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Working with Eating Disorders with Natalie Bourke

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Working with Eating Disorders with Natalie Bourke

Eating disorders are varied and complex in their presentation, so how can we identify and support these patients?

Today we are joined by holistic dietician and nutritionist, Natalie Bourke who takes us through her professional and personal expertise on eating disorders. Natalie takes us through the many different types of eating disorders, how to recognise them, and how to connect with patients who are navigating the physical and emotional turmoil of their eating disorder.

Natalie also shares with us a candid review of her own experiences and discusses how with the use of directed/specific/selected nutrition and supplements, she regained control of her eating disorder to have a healthy self image and relationship with exercise and food. 

Covered in this episode

[00:50] Welcoming back Natalie Bourke
[01:58] Types of eating disorders
[04:18] Prevailing theories for triggers
[10:14] Self-esteem and self-love
[14:19] Neurochemical changes to serotonin
[17:50] Novel therapy: antihistamines?
[20:40] Key nutritional interventions to consider
[26:44] Handling distorted body image perceptions
[34:10] Essential warning signs for practitioners to be aware of
[36:58] Where to appropriately refer?
[38:47] Choosing calorie-free supplementation
[41:44] The journey to self-acceptance

Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. 

Joining me on the line today is Natalie Bourke who's a holistic dietitian and a nutritionist, author, podcaster, speaker, and fitness instructor. She's part of the practitioner support team at BioCeuticals and runs Health by Whole Foods, a nutritional consulting business with a clinical focus on thyroid dysfunction, HPA axis dysregulation, and gut health. 

Nat is passionate about helping women build a healthy relationship with food and their body. She achieves lasting results for her clients by using wholefood nutrition, functional medicine, and holistic lifestyle advice. 

You can catch her fortnightly on The Holistic Nutritionists Podcast, with fun and quirky interviews that aim to dispel nutrition myths and guide listeners on a balanced approach to health. Her eBook, Healing Digestive Discomfort is an industry-leading guide with accessible guidance for anyone looking to start improving their gut health. 

Welcome, back to FX Medicine Nat, how are you? 
Natalie: Thanks Andrew, it's great to be back. I'm really good thanks. How are you? 
Andrew: Good thank you, really good. Now, we did a really interesting podcast previously on CrossFit. But you really enlightened me and indeed you inspired me by your openness with your own eating disorders, that's what we're going to be discussing today. And I think to start off with we need a few definitions so what types of eating disorders are there? 
Natalie: Yeah, so look there are probably four main types of eating disorders that are recognised. And I'll go through a bit of a definition of each, so we are all on the same page.  
Andrew: Great. 
Natalie: So starting with anorexia nervosa. This one is characterised by restrictive food intake or energy intake that leads to someone being unable to actually maintain what is considered to a normal or healthy weight for their age, height, and gender etc. There's also an intense fear of gaining weight or becoming overweight no matter what their current weight or appearance happens to be at the time. 
The next one would be binge eating disorder. So this one is characterised by episodes of binge eating. So basically eating a large amount of food over a very short period of time with no compensatory behaviours. And also still having that same fear of food or more so, negative body image and also a feeling a loss of control during the episode of overeating. 
Then we have bulimia nervosa. So this is characterised by repeated episodes of binge eating, as in binge eating disorder but it's actually followed by more compensatory behaviour such as purging. So there is also an excessive emphasis on body shape or weight in their self-evaluation or self-perception as well. 
And then the final one is a bit of a tongue twister, a long one. It's called other specified feeding or eating disorder, or OSFED for short. And it was actually formerly known as Eating Disorder Not Otherwise Specified. So some practitioners listening may know it as that but it's the same thing. And basically, this would present with many of the same symptoms of other eating disorders but it will not meet the full criteria for a diagnosis in any of the other categories. 
Andrew: You said something which sparked my interest just a little while back and that was ‘during their episode,’ where they have this loss of control during their episode. Are you saying there is control when they're not having an episode but then something hits, something triggers them or is this underlying simmering thing going on in their head all the time? 
Natalie: Look I think it's probably different for everyone. I think there's always an obsessiveness around food. And it's more what happens is, when they start to eat, they find it hard to stop. And then when they can't stop themselves, it's kind of like this feeling of loss of control and you just have to keep eating and eating and eating, essentially because if you stop you have to deal with the emotions that are underlying causing that binge eating in the first place. 
Andrew: Gotcha. And so what about the current theories? I remember back in my nursing day there was this prevailing theory of... particularly in women affected by…I think it was anorexia nervosa. And forgive me, back then eating disorders weren't as well defined. But there seemed to be this prevailing theory of a controlling parent, particularly a mother, a mother-daughter relationship. Is that still current or has that been overrun? 
Natalie: So look I'd say there's definitely genetics at play and also environmental factors at play. And I would say that family environment definitely has a role. But it's certainly not recognised as the only thing that's influencing the occurrence of eating disorders. So I'd probably say all experts in the field of eating disorders agree that there are both genetic and environmental components to eating disorders. And within that, there are different theories about what's contributing which we can go through. 
So probably the first one would be genetics. So there is evidence that eating disorders do have a genetic component. Though very few like, SNPs have been specifically identified at this stage. But I think the future is promising in that regard because as you know the expansion of genetic testing is just phenomenal and it's only going to continue. 

