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MODULE 4

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THOUGHTS TO ACTIONS

It takes a decision to start participating in anything. All actions or behaviours begin with a thought. To determine if a person has crossed the line from healthy to unhealthy behaviours around diet and exercise, we need to look at their thoughts about themselves. It may be unhealthy thoughts that are the cause.

The problem for anyone, athlete or the average person, is when they start fuelling their mind with unhealthy thoughts about themselves. This is where crossing the line begins. The thought ‘I need to improve my speed’ is very different to ‘I’m not good enough’, ‘I must not be worth it’, or ‘unless I perform I am not valued or loved’. A traumatic event may cause feelings of guilt and shame that lead to negative self-thoughts.

Remaining relevant. It’s the key to success for both providers and receiver of services. As you know this is especially true at this time in the aged care sector.


4.1 The impact of unhealthy thought patterns

Unhealthy eating and exercise habits can become a means of dealing with the festering mess within the mind. Eating disorders are complicated. They are not a vanity issue, or merely a body image issue. They can affect anyone. The line is crossed in thought life. Irrational fears and phobias around diet and exercise develop in an attempt to control issues people may feel are beyond their control.

Eating habits and food become tangled with emotions and feelings. Food is labelled ‘good’ and ‘bad’. Extreme anxiety, fear, guilt, shame and worthlessness are experienced if the unhealthy rituals are ‘broken’ or disrupted. Sense of worth for the sufferer is reflected in
adhering to these rituals. The longer this continues, the harder these negative patterns are to break.

We can continue to try and treat the ‘seen behaviours’, and they need to be treated, but it is the underlying emotional issues that need to be addressed if true healing is to come. It is not merely a line that is crossed. It is a tangled mess of unhealthy levels of exercise and
dieting that are motivated by unhealthy thoughts. It is not merely about learning to love your body but more about learning to love who you are.


4.2 The impact of unhealthy thought patterns on psychological and physiological health

4.2.1 Thoughts, Beliefs and Interoception

Beliefs form the basis of our actions, particularly beliefs about ourselves. Depression and anxiety are comorbid with eating disorders giving an exaggerated negative image of self, others and the future. Beliefs and anxiety may interfere with accurate interoception and the cycle that this creates, particularly with eating disorders.

Interoception

Interoception involves sensing the physiological state of the body and the ability to accurately identify emotions. For example, sensing pain, temperature, itch, sensual touch, hunger, stomach discomfort related to low pH and intestinal tension or confusion over whether someone is feeling fear or anger. The interesting thing is that sensing these physiological signs is affected by our emotional state. To determine the impact of our emotions in regards to eating disorders and how interoception is affected, our beliefs need to be taken into consideration.

The Role of Beliefs and Interoception

A belief can be defined as a mental construct that affirms or denies truth and is closely linked to the judgment process. These processes provide insight to the link between self and interoception. False beliefs affect decision-making as the individual’s perception of reality is
distorted.

To put this into context, when I, Eleni, struggled with anorexia nervosa, the core belief I had was that I was not loved unless I did things and that I was not valued as I was not allowed to have an opinion. So I started exercising obsessively and eating less. As I did this, I had my parents’ attention, whereas before I felt ignored. The anxiety around not exercising or eating became worse and my thoughts raced constantly around food, exercise and the strict regimes I set for myself. If I broke these, the anxiety increased and I felt like a failure. So I would react by eating less and exercising more. I did not feel hunger or gauge the intensity at which I ran. I could not rationally evaluate what I was doing.


4.2.2 The effect of constant states of anxiety

Research has shown that the medial prefrontal cortex (mPFC) of the brain is active when a person’s thoughts are at rest as this is when self-reflection occurs, and the power of false beliefs decreases. This means if highly anxious states dominate, the false beliefs become
stronger and so the cycles continue. Being in a constant state of anxiety about food, exercise and thinking that I would lose worth or my parent’s attention, did not allow this state of rest to occur and so the false beliefs were strengthened.

In the case of bulimia nervosa, or binge eating disorder, the binge may represent an escape from self awareness, resulting from guilt and shame. In the process of the binge, anxiety increases and the sense of being full is not acknowledged. This adds to the guilt/shame and
the destructive cycle is strengthened.


