Getting Personal: Lessons About GERD, Cancer, HAES, Bulima & Food Restriction

Read this if you are overweight. And read this if you purge through vomiting. Read this if you restrict your intake to less than you know your body needs. And read this if you've been told you have reflux, GERD or Barrett's esophagus.

Stomach--cow, not human, though!

I was recently contacted by a blogger colleague, aware of my Health At Every Size (HAES) philosophy from my blog writings. She was interested in referring a client for Medical Nutrition Therapy for reflux, with a history of Barrett's esophagus. For those of you not in the know, reflux, GERD or gastroesophageal reflux disease, is a condition where acid from the stomach comes up into the esophagus—that tube connecting your throat and your stomach—where it's not meant to be. 

Over time, that stomach acid starts to change the lining of the esophagus and cause inflammation, heartburn and discomfort. For about 5-15% of sufferers, the cells lining the esophagus begin to change, resulting in a condition called Barrett's esophagus. Barrett's esophagus can be well controlled with diet and medication, but in some cases progresses to esophageal cancer. By the time cancer is diagnosed in those patients, the cancer has invaded the area making the prognosis far from great.

My mother was diagnosed with adenocarcinoma—a cancer of the esophagus.

Now, back to the referrer. She wanted to be sure that I wouldn't focus on the client’s weight; because that's what people tend to do—just focus on the weight. What my fellow blogger was unaware of was that I was in the midst of struggling with the horrific consequences of this very common symptom, reflux, which ultimately led to cancer of the esophagus, a potentially preventable disease. And I am painfully aware of all the risk factors that contribute to esophageal cancer—including obesity. 

For most of my years, my mother popped Rolaids and Tums, those chewable antacids, like they were candy. She didn't binge, but she ate compulsively. She wasn't a drinker or a smoker—alcohol and smoking also add to the risk—but she couldn't part with her coffee which like most things acidic make things worse. And she was obese, a major risk factor for reflux. In fact, after her gastric bypass surgery, her reflux disappeared. For 8 years, in fact, she experienced little or no reflux. But it was too late; the damage was done.

Now if you're thinking you're not the intended target for this post, don't stop reading! My story, unfortunately, impacts the purgers among you as well as those dreadfully afraid to eat. So please keep reading.

While the verdict isn't in yet, there appears to be an increased risk of reflux, Barrett's esophagus and cancer, based on a study of studies, a meta analysis, on bulimics. This should come as no surprise, as acid going where it's not meant to go is what causes the problem. Fear may not drive you to change your behavior. But perhaps you haven't considered your risk of getting a potentially fatal cancer, right up there with dental issues and of course, sudden death, all consequences that you can prevent.

So where do you restrictors fit into this article?

Let me enlighten you a bit more about the treatment for esophageal cancer. The best hope for survival is to have surgery, after aggressive chemo and radiation. If you're a candidate for surgery, you're in luck. Well, sort of. The surgery requires removal of most or all of your esophagus and creation of a new pseudo-esophagus from your stomach. It's a seriously risky surgery, but can be done well by top surgeons. We were fortunate, and in fact, her past gastric bypass likely aided the situation, making it easier to use her already bypassed stomach remnant.

If you've long struggled with your weight—like my mother did—being told you have to take in many hundreds of calories a day doesn't sit too well. So any opportunity to stop the tube feeding (from which the bulk of nourishment comes during the initial and very critical weeks of healing), is taken. 

Yes, she restricted. The lack of significant weight loss convinced her that there was no issue with her minimal nourishment. Never mind that she became lethargic, spending most of her days in bed, barely able to walk. Or that she became depressed, or that her thinking was far from clear. (Yes, sometimes it's difficult to see the damage from restricting as it's happening.)

That's the state she was in this weekend when I visited. She had convinced the doctors by telephone that she was eating fine, and they were even considering removing her feeding tube tomorrow. 

Except that now she was readmitted and has a blood clot in her lung. I can't say why, these things do happen, but laying in bed fatigued from poor intake no doubt didn't help.

Back to HAES and my fellow blogger.

I fully understand the experience of the obese, being told that their weight is the cause of all evils—even the common cold! As an RD, I would never just focus on weight loss for someone with GERD. Rather, I would address symptom management with volume changes, and reduce acidic foods that aggravate the inflammation. I'd guide the patient on foods and meal content that might be contributing to the reflux.

