir, MRCP. Honorary Fellow Dept Sport and Exercise Sciences, Durham University.

References

[i]Mountjoy M,Sundgot-Borgen J,Burke L et al. IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 updateBritish Journal of Sports Medicine 2018; 52(11): 687-697DOI: 10.1136/bjsports-2018-099193

[ii]Keay NFrancis GHind K. Low energy availability assessed by a sport-specific questionnaire and clinical interview indicative of bone health, endocrine profile and cycling performance in competitive male cyclistsBMJ Open Sport and Exercise Medicine2018; 4(1)DOI: 10.1136/bmjsem-2018-000424

[iii]Keay N,Francis GEntwistle Iet al.Clinical evaluation of education relating to nutrition and skeletal loading in competitive male road cyclists at risk of relative energy deficiency in sports (RED-S): 6-month randomised controlled trialBMJ Open Sport and Exercise Medicine 2019; 5(1)DOI: 10.1136/bmjsem-2019-000523

[iv]Professor Louise Burke presenting at annual ISENC conference Newcastle 2018

[v]Assessment of Echographic Technology in Measuring Bone Health in the Clinical Setting

[vi]N. Keay. Dancing through adolescence British Journal of Sports Medicine 1998 DOI: 10.1136/bjsm.32.3.196

[vii]N. Keay. The modifiable factors affecting bone mineral accumulation in girls: The paradoxical effect of exercise on bone Nutrition Bulletin 2000 DOI: 10.1046/j.1467-3010.2000.00051.x

[viii]N. Keay, G.Blake, I. Fogleman.  Bone mineral density in professional female dancers British Journal of Sports Medicine 1997;31(2): 143-147. DOI: 10.1136/bjsm.31.2.143

[ix]Melin A, Tornberg Å, Skouby S et al. The LEAF questionnaire: A screening tool for the identification of female athletes at risk for the female athlete triad British Journal of Sports Medicine2014: 48 (7)

[x]K. Ackerman, B. Holtzman et al. Low energy availability surrogates correlate with health and performance consequences of Relative Energy Deficiency in Sport British Journal of Sports Medicine 2018; 53(10) 628-633. DOI: 10.1136/bjsports-2017-098958

[xi]N. Keay, G. Francis, K. Hind. Low energy availability assessed by a sport-specific questionnaire and clinical interview indicative of bone health, endocrine profile and cycling performance in competitive male cyclists BMJ Open Sport and Exercise Medicine 2018 4(1) DOI: 10.1136/bmjsem-2018-000424

xHeikura I,Uusitalo AStellingwerff T et al. Low energy availability is difficult to assess but outcomes have large impact on bone injury rates in elite distance athletes,International Journal of Sport Nutrition and Exercise Metabolism 2018; 28(4): 403-411DOI: 10.1123/ijsnem.2017-0313

[xiii]DEAQ Dance Energy Availability Questionnaireon line with ethical approval from Durham University