essay about we are what we eat

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Weirdly True: We Are What We Eat

• Vasundhara Sawhney

Research shows that there is a direct correlation between spicy foods and aggression.

Food is fuel for our bodies. But it doesn’t just give us energy, it can also impact our moods. Knowing this, how can we make better food choices?

• Our gut or gastrointestinal tract is home to billions of bacteria. The food we eat directly affects our gut health (or the balance of good and bad bacteria) and influences the production of neurotransmitters (our body’s chemical messengers that are constantly carrying messages from the gut to the brain).
• Because different foods trigger different moods, we can strategically choose foods that evoke desirable mood-states. For keeping our moods even and balanced, especially in the work environment, we can consume foods that promote good bacteria in our guts.
• We should also consider the physiological reactions various foods trigger. For example, it might make sense to serve and consume a mild or sweet fare during a get-together with friends and family, and, maybe consume spicy food ahead of a confrontational meeting in which we don’t want to be run over.

What do you turn to when you’re feeling low?

• Vasundhara Sawhney is a senior editor at Harvard Business Review.

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You Are What You Eat—And What It Eats Too

A dozen years ago, a New York Times Magazine article titled “Power Steer” changed the way Americans thought about meat. “We are what we eat, it is often said,” wrote author Michael Pollan, “but of course that is only part of the story. We are what what we eat eats too.”

A bit of an awkward phrase, perhaps, but a salient point, not lost on the thousands of Americans who collectively plunk down $380 million a year for grass-fed beef. When we eat animals, we are inheriting their diet—as well as several other aspects of their lives.

But what about when we eat plants? Plants don’t, strictly speaking, eat , but they are no less embedded in their ecological relationships than animals are. Perhaps most importantly, plants take up nutrients from the soil in which they grow, and the meal on offer varies tremendously depending on how that soil is managed. So does it matter, for human nutrition, what our plant-based foods eat?

Organic farmers Doug Crabtree and Anna Jones-Crabtree grow a diverse rotation of 21 different crops at Vilicus Farms in Havre, MT

Healthy soils –> healthy plants –> healthy people?

Recent research from a team of authors led by Newcastle University professor Carlos Leifert suggests it does matter what our plants “eat.” Analyzing 343 studies that compared the nutrient content of organic and conventional food, Leifert and his colleagues found that the organic crops contained an average of 17 percent more antioxidants than the conventional ones and that the effect was particularly pronounced in certain crops, for which organic management offered as much as a 60 percent antioxidant boost. Flavanones, associated with a lower risk of stroke , were an average of 69 percent higher in organic foods tested. Data on pesticide residues varied across the studies, but showed a clear trend: overall levels of pesticides were ten to 100 times lower in organic food.

This study offers some of the best evidence yet that healthy soils lead to healthier plants, and, very likely, healthier people. And here’s the kicker: it’s probably a gross underestimation. Here’s why:

Next generation organics: Beyond the no-no approach

From the plant’s eye view, the certified organic diet is rather like the old-school crash diet you might have tried before prom: it’s all about what you don’t eat. While organic certifiers encourage proactive soil management practices like composting, cover cropping, and soil-building crop rotations, the segment of our organic laws and standards with legal teeth is the list of no-nos: the chemicals that organic producers are not allowed to use. Observing these no-nos is critical for human health—not just to reduce pesticide residue on food , but to reduce chemical exposure for farmworkers and rural communities, and to reduce the carbon footprint of our food system.

And yet, to truly reap the potential of paying attention to what our food plants eat, we need to put them on a more comprehensive diet: the kind that emphasizes eating the good stuff, rather than just avoiding the bad stuff. We don’t have a widely-used system of standards to track which plants are eating good stuff, so this is where knowing your farmer comes in handy.

Meet the Lentil Underground

As part of my dissertation research at UC Berkeley, I got to know a group of farmers in Montana who’ve been assiduously paying attention to their plants’ diets since the late 1980s. At that time,

Jerry Habets, an organic farmer in Conrad, MT, is experimenting with a triple intercrop of buckwheat, Black Kabuli chickpeas, and Petite Crimson lentils. Photo credit: Su Evers.

Montana agriculture was dominated by chemically supported wheat monoculture, and the result was soil erosion and rural bankruptcy. So a handful of farmers decided to revamp their farms to provide a better base of soil nutrients. Instead of just planting one crop that was designed to draw nutrients out of the soil, they developed a rotation of crops that would also contribute nutrients back: a community of plants that would feed one another.

Because most of these farmers eat their own crops, they understand on a visceral, anecdotal level that better plant nutrition translates into better human nutrition. I’ve mentioned the Leifert et al. study to a few of them, and they weren’t surprised to learn that organic crops came out 17% ahead of conventional ones in terms of antioxidants. They wondered how much higher that number could be if organic certification standards were explicitly focused on improving plant nutrition, instead of just eliminating the most toxic chemicals. They’d love to partner with researchers to improve the nutritional performance of their systems and pack their lentils and grains full of micronutrients, and they’ve been working with Dr. Alison Harmon, Associate Professor of Food and Nutrition at Montana State University , to educate the public about how to cook and eat lentils.