I think one of the big issues though is that it's really hard to get a large enough sample size to produce statistically significant results you know, and look for SNPs in that regard. 

Andrew: Yep. 

Natalie: And you know, that is kind of my take on it. I'm certainly not a genetic expert but that's what I could see as being one of the barriers. 
In terms of what has been done though, so basically they have done family studies of those with anorexia and bulimia and have found a higher lifetime prevalence of eating disorders among relatives of eating disorder sufferers

Andrew: Right. 

Natalie: And also they've done twin studies which also suggest that both anorexia and bulimia are significantly influenced by genetic factors. So basically when they are looking at the differences between identical and fraternal twins, correlations are actually twice as high in identical twins compared to fraternal twins. So that obviously is a suggestion that, hey, there might actually be a genetic component here, and something to consider for sure. There are various theories around what the genes are influencing to increase the risk for eating disorders. 
So one example that I often give when I'm explaining it to people is the influence that genes have on personality traits which you know, obviously environmental factors also come to play in that. But it makes sense to an extent because we do actually see common personality traits in those with eating disorders. So some examples of these would be things like perfectionism, obsessive compulsiveness, negative emotionality, harm avoidance and also that real core low self-esteem. 

So specific additional personality traits may be associated with each type of eating disorder. And another thing that's very important to take into consideration is that prolonged starvation actually induces changes in cognition behaviour interpersonal characteristics. So in that regard, it can be difficult to separate the psychological causes from the psychological effects of eating disorders. 

Andrew: Yes. 

Natalie: And it does become a bit of a chicken or the egg situation. 
Andrew: Yeah, before we go deeper and I mean, that's a big dive that one, chicken or egg. But just before we go into that, with regards to the genetic component, I see a sort of quasi-link here with the genetic component of addictions. 
Natalie: Yeah, definitely. 
Andrew: It's sort of along this spectrum almost of OCD, addictions, eating disorders. So is it a case where you've got probably a genetic component, let's face it, but also combined with the self-esteem issues and perhaps, you know, an environmental or a familial issue, a family issue, where something basically creates the perfect storm? 
Natalie: Yeah, I definitely think that's the situation. I don't think that there is any one specific cause and I don't think there’ll ever be. I do think that there is a bit of a perfect storm situation that does come about. And absolutely, when you're saying you know, there's similarity there with other mental health disorders, is there? Definitely. I mean, we know that anorexia and bulimia and these eating disorders they, you know often co-occur with things like OCD and depression, anxiety. As you would expect when you know, being obsessed with food and body is your world there has to be some degree of angst that comes with that for sure. 
Andrew: Now, the interesting thing there, of course, is self-esteem. It's a lifelong process, begins in childhood and it evolves. We've got the nature versus nurture theory there. Both of which I think are important. Where does self-esteem form and can it be changed? 
Natalie: Yeah, look I think that as you’ve said, we have a genetic pre-disposition to some of our behaviours. And particularly I would say a person, a client has like influences on the serotonin, dopamine type situation, which I'll share some interesting research with you shortly on that when we go deeper into that. 

But I think in terms of environmental that's obviously where a big part of it comes in. If you're constantly told that you're not good enough or you're, for example, a lot of girls that are in sports from a young age that have an emphasis on body composition or body image. So things like gymnastics, dancing, like ballet, there is definitely a component of focus on that. 
And also I think if you've got parents or friends or sisters or people who you're surrounded with that have a big focus on body image. Then and they're picking themselves apart, then it's definitely something that kind of filters out to you and you do start picking yourself apart in that same way. 
In relation to your question of can, you change it? I'm of big belief that you can change it. And when we talk about my personal experience down the track I can definitely give...share some insight there. But I do think that's possible, I think it's very difficult and I think that anyone listening that has experienced difficulty with body image issues, knows that it's a very hard thing to practice self-love, and self-love of your body. But it's definitely worth it and it's one thing that gets stronger with practice and with time. 
Andrew: And it seems to be this taboo thing. Self-love versus arrogance, it's totally different. They're two totally separate things. With regards to that self-love image, how important is these external influences like, for instance, media? You know, we've been through the waif period over a decade ago now. It was horrible to see these models that were skeletal. 
Natalie: Yeah, it's... and look I think that there is absolutely a role that media have. Because they have a huge influence on our conditioning of what we think people want from us. 

