What Are We Really Weighing?

This past week I’ve had a lot of clients bring up their scales. And it made me wonder, with household scales, whether for body weight or for weighing food, what are we really weighing? And how do the numbers on a scale potentially serve as fillers for something deeper that perhaps cannot be measured so easily?

When we’re out of touch with what we’re feeling, sometimes we unconsciously seek ways to express those feelings. And the scale could be one such way. Because a scale is concrete science, right? I had to look up the actual definition of weight, which reads: Weight is the measure of a body's relative mass or the quantity of matter contained by it, giving rise to a downward force; the heaviness of a person or thing. So we’re essentially measuring our own heaviness and what we contain.

I don’t know about you, but I use the word heavy to describe a mood sometimes, or even to describe the state of the world, or to express the impact of some piece of unsettling or unpleasant information - that’s really heavy, I might say. Could we be using the scale to measure how heavy we feel in relation to something, perhaps even something intangible or so far, unknowable? And if the number on the scale goes down, it often lightens our mood too, right? We’re both objectively and subjectively “lighter”.

What about measuring what we contain? What if we could measure or quantify our emotions: Our anger, our sadness, our pain, our loneliness, on a scale, making it visible, and tangible? Could that be partially what we’re attempting when we weight ourselves? It can be terribly disappointing to see what we contain - all of our doubts and fears and aggression and destructiveness and narcissism - all normal human traits that tend to bring us shame and guilt, that we are generally pretty careful to keep at bay and hidden from public view, sometimes hidden from our own view. And sometimes we say, “the scale doesn’t lie” and maybe that’s the inherent dilemma of the scale: It captures our “heaviness” even when we try to hide it from view.

On a practical level, the scale is also measuring what we’ve taken in - food scales can capture and regulate how much we take in to ourselves. And the body weight scale captures the aftermath: What we’ve allowed in or haven’t allowed it. And if we’re trying to keep something, or someone, out, out of fear of being hurt, being vulnerable, being overwhelmed, being intruded upon - then it makes good, logical sense we might attempt to regulate that and then try to see how well we’ve done. This is one reason why I do not necessarily encourage clients to get rid of their scales right away - they are often serving a psychically important purpose, serving as a reliable safety mechanism of sorts. And ripping off a bandaid is good way to leave a gaping wound before it has had sufficient time to heal and time to explore alternative ways to protect oneself.

When we are looking at a body weight scale, I sometimes wonder if it matters what the client is actually measuring. For instance, if we cut our hair or even use the restroom before weighing, that number would go down. So it’s not necessarily always about measuring fat loss - which is what clients typically report wanting to lose in the name of health and wellbeing. Gaining or losing fat weight cannot happen in a matter of hours or days. So any number that changes on a scale that quickly is not measuring fat. More frequently the scale is measuring water fluctuations. And the water content of our bodies is constantly shifting - relative to how hydrated we are, relative to how much water we’re storing in our cells and in our muscles at any given moment, relative to how our bodies respond to being awake or asleep for extended periods of time - but the number is not reflecting fat gain or loss.

Water is stored in the muscles and in the liver alongside something called glycogen, which is the storage molecule for glucose, or energy. So when we have glycogen on hand for quick energy needs - which is a good thing from a biological perspective - we automatically store more water too. So relying on the number on the scale to indicate fat can actually backfire and make people think they need to restrict more, which can cause that number to fluctuate even more with increased dehydration and lack of glycogen stores, perpetuating the myth that fat is being lost. A good dietitian can help discern the difference and explain what is actually happening in the body when we see numbers shifting on a scale. Trying to interpret this alone can be a recipe for a going down a rabbit hole that can be difficult to climb out of solo.

Essentially what I am suggesting is that the pursuit of weight loss according to a scale is the surface layer of a much more complex, emotional pursuit. When clients come with the wish for weight loss, often we will address the short- and long-term risks, rewards, and consequences of these pursuits  We all know weight can be lost through a variety of avenues these days - that is generally not in question. But what can also be examined are the longings, wishes and desires behind this pursuit, as well as some basic biologic education that can ultimately help us understand how we might be helping or hurting ourselves in the name of health.