But would I avoid discussion of weight loss in an obese patient, if their eating were excessive for their need, if they had been gaining weight? Or for that matter, if portion adjustments could be made, reducing both calories and stomach volume that would improve acid reflux, and also result in weight loss? Studies show an association, and that's not to say that all obese people need to lose weight. I get it.

That said, for those with GERD, losing weight tends to improve symptoms, and gaining weight tends to worsen them in obese individuals, especially in those with intra-abdominal obesity.  

Thanks for reading. Please do me a favor and share this with someone you know whose's at risk. Tweet it, blog about it, Facebook 'like' it or simply talk about it.

Thinking It's All Your Fault?

That’s what they’re thinking, isn’t it? And likely you believe it too. Whether you’re fat or thin, healthy or unhealthy, fit or not, we need to place blame. It’s too hard for us to accept what’s not in our hands to control. We blame your weight on your eating and your diseases—even when there may be no link; we unfairly blame the parents for their child’s eating disorder; and we yearn to believe that it was your actions that caused your disease. Here are just a few examples of this I’ve recently encountered:

• "You’re too fat and of course you must eat poorly. And you’re lazy, too. Shouldn’t you be moving that 350 plus pound body around better—faster, longer, more gracefully? Your knee problems, your reflux, your high blood pressure—they’re all caused by you, don’t you think?" It doesn’t matter that you were an overweight baby and a chunky child—cute then, but not for the adult you. No, it bothers us to see people outside the “perfect” range. 
• The first question they ask is “Was he a smoker?” And the answer is no. Not a smoker nor a drinker yet my father died from primary lung cancer which spread to his liver. And no, there were not even asbestos or environmental factors. And my relative’s recent diagnosis of stomach cancer—rarely seen in the US but common in Japan—where they tend to be slimmer, I might add—was not caused by her weight nor her diet—those pickled, fermented and smoked foods associated with this cancer are not in her repertoire of foods regularly consumed.
• I was sent many an internet, urban legend article on diet soda and multiple sclerosis after my diagnosis of MS. They were well-intentioned senders. They just wanted to find the answer, to find a cure. Never mind that the best research facilities still don’t have a cure, and that I can count on one finger how often I drank a diet beverage over the past months. But they thought they were being helpful. Wouldn’t it be great if I had caused my MS, and then I can equally easily undo it?
• It’s the families, isn’t it? You know, that cause the anorexia? Wasn’t her mother always dieting? What about the home environment? Didn’t her sister also have an eating disorder?

Randomness is difficult to accept. If there’s no cause and effect, it means we can’t do anything to protect ourselves from all the bad things that may befall us. It means we have no control over the future of our health, of our survival, and of the risk to those that we care about. It leaves us feeling way too vulnerable.

We want to place blame. If her cancer was caused by her weight or her gastric bypass surgery, then it won’t happen to me. If his cancer was due to smoking or asbestos, then I am safe. Cut out the diet sodas and I’ll be free from risk of neurological disorders. If mothers cause anorexia, then I can change how I parent and prevent my child from getting it.

If only life were this simple. An eating disorder is complex, and can’t easily be caused from environmental influences. It likely involves a genetic predisposition, some triggering event, and environmental support to maintain it. Yet that doesn’t mean that parents are helpless. They may help prevent an eating disorder in a high risk individual by keeping eating on track and preventing the dieting that all too often results in an eating disorder. And they can certainly actively support their child’s recovery!

My MS and the ALS of a dear relative will not be cured with nutrition or weight change. But we can take control of our stress and maintain the health of the functioning bodies we do have. We can eat well to feel well—and yes, that includes cupcakes in addition to whole grains!

As for the myth that your weight is responsible for all evils? Reread this old post!

All hope is not lost. Even conditions we didn’t cause, we have a role in repairing. Yes, even the cancer. Getting the best treatment team and following the recommendations of your medical team is key. Reducing stress and keeping a positive attitude are critical remedies as well.

So when the conversation goes down that path of placing blame, politely educate the naïve inquisitor. And when you’re thinking it’s all your fault, think again.

On my list of "to dos"!

But don’t free yourself from the responsibility of taking action, of taking control of your health in all the ways that you can. And whether you have a terminal illness or a progressive condition or are 100% healthy, start living like you don’t know what tomorrow will bring. Because the truth is—you don’t. 

Thanks for reading. As always, I’d love you to share this if you liked it. Now there’s some action you can take!