4.2.3 The need to challenge false beliefs

This shows that false core beliefs need challenging in order to break these behaviours. I believe it takes professional help for a person to examine these beliefs and to determine their accuracy especially when they have existed for years. Ways of challenging these false
beliefs and then replacing them with accurate ones is vital to changing the behaviour and breaking the cycle. It is not easy and requires effort, but with the right help and support, it is possible.

Reference: http://link.springer.com/article/10.1007%2Fs00429-010-0258-9


4.3 The Development of Poor Habits

These patterns may become addictive. Whether these addictions are substances or behavioural, they have physical, psychological and social consequences

Addictive behaviours can:

  • Become obsessive whether activity, substance or object, despite negative effects on health, performance or relationships
  • Be difficult to cease
  • Cause heightened anxiety if they are interrupted
  • Are often comorbid with low self-esteem and depression
  • Make a person feel they are in control as long as they are engaging in the behaviour
  • Be denied as having negative consequences
  • Be hidden from family or close friends
  • Be extremely difficult to give up even if someone is wanting to
  • Cause distrust in relationships
  • Cause social isolation as the behaviour becomes the most important thing to maintain
  • Make it difficult to accurately describe emotions
  • Make it difficult to acknowledge physiological responses
  • Lead to irrational decision making
  • Affect outcomes in other areas of our lives

4.3.1 Self-Imposed Eating and Exercise Rules Cycle

IMAGE

In Module 1 you completed a mind map of yourself and in Module 2 and 3 we listed healthy and unhealthy behaviours relating to food and exercise. There may be so many more that we have not listed here and may not have to do with food or exercise, both healthy and unhealthy.

TABLE

Unhealthy Food Behaviours

Cut out food groups or particular foods without medical diagnosis
Follow someone else’s diet to suit you
Have a fear of certain foods
Be anxious about eating
Fear attending social events because of eating
Use supplements instead of whole foods
Avoid eating socially
Have an obsession with measuring, counting or weighing food and counting calories or fats
at the expense of physical, emotional, social and mental well-being.
Follow rigid eating rules
Label yourself as ‘bad’ or a ‘failure’ if you break diet rules
Label food with an emotional attachment or judgment
Have an over reliance on quick-fix strategies
Use compensatory behaviours such as vomiting, laxatives, diuretics, extreme fasting
Use food as a reward
Feed others but not eat
Excessively deny yourself of desired foods
Engage in excessive restricted eating
Restrict fluids or excessive drinking
Use water to suppress appetite
Use distracting behaviours to ignore hunger cues e.g. smoking/exercise
Use illegal or banned substances to control body composition
Not eat food prepared by others
Eat in secret
Eating abnormally amounts of food in a short space of time
Feel guilty after eating
Fear feeling full

Unhealthy Exercise Behaviours

Exercise while sick and injured Exercise as a means of punishment or control Not allow time to recover sufficiently causing poor performance, frequent illness, disturbed sleep and alterations in mood. Engage in guilt driven exercise without enjoyment Exercise through pain Label yourself as a failure if you break an exercise regime Use exercise as a reason to eat Engage in extended bouts of exercise of any kind (more than 60min) multiple times a day. Have an addiction or compulsion to exercise, including in private Experience anxiety related to inability to exercise Feel the compulsion to exercise more Have menstrual dysfunction due to excessive exercise and diet habits Have a compulsion to perform cardiovascular exercise.

Engage in deliberate behaviour to maximize energy expenditure Believe that exercise takes precedent over other life activities Use competitive sport as an excuse for extreme exercise regimes

Other unhealthy compensatory behaviours

Use of laxatives
Engage in purging
Smoke cigarettes
Use of diet pills
Drink unusually large amounts of water
Use of illegal substances to effect body composition

Using the table of unhealthy thoughts and actions write these around the Self-Imposed
Eating and Exercise Rules Cycle above, in the place that you feel they occur.

The beliefs we have of ourselves are powerful! Not only do they cause us to behave in certain ways, including diet and exercise behaviours, they may lead us to neglect other aspects of our lives. If negative beliefs are stronger than positive ones, we often don’t believe anything good about ourselves. Using diet and exercise to control our body size and shape is often NOT anything to do with appearance, but rather the need to feel in control of other circumstances and emotions. Actually it is the negative beliefs that control us!


4.3.2 The Binge Purge Cycle

In Module 2 we looked at lists of healthy V unhealthy eating and in Module 3 exercise behaviours. Our behaviours, whether healthy or not, at a certain point in time, serve a purpose. That purpose may be different for each of us at different points of time. The cause and effect needs to be examined to determine if these are healthy or not, but when we are caught up in these cycles, we may not clearly see what is really happening is actually unhealthy.