Treating eating disorders through a psychodynamic lens as a dietitian

I practice “nutrition therapy” a term that can leave a lot to the imagination without a more thorough explanation of the work I do with clients. I am trained and licensed Registered Dietitian Nutritionist for 18 years, having gone through all the required schooling, internships, exams, and continuing education to qualify as such.

Like most professions, this title affords me a specific scope of practice that includes providing nutrition monitoring based on labs and vitals, and nutrition recommendations based on the most current, peer-reviewed research, and based on the disease state of my clients. Nutrition recommendations may include caloric-intake, specific types and categories of foods, meal- and snack-ideas, and grocery shopping strategies, among others.

But when it comes to treating eating disorders, nutrition therapy extends beyond basic day-to-day needs and encompasses complex psychological underpinnings that often require more than traditional nutrition advice. To this end, I am also a Certified Eating Disorder Specialist (CEDS) through the International Association of Eating Disorder Professionals (iaedp), having also completed 2500 supervised hours and the required education, case studies, and examinations.

As a CEDS, I have additional knowledge of the medical complications and psychological factors influencing eating disorder clients, and of more tailored treatment approaches. In the later stages of eating disorder recovery, I may introduce Intuitive Eating strategies as a way to tailor feeding needs to each unique individual, guiding clients to attune to their body’s hunger and fullness cues to determine how much and which foods to consume on any given day.

But even beyond these strategies lies the client’s mind, a rich and meaningful realm that informs every food decision, far more powerfully than any strategy or advice I could give. The opportunity then is to help the client explore their own mind, and my role in it, to help them understand and work through resistances to improving their relationship with food and body, and to understand and work through resistances to me assisting in this process.

This is operating all the time in sessions, whether it is directly discussed or even consciously understood. Indeed, my intention in any session is to hear what the client is saying while simultaneously feel what is not being said or voiced. For instance, many clients with eating disorders begin our work together by requesting a meal plan in the very first session, and if I were to grant this request without hesitation or examination, it often sets up a power dynamic that stalls rather than progresses the treatment.

Instead I might start by asking how the client imagines a meal plan would be helpful, who should create this meal plan, how would I know if they didn’t like or agree with the meal plan, what would happen if the meal plan could not be followed. The goal is to allow for any unconscious resistances to be worked through before taking the ultimate action - sometimes actually co-creating a meal plan, but other times a different, more creative strategy and understanding evolves out of the conversation. This is the “psychodynamic” aspect of my work: Relational, resistance-focused, and creatively-minded.

In order to help me understand my clients and my work through this comprehensive lens, I have completed a 2-year Certificate Program through the Center for Modern Psychoanalytic Studies in New York City, and continue to take continuing education classes at this institute and other similar ones, including the Academy of Clinical & Applied Psychoanalysis in Livingston, New Jersey. I also continue my own modern psychoanalytic supervision under a trained analyst, as I have done for the past 18 years.

Modern Psychoanalysis/Psychodynamic work can be defined as an opportunity to make (often limiting) unconscious attitudes, beliefs, and patterns conscious so they can be worked through and client goals can be more readily and realistically attained. I hold this understanding in my mind when I work with clients to offer nutrition therapy.

Bully ON the Block: Mast CEll Activation Syndrome and Its Implications for the Eating Disorder population

It’s no secret that immersion in and recovery from an eating disorder typically brings a host of physical discomforts, including gastrointestinal distress, mood shifts, bodily aches, and other ailments. But what is becoming more clear in recent literature is that these conditions are not necessarily driven by the eating disorder alone; in 20-25% of cases, they may also be indicative of an underlying immune condition called Mast Cell Activation Syndrome that afflicts the eating disorder population in numbers larger than the general population.

What is Mast Cell Activation Syndrome?