Andrew: Yeah. 

Natalie: And what we think people want us to look like and to be like and it's hard if you're not consciously trying to be aware of that, it does subconsciously start to form your conditioning about what maybe you should look like so there's definitely an influence of that. 

But I would say that it's not the only thing because obviously we're all exposed to those kind of messages to some degree and a lot of women will diet, a lot of women will you know, read magazines and see all that stuff but not every woman goes on to experience an eating disorder. So I think that's where we recognise that absolutely it plays a part and it needs to be addressed, and I think there is more of a movement towards positive body image that's happening slowly. But I also I think that it can't be as simple as that. 
Andrew: No, it contains its own pressures as well as you say. And you were very brave in admitting this in our last podcast in CrossFit. And you spoke about your own issues with regards to you know, controlling your eating to a state where it actually became a problem whilst you were engaging in exercise. So was this sort of undoing the sort of goodness if you like? 
Natalie: Yeah, definitely. And just bringing it back to what we kind of started with, in terms of the kind of neurological changes that go on with eating disorders or what kind of effect is happening. I think it's really an important thing to discuss in relation to serotonin and dopamine dysregulation in people with eating disorders. Because I think that helps to also explain to other people that, "Hey, it's not just this superficial obsession with how someone looks it, it's not as simple as that. There are actually neurochemical changes that are going on." And I'd love to share with you a bit of information about serotonin and dopamine and how that's dysregulated to help practitioners and listeners understand that it isn't as simple as being self-obsessed and self-absorbed by choice. 
Andrew: No, please do, because that's... I think this is crucial that we explore this so let's go into that now. What are these main things? 
Natalie: Yes, so people with anorexia have actually been found have elevated levels of serotonin which is independent of the stage of the illness. And these really high levels of serotonin have been associated with higher levels of anxiety. And interestingly, people with anorexia can actually lower the amount of serotonin their bodies make by starving themself. Which is why restricting their food intake to relieves their anxiety to an extent. 

However, what happens is the brain will actually sense that decrease and express more receptors to essentially get more out of what's there. And so more food restriction is required to get that same effect. And that's partly why re-feeding is so incredibly difficult and distressing for anorexic sufferers. Because you know, there's just this influx of serotonin and you're hypersensitive to it and their anxiety is just at an all-time high. 
Andrew: Do we, therefore, try and reduce serotonin because isn't that going to make more receptors and cause a worse 22? Or do we actually try and nourish the body in different ways so that we have this let's say a graceful decline of 5-HT receptors? 
Natalie: Yeah, look I think the latter is probably a better approach. I can't say I've seen a lot of research in either direction that is conclusive as to what would be the best thing to do. 

I do know that there hasn't been very much success with using things like SSRIs and I find that really interesting. I mean, there's a small amount of success with some people but definitely, the overall consensus is that they aren't the best option. Yet they're continually prescribed. Because in a GPs office, when you've got someone that is depressed in front of you and has an eating disorder, you know, an antidepressant seems like the logical thing to prescribe and gives them something actively to do. 
And in a sense, it's very hard and we have to recognise that anorexia eating disorders are incredibly frustrating and difficult to treat. And so sometimes you know, doctors do just reach for what they reach for. But I think that it's starting to become less of a kneejerk reaction in that regard and there are other treatments that are starting to be more recognised. 
Andrew: What sort of treatments are we talking about here? 
Natalie: So I think more viewing it as a holistic approach so addressing nutrient deficiencies in some clinics. And also making sure that there is definitely a psychological component to it in terms of psychological management. 

So making sure people have access to psychologists and probably the most common therapy that's used is CBT and mindfulness. And those kind of approaches. And group therapy, all those kind of things that are definitely been used. Interestingly actually, one thing that they have trialed using...that helped with weight gain was actually an antihistamine. It hasn't been successful in all studies but there were a couple of trials where an antihistamine was used and that actually helped with producing weight gain so I found that quite interesting. 
Andrew: Yeah, any purported mechanism, H2 antagonism? 
Natalie: Yeah. So what happens is that there seems to be an increased expression of H1 receptors which are associated with the regulation of appetite. And in anorexic patients, we actually know that they have higher levels of histamine and that helps suppress their appetite. 