Of course, this isn’t how American land grant universities have traditionally approached nutrition (of either soil, ecosystems, or humans), so the researchers and the funding needed to do these studies are extremely scarce. But, a growing number of scientists are pushing for change and the USDA is considering taking environmental sustainability into account in our national dietary guidelines–for the first time ever. We may be getting closer to integrating the science of agroecology and the science of nutrition, toward a holistic approach that would follow nutrients from the soil, to plants and animals, to human bodies. As Sir Albert Howard famously wrote in his Agricultural Testament , it’s all one subject.

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Philosophy of Food

Guidelines for an Authentic Approach to Eating

• Philosophical Theories & Ideas
• Major Philosophers

• Ph.D., Philosophy, Columbia University
• M.A., Philosophy, Columbia University
• B.A., Philosophy, University of Florence, Italy

A good philosophical question can arise from anywhere. Did you ever think, for example, that sitting down to dinner or strolling through the supermarket might serve as a good introduction to philosophical thinking? That is the foremost philosopher of food’s credo .

What’s Philosophical About Food?

Philosophy of food finds its basis on the idea that food is a mirror. You may have heard the saying ‘we are what we eat.’ Well, there is more to say regarding this relation. Eating mirrors the making of a self, that is, the array of decisions and circumstances that bring us to eat the way we do. In them, we can see reflected a detailed and comprehensive image of ourselves. Philosophy of food reflects on the ethical, political, social, artistic, identity-defining aspects of food. It spurs from the challenge to more actively pondering our diets and eating habits so as to understand who we are in a deeper, more authentic way.

Food as a Relation

Food is a relation. Something is food only with respect to some organism, in a set of circumstances. These, first of all, are bound to vary from moment to moment. For instance, coffee and pastry are a fine breakfast or afternoon snack; yet, to most of us they are unpalatable for dinner. Secondly, circumstances are bound to involve principles that are, at least in appearance, contradictory. Say, you refrain from eating soda at home, but at the bowling alley, you enjoy one. At the supermarket, you buy only non-organic meat, but on vacation, you crave for a McBurger with fries. As such, any given ‘food relation' is first and foremost the mirror of an eater: depending on the circumstances, it represents the eater’s needs, habits, convictions, deliberations, and compromises.

Food Ethics

Probably the most obvious philosophical aspects of our diet are the ethical convictions that shape it. Would you eat a cat? A rabbit? Why or why not? It’s likely that the reasons you give for your stance are rooted in ethical principles, such as: “I love too much cats to eat them!” or even “How could you do such a thing!” Or, consider vegetarianism: a large number of those who conform to this diet do so to prevent unjustified violence being done to animals other than human. In Animal Liberation , Peter Singer labeled “speciesism” the attitude of those who draw unjustified distinctions between Homo sapiens and other animal species (like racism sets an unjustified distinction between one race and all others). Clearly, some of those rules are mingled with religious principles: justice and heaven can come together on the table at, as they do on other occasions.

Food as Art?

Can food be art? Can a cook ever aspire to be an artist on a par with Michelangelo, Leonardo, and Van Gogh? This question has spurred heated debates over the past years. Some argued that food is (at best) a minor art. For three main reasons. First, because foods are short-lived in comparison to, e.g., chunks of marble. Second, food is intrinsically linked to a practical purpose – nourishment. Third, food depends on its material constitution in a way in which music, painting, or even sculpture are not. A song such as “Yesterday” has been released on vinyl, cassette , CD, and as a mp3 ; food cannot be alike transferred. The best cooks would hence be very good artisans; they can be paired with fancy hairdressers or skilled gardeners. On the other hand, some think that this perspective is unfair. Cooks have recently started featuring in art shows and this seems to concretely disprove the previous remarks. Probably the most famous case in point is Ferran Adrià, the Catalan chef who revolutionized the world of cooking over the past three decades.

Food Experts

Americans keep in high esteem the role of food experts; French and Italians notoriously do not. Probably, it’s because of different ways to regard the practice of evaluation of a food. Is that French onion soup authentic? The review says the wine is elegant: is that the case? Food or wine tasting is arguably an entertaining activity, and it’s a conversation starter. Yet, is there a truth when it comes to judgments about food? This is one of the hardest philosophical questions. In his famous essay “Of the Standard of Taste”, David Hume shows how one can be inclined to answer both “Yes” and “No” to that question. On the one hand, my tasting experience is not yours, so it is totally subjective; on the other, provided an adequate level of expertise, there is nothing odd with imagining to challenge a reviewer’s opinion about a wine or a restaurant.

Food Science

Most foods we buy at the supermarket carry on their labels “nutritional facts”. We use them in order to guide ourselves in our diet, to stay healthy. But, what do those numbers have to do really with the stuff we have in front of us and with our stomachs? What “facts” do they help us establishing really? Can nutritionism be regarded as a natural science on a par with – say – cell biology? For historians and philosophers of science, food is a fertile terrain of research because it raises basic questions regarding the validity of laws of nature (do we really know any law regarding metabolism?) and the structure of scientific research (who finances the studies on the nutritional facts you find on the labels?)