The Binge-Purge Cycle

DRAG AND DROP

Drag and drop the following words into the red boxes around this cycle where you feel they
belong:

  • Anxiety
  • Guilt
  • Control
  • Regain Control
  • Shame

4.3.3 Recognising your Emotions

Have you ever experienced the cycle above? Yes or No

Commented [1]: For Developer: If answer yes, people
get taken to Activity: Emotions in the Binge-Purge
Cycle, before they are taken to 4.3.4. If answer No,
people are taken direct to 4.3.4

Activity: Emotions in the Binge-Purge Cycle

DRAG AND DROP


4.4 Unhelpful Thinking Habits

Unhelpful thoughts usually occur before, during and after stressful situations. The longer we allow these thoughts to occur, the more they become a habitual way of thinking. The sooner we can identify these, the sooner we can start to examine them to determine how
realistic they are and if in fact they are founded. As soon as we determine that they are unfounded, it becomes easier to see ourselves and situations that cause distress in a new, more healthy way.

Match the Unhelpful Thinking Patterns below with its most appropriate description and example.

DRAG AND DROP


4.5 Risks of Unhealthy Habits on our Mind and Body

These thoughts, behaviours and cycles have long term effects on our physical, mental, social
and cognitive health. They are a rip off of lives that can be lived with joy and full of
potential! We take a look at some of the negative consequences of unhealthy coping
behaviours here.

4.5.1 Effects of long term starvation

Interactive body with hover over dots that when you hover over, the items below pop up.

Commented [4]: body systems image here to hover over
to show effects (fingers image or do we look for
separate body systems images?

Emotional disturbance
Dry yellow skin
Anxiety and mood fluctuations
Loss of bone density
Unable to care for self adequately
Increase Polycystic ovaries
Reduction or ceasing enjoyable activities
Decreased memory
Thinning hair
Dizziness
Poor concentration
Body Image Disturbance
Weakness and tiredness
Hypothermia
Education interrupted
Low self esteem
If prepubescent, incomplete secondary sexual characteristics e.g breast development, pubic
hair, beards in males
Decrease in quality of life
Low reproductive hormones (LH and FSH)
Importance of eating disorder above all else
Reduced brain volume
Muscle cramps
Cardiac dysrhythmia
Raised Cortisol levels
Depression
Progressive osteopenia
Menstrual disturbance/cessation
Obsessive-compulsive disorder
Loss of muscle strength
Linear growth impaired
Increased bone fractures
Infertility
Difficulty in engaging in intimate relationships
Employment difficulties
Social isolation especially eating with others
Feelings of guilt

https://www.youtube.com/watch?v=uKUSGOB-0V8 (unsure about this? What do you think Inger? Would it be a trigger for some or do we use it as learning?)

Commented [5]: Let me know what you think of this clip.Is it too much?
Commented [6]: Hmmmm… can we ask Sarah or another professional? Ps. the video is black. Audio
works, but not the image.

The video below is of French woman Isabelle Caro. It clearly shows how her environment impacted her thoughts and beliefs about herself. These in turn formed the foundation of unhealthy behaviours that led to anorexia. Sadly, she has since died from the complications of this illness.

https://www.youtube.com/watch?v=uKUSGOB-0V8 (anorexia’s childhood roots)

According to Isabelle’s story:
What does she describe her family life like?
What was her mother’s phobia and how did Isabelle interpret this?
What issues does Isabelle feel are difficulties she faces in this video?
Isabelle Caro died at age 28 on November 17, 2010


4.5.2 Risks of Purging, laxative use and diuretics

Commented [7]: body systems image here to hover over
to show effects (fingers image or do we look for
separate body systems images?

Interactive body with hover over dots that when you hover over, the items below pop up.