So in that regard, it's kind of treating the reduced appetite side of things and helping...I guess helping them gain weight. So from that perspective that's the main way, it's working from my understanding. 
Andrew: Right, and do you know which antihistamine they used, one of the drowsy ones? 
Natalie: I'll have to go back and have a look. 
Andrew: That'd be really interesting. I guess I was really interested in this sort of cross-reactivity between the H1 and H2 receptors. For instance, there's the old you know, antacids which an antihistamine will have some slight crossover with. And I'm just wondering about it’s sort of brain-chemical-stomach action. I'm wondering about that. 
Natalie: Yeah, look that's really interesting and I can't say that I know a whole heap about that but definitely something to look into further. Because it's just it starts to kind of all add up. 

So just to backtrack a bit I did actually find the name while I was listening to you there. So it was actually cyproheptadine, that was the antihistamine that was used. 
Andrew: No idea. 
Natalie: It did help yeah. 
Andrew: Never heard of it. I'll have to look up something. 
Natalie: Will, it helped some people yeah. 
Andrew: We'll put something off on the FX Medicine website for our listeners, that's great though. 

So what about other nutritional aspects and I guess we go here you know, what's cause and what's effect? I remember years ago reading something from Professor Derek Bryce-Smith. He was at Reading University, looking at zinc deficiency in rats. And he found that they tended to have an eating disorder once the brain zinc levels got below a certain level. Now, obviously, that's based on autopsy, it can only be done in rats ethically. But it was very interesting that when he gave a certain type of zinc, zinc heptahydrate I think it was, that they tended...these rats tended to spontaneously recover from their anorexia. So cause or effect? 
Natalie: Yeah, well look, I don't think we know yet. I think that absolutely zinc has a role to play and you'll see that the kind of symptoms of zinc deficiency and the symptoms of anorexia are quite similar. 

So we do see that you know, loss of taste and smell and decreased appetite and all those kind of things. So research definitely does show that many patients with anorexia are deficient in zinc and not surprisingly. I don't think that zinc is the only thing to blame, but I do think that zinc status or rather correcting zinc deficiencies is a promising and important step in assisting someone to recover. Particularly with anorexia because we know as I said, that zinc is essential to neurological function and has important impacts on appetite and sense of taste, which is obviously linked to the enjoyment of food. 

Andrew: Yeah. 

Natalie: So, of course, you know, the impact of zinc on things like depression and anxiety is also important because we know that those conditions also often co-occur with anorexia. So absolutely, zinc is part of the story and I know that there's been a number of trials done on using zinc supplementation in anorexic patients
And I think there is one done that actually showed a two-fold increase of the rate of increase of body mass index in zinc group compared to controls. And I believe that was 14 milligrams of zinc for two months. I don't recall which type of zinc it was for that trial. But I know it was actually another one that was a randomised double-blind placebo-controlled trial and that used 100 milligrams of zinc gluconate. And that was given to...that was given daily and that actually showed a 10% increase in body mass index. So the rate of increase in BMI of the zinc-supplemented group was twice that of the placebo. 

So I absolutely think that the zinc supplementation should be a key thing that all practitioners that are treating anorexia need to use because it's simple, it's cheap and it's effective. And no it won't solve all parts of the problem but anything that can help should be used because as I've said you know, time and time again, it's notoriously difficult to treat. 
Andrew: The thing I like about that is the rather judicious dose that was used. That's quite not just attainable but safe as well. We're not going to run into any long-term problems with you know, copper interaction and things like that using that low dose, that's quite encouraging. 
Natalie: Yeah, exactly and you know, the other thing that I actually would recommend that practitioners look into supplementing with, would be fish oil. 

So we know that essential fatty acids are also really important in neurological health and this is essentially a neurological condition. And we know that, for example, just 1,000 milligrams of EPA has actually demonstrated equal effectiveness to 20 milligrams of fluoxetine in major depressive disorder. And these patients with eating disorders are depressed. So if it is as simple as giving someone some EPA and DHA in the form of a supplement then it's definitely worth a go. 
Andrew: I've spoken with Elizma Lambert with...regarding addictions and she uses GABA, oral GABA to balance out dopamine, the sort of reward system. Do you find this useful with people with eating disorders? 
Natalie: Yeah, definitely. I think GABA has a role to play. I would say that it's a bit of a...it works for some people and not for others. 