Mast Cell Activation Syndrome (MCAS) is a disruption in the normal functioning of the immune system where a type of immune cells, called mast cells, release larger than normal amounts of chemical mediators, or histamines, in response to a variety of external stimuli, including food, stress, and other environmental factors. While the origins of MCAS are still unclear, studies point to underlying genetic mutations that are triggered by a stressful event, like the starvation state of an eating disorder. Because mast cells are located throughout the body, particularly in areas that interface between the internal and external environments, a large number of organ systems can be impacted by MCAS, making it difficult to recognize and diagnose.

What are the Symptoms of MCAS?

Patients who suffer from MCAS may experience symptoms in 2 or more organ systems and may mistake physical symptoms for other conditions. In the gastrointestinal tract, symptoms may include diarrhea, constipation, general abdominal discomfort, GERD, bloating/distension and cramping. Neurologic MCAS symptoms may mimic other conditions and appear as OCD-like thoughts and behaviors, mood swings, depression, anxiety, insomnia, and fatigue. Some people who suffer from MCAS experience more typical allergy-like symptoms including wheezing, rashes, hives, skin flushing/itching, and sinusitis. Other skin conditions like cysts, cystic acne, and edema are also common occurrences. Reactions to heat, altitude, alcohol, artificial dyes/additives and certain environmental allergens like pollen and mold all fit under the MCAS umbrella of symptoms. Reproductive system conditions like unusual menstrual cycles and endometriosis; fibromyalgia-like joint pain; and blood pressure/heart-rate dysregulation are all possible symptoms as well. Indeed, MCAS can and does exist alongside other common conditions like IBS, mood disorders, SIBO (Small Intestinal Bacterial Overgrowth), POTS (Postural Orthostatic Tachycardia Syndrome) and others, making diagnosis complex.

How is MCAS Diagnosed?

There are currently two schools of thought for diagnosing MCAS, commonly referred to as Consensus 1 and Consensus 2 criteria. Consensus 1 criteria guidelines are much more stringent and have the potential to miss up to 80% of MCAS cases. This criteria involves a lab test to measure tryptase levels in the blood, but the test must be performed within 4 hours of the onset of a flare, and most labs are not equipped to perform this kind of testing. Consensus 2 criteria includes the presence of symptoms in 2 or more organ systems AND responsiveness to the medication regimen commonly prescribed for MCAS patients. Consensus 2 criteria may also take into account lab tests and relies on the Mast Cell Activation Syndrome Questionnaire to help narrow down the likelihood of its presence.

How is MCAS Treated?

The goal of MCAS treatment is to stabilize the mast cells so they do not release such a large volume of histamine in response to stimuli. Over-the-counter mast cell stabilizers include H1 Blockers (Allegra, Claritin) and H2 Blockers (Pepcid AC, Tagamet), and the antioxidant flavonoid Quercetin. Prescription medications include Sodium Cromolyn, Ketotifin, and Low-Dose Naltrexone. Reduction of exposure to known stimuli is also considered first-line treatment for MCAS.

Special Considerations for the Eating Disorder Population

Working with an eating disorder clinician who has awareness of MCAS can be critical in receiving effective, comprehensive care. Because eating disorders are already restrictive by nature, working with a clinician who helps to find the right balance between limiting known trigger-foods while medications are kicking in and maximizing food/nutrient intake is key in treatment. Because all foods induce a release of histamines, following a low-histamine diet is not typically warranted for patients who suffer from both MCAS and eating disorders. Many patients who suffer from MCAS have seen an overwhelming number of specialists, including endocrinologists, dermatologists, gynecologists, naturopaths, and others who may have missed the overarching MCAS diagnosis and/or may not be well-versed in eating disorder care. At worst, patients may have experienced medical skepticism at the legitimacy of their symptoms. Because MCAS flares often increase in adolescence, the condition can also be the trigger for an eating disorder, and not merely the fallout from one.

Bottom Line

MCAS is a complex illness that can make eating disorder care and treatment even more nuanced. Working with a clinician who has a working knowledge and understanding of both conditions can mean the difference between timely, effective, safe care and more prolonged suffering/poorer outcomes. Contact Amy to learn more about how she can assist in evaluating and treating both diagnosed and suspected MCAS in conjunction with eating disorder treatment.