Extreme feelings of guilt and shame
Heightened anxiety
Eating in private
Calluses on knuckles
Purging behaviours dominate daily life
Secretive behaviours
Avoids eating with others
Relationship difficulties
Lethargy
Feeling bloated
Derogatory thoughts about self
Physical self loathing
Constipation
Swelling or puffiness of the skin (Oedema)
Other self harm behaviours
Poor impulse control
Dehydration
Salivary glands may be enlarged
Possible alcohol and drug abuse
Fatigue
Body Image Disturbance
Abdominal pain
Electrolyte abnormalities
Increased tissue pH levels
Swollen hands and feet
Low self esteem
Erosion of dental enamel
Metabolic acidosis
Gastric dilation
Risk of gastric rupture
Cardiomyopathy
Heart Conduction abnormalities
Abnormal electroencephalographic (EEG) findings
Hormone abnormalities
Menstrual disturbances
Thyroid stimulating hormone disturbance
Coronary Heart disease
Fluctuating Body weight
Obsessive-Compulsive behaviours


4.5.3 Risks of Binging

Commented [8]: body systems image here to hover over
to show effects (fingers image or do we look for
separate body systems images?

Interactive body with hover over dots that when you hover over, the items below pop up.

Eat more rapidly than normal
High blood pressure
Extreme feelings of guilt and disgust with one’s self
Eat alone
Obesity may be common in those who binge
Depression
Increased risk of stroke
Low self esteem
Diabetes
Heart Disease
https://www.youtube.com/watch?v=NPgHu2Lup94 A first Person account of Binge Eating
Disorder (male)


4.5.4 Muscle Dysmorphia

Interactive body with hover over dots that when you hover over, the items below pop up.
Compulsive need to maintain training schedule
Loses focus on work commitments
Loses focus on recreational activities
Increased anxiety to expose body to others
Preoccupied with inadequacy of muscle mass
Continued training despite injury
Constant mirror watching
Abuse of steroids and other substances
Body image disturbance
Obsessive compulsive behaviours
Extreme anxiety
Impaired social functioning
Rigid dietary Intake
Excessive exercise
Mood disorders
Muscular- Skeletal injuries
Renal Failure
Cardiac complications

Considerations
Which of these health risks do you recognise in yourself?
Are there any health risks mentioned that you were not aware of?
We strongly recommend having a medical assessment to check any areas of concern.


4.6 Contraindications and Medical Complications

The risks mentioned above present serious contraindications for exercise. Contraindications are activities that may be harmful to a person.

  • Impact activities are totally discouraged if risk of osteopenia and/or osteoporosis
  • Increased Cardiovascularcomplications if decrease in heart size from starvation.
  • No exercise if BMI lower than 14
  • Cardiorespiratory Exercise is contraindicated for anyone that engages in vomiting as a compensatory behaviour due to electrolyte disturbances
  • Dizziness, palpitations and /or angina.
  • Peripheral edema; tiny blood vessels may leak fluid into surrounding tissue
  • Renal, liver and cardiac complications from substance abuse

4.7 Impact of Gut Health on the Mind

Another interesting consideration is the growing research on gut microbiota and how this impacts mental health. Anxiety is a common trait for all eating disorders and this has a huge impact on the diversity of gut microbiota and the hormones that influence positive mental
health. Combines with restrictive eating, substance abuse, compensatory behaviours and possible substance abuse, these dynamics are worth consideration.

Diet, Gut Microbiota and Mental Health.

The biggest contributor to mortality globally is a poor diet. Depression and anxiety, which often have a comorbidity with substance abuse, are the largest of the depressive disorders. The effects of diet on physical and mental health are well documented. In fact, over the last five years, close to 4,000 articles have been published on microbiota and gut health. The gastrointestinal system is the largest immunity organ of the body. This article will take a look at the links between gut health and mental health.

What are the Gut Microbiota?

Gut microbiota are microorganisms that are present in the gut. There are 1014 gut microbiota, 10 times the number of human cells and 2/3 of these are specific to each person. They are like our identification, with more than 3 million genes. That is 150 times more than human genes. Their functions include aiding digestion, production of vitamin B and K, fighting against other microorganisms to maintain intestinal health and supporting the immune system (1).

There are over 1,000 species of these microbiota and certain species of these bacteria have a role in the production of organic chemicals that known as neurotransmitters.

Some of these are neurotransmitters include:

• Norepinephrine acts as a hormone neurotransmitter in the brain.
• Serotonin is primarily produced and found in the gut and central nervous system and helps regulate body processes, constrict smooth muscle and contributes to well-being and happiness.
• Dopamine is produced is several areas of the brain and helps control the brain’s reward and pleasure centres and regulates movement and emotional responses.
• Tryptophan is an essential amino acid that the body cannot produce and must be obtained via the diet and is a precursor for serotonin and melatonin production.

How does this impact mental health?