I guess to explain the kind of dopamine connection a bit further in relation to anorexia. It's actually...so the leading hypothesis is that anorexia is associated with an overproduction of dopamine which leads to anxiety and harm avoidance, hyperactivity and also the ability to go without soluble things like food. And then on the contrary, research has shown that bulimia is associated with lower levels of both dopamine and also some of its receptors. And that binge eating is significantly associated with dopamine release in certain parts of the brain.

Andrew: Right, right, right. 

Natalie: And I guess also and not surprisingly, binging disorder has been linked to hyper-responsiveness to rewards such as food. Which obviously makes food more rewarding, more pleasurable than people without the disorder and leads to that continuation of that compulsive over-eating. 
Andrew: So I could, therefore, imagine that something like the smell, the aroma of food would be vastly different, or would have vastly different effects from an anorexic versus somebody with bulimia. 
Natalie: Absolutely, yeah. And we've got the influence of both zinc deficiency and also the dopamine coming into play there so yeah, definitely. So, when anorexic patients tell you that they can't smell their food, that their food tastes horrible they're not lying, it is true, it is happening for them and that is real. 
Andrew: So now, also talking about their experiences of food and now let's take that to what they see in the mirror? 
Natalie: Yes, so there's definitely distorted body images happening. So what they...and I guess this is something that's incredibly frustrating for families and friends to understand. Because the difference between what they see and what the anorexic person sees in the mirror is absolutely completely different and there is that distorted body image. 

I don't think we know the exact mechanism of why that's happening at the moment but it does have to do with neurological changes and everything that's going on there. And it is real and I can tell you from personal experience that when you...for example, a good example would be that you would go for a run and you would come back and you'd look in the mirror and your thighs would be smaller than they were when you first went for your run. Then you would have something to eat something as simple as like an apple and you would go back to the mirror again and you'd look in the mirror and they had grown, they'd almost doubled in size. And it's incredibly distressing but it is incredibly real as well. 
Andrew: But as you say, incredibly frustrating for caregivers and family because they can't see that change. So it's kind of like to me that you know, when I did my psych nursing component how you know, if somebody was having a psychotic episode they were explaining things that were not there. So they were explaining spiders you know, radioactive clouds, creeping over. I'll always remember these stories. I had the greatest conversations with these patients. 

So what they would explain I could not see. And I remember the supposed best way to handle it, me not being fully a trained psych nurse, so please take that into consideration, was that you would say, "I understand that's real for you. I'm sorry I can't share that reality." Does that change when somebody says to you suffering from an eating disorder “I can't see what you're seeing?” 
Natalie: It's very...it feels very...like from a patient's perspective from being having anorexia myself, it's when someone says that, it feels very frustrating and very isolating. Because you just can't comprehend that someone could possibly not seeing what you are seeing. And likewise, you know, it's kind of, it's a two-way street you know, that that person can't see what you're seeing and vise versa. 

And It's hard because no matter what you say as a family member, as a caregiver or a friend to someone with anorexia it's always wrong because we'll twist it in our minds to suit our kind of perception and how we and thinking about things. Which is why it's so frustrating. 
Andrew: Okay, so from a practitioner perspective how should you handle that? 
Natalie: Look, I think that it is different for everybody. I think that one of the number one things that's important to do is to not place any importance or emphasis on how they're looking, whether that be that they have put on weight or they have lost weight. Focus on health and focus on nutrition and that nutritional status. 

Because if you are focusing on weight, whether that they have put on weight or they have lost weight when they've come to see you then it's feeding into that being important for them. So I think that, of course, it important to acknowledge you know, what changes have occurred but not putting any emotional words around that or not putting a tone in that, you know, "You've put on weight, I'm really happy for you, like I'm really proud of you, that's great." Because that will still send them into a fear. So I think the less importance that you can place on that and less focus you can place on that, and the more you can pull it towards health and nutritional status, it kind of makes it a little easier for them to not react poorly to. 
Andrew: And I can imagine this reaction. I mean, that must cause so much stress when there's a conflict going on, of what one person sees compared to what another person really does see. 
Natalie: Yeah, absolutely and it's interesting because there's actually a disturbance also, in relation to memory processing and storing, particularly in relation to the serotonergic system. 

So what actually has been hypothesised is that anorexic patients have an increased ability to store negative memories associated with their bodies. So, for example, if they have been teased when they were younger about being fat or having big thighs or whatever it is. It's actually easier for them to store that memory and harder for them to actively or voluntarily inhibit that memory from resurfacing. 

So I think it's called, from memory, The Allocentric Lock theory and I think if anyone wants to look into it further they can. But I think that's interesting because it means that for a normal person, you know, as women I know we all have those moments where we're just like, "Oh, I'm not looking very good today or you know, my legs look big today." Or something like that but we can kinda get rid of that thought pretty quickly most of the time. 

For anorexic patients they can't get rid of it, it's with them. And it does lead to a lot of stress and a lot of anxiety and they feel like that all of the time. So they're actually constantly in that kind of flight or fight response and that in itself as we know kind of shuts down digesting and reproducing, and appetite and feeds into that disorder further. 
Andrew: That's an interesting thing you say about the Allocentric Lock theory. I recall something about this you know, like danger signals. That actually had a function when we were evolving as an animal as a primate. And that is basically these negative things basically like, "Don't touch the stove it'll burn you," were actually a saving device so that you could live. But what's happening here is that it's now directed not towards your safety but your body image. 
Natalie: Yeah, exactly. And it's horrible and I think one analogy that I could give people to give a bit of insight into actually what it feels like being on the inside of the head of someone with anorexia. Is that imagine that you are in a grocery store and you turn your back for one second and your little toddler that's two years old has gone missing and you can't find them. And that rush and fear that just comes over and you can't focus on anything else. And that's what it feels like all of the time to be in the head of an anorexic person. 
Andrew: All of the time. 
Natalie: You're constantly in fear and that's how it feels. And the only thing that relieves that in most situations is controlling food and starving yourself essentially. And for some people exercise plays a big role as well. 
Andrew: But it's in a vain attempt to control neurotransmitters. This is this really interesting way in which the body will try and save you, at least to an extent. 
Natalie: Yes, exactly. 
Andrew: So warning signs what do practitioners need to be aware of? You won't get, or very rarely, you'll get up a patient walking and saying, "Hi, I have an eating disorder and I'd like to be treated." What do practitioners need to be alert to therefore so that they can pick up let's say being suspicious of an eating disorder without being paranoid of an eating disorder? 
Natalie: Yeah, look I think anyone who comes in and who presents as being really preoccupied with body appearance and with weight and with food. Anyone that presents with a distorted view of their body and you'll pick up on this in conversation. Anyone who has really specific food diaries and I'm talking about they're like, "I had 100 grams of chicken with eight grams of almond spread," those kinds of really detailed things. If they are coming in and they're wearing a lot of baggy clothes frequently. 

If you notice...I guess this is more of a family, friends type of symptom or warning sign. If there's withdrawal from friends or family or avoidance of social situations or any kind of anxiety around mealtimes or food. So if people need things to be a particular way. Or they get quite anxious if, for example, the wrong brand of something is bought, that can often be another sign. 

Then in terms of bulimia and bingeing disorder, a few more that I'd add would be if they've got a lot of dental issues. 
Andrew: Ahh, of course. 
Natalie: Yeah. If there's...at home this would obviously be something that more family are looking out for. But if there's missing food from the cupboard or the fridge that you can't really explain. Like you know, your husband didn't eat it or he wouldn't like it and it's gone missing and you know, you didn't eat it then that's another hint. If there's a lot of empty packets of food in cars. If there's uneaten or chewed food in the bin or lots of packages, like lots of food packages in the bin. 

Also, another one that's quite interesting is always insisting that they'll clean up after dinner because often they'll clean up and they'll pick at food while they're cleaning up and then that will turn into a binge later. 
Also, anxiety around making food or baking in particular. Because they will find that they can't make, for example, a batch of brownies and only eat one. It will become a huge... it will become a binge. And then you'll often find leftovers, if there is any, in the bin outside. And the other final warning sign, I'd probably say, is a really smelly drains in the shower because often people with bulimia will actually go in the shower to purge. Because there's the sound of that the shower trying...kind of disguising it if they are living with other people. 
Andrew: There's so much to consider here, isn't there? And I guess it would largely revolve around the caring nature of the family to actually act on those suspicions. So what about appropriate referral though? If you suspect as a practitioner that there's an eating disorder in play what should you do? Where do they get sent? 
Natalie: Yeah, look I think it's really important to refer them to a psychologist. And if it is outside your practice realm then I do think you can also refer to another practitioner that specialises in eating disorders or has some experience in that area. Because it is absolutely one of the most difficult and frustrating disorders to treat. 