The vagus nerve is a direct connection between the brain and the stomach and transmits changes in hormones, neurones and bacterial alterations in the
bowel to the brain.

Changes in gut microbiota occur due to highly processed diets which are high in sugar and fat, stress and chemical substances.

An imbalance of our gut microbiota decreases levels of norepinephrine and dopamine in the brain. Tryptophan cannot be synthesised efficiently and this
then affects serotonin and melatonin production 1.

Diets high in fat, sugar and low-fibre carbohydrate result in systemic inflammation as harmful bacteria and foreign antigens seep through the damaged lining of the gut epithelial wall, into the bloodstream and eventually to the brain (2). Comorbid behaviours to anxiety are often binge drinking and other substance abuse. This causes more alterations to gut microbiota, further depleting the organic neurotransmitters. Cortisol levels increase in this stressful systemic environment further contributing to systemic inflammation.

Foods that promote healthy gut microbiota:
The International Society for Nutritional Psychiatric Research (ISNPR) exist to grow in the field of nutritional psychiatry. They have produced many papers on a range of topics associated with gut microbiota health and the effects on depression and other psychiatric disorders. Research has found that the following foods provide antioxidant properties and
positively influence intestinal microbiota including an increase of lactobacilli and bifidobacteria and ultimately improving brain health and depression:

• Fibre-rich carbohydrates
• Whole fruits and vegetables
• Cocoa
• Coffee
• Green Tea
• Blueberries
• Curcumin
• Fermented rice
• Foods rich in Omega 3 Fatty acids

Magnesium and Zinc also assist in preserving the diversity of gut microbiota and decreasing the systemic burden. In fact, research consistently shows that low levels of zinc in the diet is linked to long-term depression (2).

In 2009, research by Sanchez-Villegas et al., revealed after a 10-year follow-up of individuals involved in a seminal study, that the Mediterranean-style diet, had reduced the risk of depression (3). In 2010, an Australian study determined that a diet including vegetables, fruit,
beef, lamb, fish and wholegrain foods, had a positive effect on reducing the risk of anxiety disorders and major depressive disorder (4).


4.7.1 The Impact of Exercise on Gut Health

Exercise has also been well documented in reducing the risk and also improving depression and anxiety. In relation to the diversity of gut microbiota and exercise is
closely related to diet. As mentioned above a processed diet high in fats and refined carbohydrates with no physical activity levels can lead to obesity, causing systemic inflammation and changes in the diversity of gut microbiota.

However, excessive exercise combined with restrictive dieting, where many food groups are eliminated, can also have a negative effect of the diversity of gut microbiota. A study by Clarke et al., concludes that exercise can be beneficial in improving gut health but this is a complicated relationship affected by dietary extremes.5. Excessive exercise is often characterised by anxiety if exercise sessions are missed and this stress also affects gut health.

This is just a brief introduction and summary of a few articles on the growing research on this topic. A balance of exercise and a diverse diet, low in processed foods and low in harmful behaviours often used to manage stress, can positively impact the diversity of systemic inflammation and gut microbiota. This is also the case for chronic physical illnesses like obesity and diabetes. Medical consultation and supervision are always recommended.

More research articles can be found at http://www.isnpr.org

References:

1. Evrensel, A., & Ceylan, M. E. (2015). The gut-brain axis: the missing link in depression. Clinical Psychopharmacology and Neuroscience,
13(3), 239.
2. Bested, A. C., Logan, A. C., & Selhub, E. M. (2013). Intestinal microbiota, probiotics and mental health: from Metchnikoff to modern
advances: Part II–contemporary contextual research. Gut pathogens, 5(1), 3.
3. Sanchez-Villegas A, Delgado-Rodriguez M, Alonso A, et al. Association of the Mediterranean dietary pattern with the incidence of
depression: the Seguimiento Universidad de Navarra/University of Navarra follow-up (SUN) cohort. Arch Gen Psychiatry 2009; 66: 1090-
1098. <PubMed>
4. Jacka FN, Pasco JA, Mykletun A, et al. Association of Western and traditional diets with depression and anxiety in women. Am J
Psychiatry 2010; 167: 305-311. <PubMed>
5. Clarke, S. F., Murphy, E. F., O’sullivan, O., Lucey, A. J., Humphreys, M., Hogan, A., … & Kerins, D. M. (2014). Exercise and associated
dietary extremes impact on gut microbial diversity. Gut, gutjnl-2013.

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