And I'd also recommend having a GP on board particularly when it's more severe. Because there are electrolyte imbalances that can happen and that becomes a medical emergency and they will need to be put into an in-patient program. So I think those would be the main referrals that I'd have in my mind. Because it's important that early treatment happens because the longer it goes on, the harder it is to get out of it. 
Andrew: Do you look for any specialised qualifications in psychologists or GPs? 
Natalie: I would look for psychologists that do have a clinical focus on eating disorders or who have done further training in that area and there are plenty around. I think a really great resource is The Butterfly Foundation. They have lots of resources, they even have like a free phone line that you can call and they have counselors that are trained in eating disorders on that line. So it's a great place for information for further referrals and information of where to get help and there's lots of experienced people there that would be able to point you in the right direction. 
Andrew: Okay, I also have to ask about the appropriateness of supplements? So you know, we've spoken about zinc and that it's got a usefulness. We've spoken about some things that might be based around inflammation or relaxation. But do you find any issues with certain supplements? 
Natalie: I think when you're treating someone with anorexia it's probably easy to get capsules and supplements into them that way, but when you start to add the things that have like a protein powder or things that have like a calorie value to them, it makes a lot more difficult to ensure compliance. Because on days when they don't feel like they deserve that food or they can fit that into their quota of calories that they’ve set for themselves they're not going to take it so you're not going to get that consistency. 

So in the initial stages, I think using something like yeah, zinc definitely, a multi-vitamin can even be helpful and also definitely those essential fatty acids and then from their working based on where that person is at. So I definitely think that a focus on B vitamins and also protein powders to an extent, once they're more on board with eating more, can be helpful. But I think in the initial kind of "get them out of danger" situation, it's best to give them capsules or tablets that they know don't have any effect on their weight, per se. 
Andrew: Yeah, but this I guess would be a double-edged sword in that...and perhaps you can explain how you felt. You know, for instance, would there be a choosing of non-caloric supplements in a vain attempt to avoid calories while still maintaining nutrition, you know that sort of...? 
Natalie: Look there would be. But I think that that's going to happen anyway and it's a bit of cost-benefit analysis situation here. 

So your end goal is obviously to get them eating more but it's going to take a while to get them to that place. And I think that giving them nutrients in the first place, for example, things like zinc can actually help them to become more interested in food because it helps with that kind of increased appetite and also helps with the sense of taste and smell of food, so it becomes a bit more pleasurable. 

So unfortunately it's not really a win-win situation in all cases. It's a bit of a, "What am I going to get the most benefit from at a small cost, of yes having that risk that they will justify that they don't need to eat because they're taking supplements. You just kind of have to make that assessment. And in many situations, personally and professionally, I’ve found that getting them out of the woods, at least, with some supplements that don't have any calorie value to them, can be helpful. 
Andrew: Now, I've got to make a real point here about your courage with this because you... What I see now and I've known you as a colleague for a number of, what is it? Just over a year now isn't it? 
Natalie: Yeah, yep. 
Andrew: And yet what I see is this quietly confident lady who really knows her stuff. So I have to ask, with regards to your previous experiences, do you still run into triggers where you go, "Uh-oh, I know what's happening now." Or do you find that you are, dare I say that word, ‘cured’? You know, what goes on now with you? 
Natalie: Yeah, look it's my personal believe that an eating disorder never leaves you but you get a lot better at managing it and it doesn't become your world. 

So I would say that I now can control those thoughts and I'm aware of when they come up and I don't act on them. So I would say I still have a tendency to, when other things in my life are out of control, the first thing when I'm not being conscious of it, the first thing that I'll want to control is food and exercise. 

But my… I guess now that I have built up that muscle that's like, "Hey, no, this is not what you need to do. This isn't going to make you any happier, any more successful, any more loved." That voice is stronger than the one that says, "You have to do this to be accepted." So I think that it doesn't leave you but you become a lot better at finding strategies to actually manage that voice and it doesn't rule your world anymore. 

So that's really...it's really exciting to get to that place because you know, especially when most people spend quite a long time on the opposite side of the fence. 
Andrew: Yeah, so I've got to say therefore on this concept of self-love, self-acceptance, self-esteem, what are the best resources that you found helped you? What can you recommend for other practitioners to help their patients? 
Natalie: Yeah, I think the number one thing is to get out of the environments that trigger you. So for me, I used to do a lot of exercise in like a traditional gym that was just near my house. And a lot of people knew me there as a person that was always exercising, that was always "healthy and fit." And I found that removing myself from that environment where I was projecting, I guess, things onto them that I thought I needed to uphold in terms of that skinny look, that you know, exercising all the time, always eating the right foods. I removed myself from that environment. I also removed myself from any kind of friends or situations that made me feel like I should focus on my body image at all. 

And what I replaced these things were was...and this is just me personally, what worked was I actually...well, that's how I got into CrossFit actually, was to focus on an activity, it doesn't have to be CrossFit. An activity that is based more on performance in terms of, "What can your body do?" as opposed to, "What does my body look like?" And the other thing that I did was to start yoga and to start actively going there to a really, really wonderful studio that has a focus on all of those self-love messages that are really important. And starting to read those kind of books that do encourage you to recognise that there is way more to you than your physical appearance. 

And definitely the last tip I would give is doing a social media clean out. So that means that going through your Instagram and unfollowing anything that makes you feel like you should look a certain way or be a certain way. So we are all guilty of doing the old scroll through Instagram and looking at all these fit women with abs or models and what not. And all it does is make you feel horrible and so there's no...it does you no justice by continuing to put those subconscious messages in your head. So it's really about getting on your own side and finding more things that can actually support you as opposed to make you feel you know, bad about yourself. 
Andrew: Natalie Bourke, I cannot thank you enough for being so brave in sharing you know, what seriously I know that you manage it really well now. You look the epitome of health. You teach others about how to attain that. But you are acutely aware of the aspects that are underlying an eating disorder so you can really truly know what they're seeing and feeling which is way different from what we see and feel. And I just thank you so much for taking us through the issues presenting those people with eating disorders. Hopefully, this will give some ammunition for practitioners, listeners out there, so that they can appropriately treat or refer those patients that come across their paths who need help. So thank you, very much for taking us through this on FX Medicine today. 
Natalie: My pleasure Andrew, and look, I think there's therapeutic value in sharing your story as well. So I don't have any problem with sharing my story with people and I think that it can be very beneficial for others to do the same. 
Andrew: Applause to you. This is FX Medicine, I'm Andrew Whitfield-Cook.

Additional Resources

Natalie Bourke
Health by Wholefoods
The Holistic Nutritionists Podcast
eBook: Healing Digestive Discomfort by Natalie Bourke
Professor Derek Bryce-Smith
The Butterfly Foundation

Research explored in this episode

Mazzeo S, Bulik C. Environmental and genetic risk factors for eating disorders: What the clinician needs to know. Child Adolesc Psychiatr Clin N Am. 2009 Jan; 18(1): 67–82.

Thornton L, Mazzeo S, Bulik C. The Heritability of Eating Disorders: Methods and Current Findings. Curr Top Behav Neurosci. 2011; 6: 141–156.

Steiger H. Eating disorders and the serotonin connection: state, trait and developmental effects. J Psychiatry Neurosci. 2004 Jan; 29(1): 20–29.

Claudino AM, Hay P, Lima MS, et al. Antidepressants for anorexia nervosa. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD004365.

Yoshizawa M, Tashiro M, Fukudo S, et al. Increased brain histamine H1 receptor binding in patients with anorexia nervosa. Biol Psychiatry. 2009 Feb 15;65(4):329-35.

Birmingham CL, Gritzner S. How does zinc supplementation benefit anorexia nervosa? Eat Weight Disord. 2006 Dec;11(4):e109-11.

Birmingham CL, Goldner EM, Bakan R. Controlled trial of zinc supplementation in anorexia nervosa. Int J Eat Disord. 1994 Apr;15(3):251-5.

Jazayeri S, Tehrani-Doost M, Keshavarz SA, et al. Comparison of therapeutic effects of omega-3 fatty acid eicosapentaenoic acid and fluoxetine, separately and in combination, in major depressive disorder. Aust N Z J Psychiatry. 2008 Mar;42(3):192-8.

Bailer U, Narendran R, Frankle WG, et al. Amphetamine induced dopamine release increases anxiety in individuals recovered from anorexia nervosa. Int J Eat Disord. 2012 Mar; 45(2): 263–271.

Bello N, Hajnal A. Dopamine and binge eating behaviors. Pharmacol Biochem Behav. 2010 Nov; 97(1): 25–33.

Broft A, Shingleton R, Kaufman J, et al. Striatal Dopamine in Bulimia Nervosa: a PET Imaging Study. Int J Eat Disord. 2012 Jul; 45(5): 648–656.

Davis C, Levitan RD, Yilmaz Z, et al. Binge eating disorder and the dopamine D2 receptor: genotypes and sub-phenotypes. Prog Neuropsychopharmacol Biol Psychiatry. 2012 Aug 7;38(2):328-35.

Riva G. Out of my real body: cognitive neuroscience meets eating disorders. Front Hum Neurosci. 2014; 8: 236.

Riva G. Neuroscience and eating disorders: the allocentric lock hypothesis. Med Hypotheses. 2012 Feb;78(2):254-7.

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