Food Politics

Food is also at the center of a number of funding questions for political philosophy. Here are some. One. The challenges that food consumption poses to the environment. For example, did you know that factory farming is responsible for a higher rate of pollution than airfare travel? Two. Food trades raise issues of fairness and equity in the global market. Exotic goods such as coffee, tea, and chocolate are chief examples: through the history of their commerce, we can reconstruct the complex relationships between continents, States, and people over the past three-four centuries. Three. Food production, distribution, and retail is an opportunity to talk about the condition of workers across the earth.

You Are What You Eat: Essay Example

You are what you eat essay introduction.

• Healthy eating habits

We Are What We Eat Essay Conclusion

A person living a modern life should learn to eat healthy since whatever a person eats will determine their health condition in the long run. Eating healthy would lead to being in good condition, but eating junk food would lead to complications to one’s health.

The human body has a way of regulating some of the functions of the body in order to remain healthy, but the body would react to what it is fed on.

Certain types of foods are essential for the functioning of particular parts of the human body. The different types of foods that contain vitamins, proteins, and carbohydrates are necessary in the human diet. Fats are also essential for the body’s functioning, and a lack of it in the diet might be very dangerous.

Healthy Eating Habits

Healthy eating habits include adopting a healthy diet in daily meals. This diet would ensure that one leads and maintains good general health. Modern lifestyle involves eating junk foods that are not necessarily healthy.

This might cause many diseases and conditions that would have otherwise been avoided if a healthy diet were adopted. The types of diseases that can be avoided using healthy foods include hypertension, cancer, heart disease, and obesity. Healthy eating habits include the taking of appropriate amounts of both macronutrients and micronutrients (Fernandez & Calle, 2010).

Healthy living involves consuming the correct amounts of essential nutrients and drinking adequate amounts of water daily. It is not enough to take all the vital nutrients; having them in the right quantities is also crucial. Eating a limited amount of nutrients may lead to deficiency, while eating them in excess may also lead to serious conditions and diseases. Water is an important part of a diet since it makes up at least 60% of the human body.

Many people today are classified as overweight and obese. This condition occurs when a person feeds on excess fats and carbohydrates and fails to exercise to reduce these amounts in the body (Katz, 2003).

Since the body reacts to whatever it is fed on, it tends to store the excess carbohydrates and fats (lipids) in the adipose tissue below the skin. This forms a thick layer below the skin, which explains why people grow fat.

Overweight or obese individuals have a high Body Mass Index (BMI), which has been proven through research to affect the individual’s mobility and performance.

Obese individuals have trouble when moving or performing tasks due to the immense weight they carry whenever they work. Therefore, research suggests that a person should maintain a normal weight, which is achieved through eating healthy and exercising.

Although fats have negative effects when taken in excess, there is even greater danger when one adopts a no-fat diet. Many advertisements talk about the benefits of a no-fat diet (fad diet,) and multiple individuals seeking to either lose weight or maintain their physique follow them.

However, research does not advocate for this due to fats (lipids or fatty acids) having important functions in the body (Strychar, 2006).

Taking food without fats may turn fatal due to the body’s inability to perform some of the functions that are enabled by the presence of fats. Firstly, the body of the organism may lack the ability to absorb some essential vitamins such as vitamin K, D, E, and A.

These are the fat-soluble vitamins and need dietary fats to absorb properly. Lack of these vitamins in the body leads to various diseases and conditions, such as night blindness and rickets. The body’s immune system would also be deteriorated due to the lack of these vitamins.

Research has also confirmed that a no-fat diet might affect mental health and is a likely cause of depression (Maes, 1996). Research also suggests that low intake of essential fatty acids (caused by a no-fat diet) increases the chances of getting breast, colon, or prostate cancer. This is caused by the lack of omega-3s in the body.

No-fat diets also have a part to play in heart disease and cholesterol levels. This is because a diet without fat causes the good cholesterol (HDL) to reduce and the bad cholesterol to be accumulated in the liver (Mensink, Zock, Kester, & Katan, 2003). Heart disease develops when the good and the bad cholesterol go out of balance. Therefore, fats are essential to the human body.

A healthy diet also needs to have portions of fruits served to the individual. Fruits provide essential micronutrients such as vitamins. Vegetables also provide essential vitamins to the body. Lack of vitamins may put the individual at risk of suffering ischaemic heart disease, gastrointestinal cancer, stroke, and many other complications.

A modern person should adopt a diet that constitutes the right amount of proteins too. Proteins are important for the individual’s growth. They also make up many body structures, including hair, skin, and muscles.

Proteins also aid in the regeneration of dead cells in the body, which is why they play a vital role in a person’s survival. A modern individual should also ensure that the meal has minerals such as iodine, calcium, magnesium, potassium, and sodium. Iodine has been made easily available in the iodized salt. These minerals are required in small amounts, but their functions are quite important.

It is important for every individual to adopt a healthy eating habit. The modern person faces various challenges due to the types of food that are available in the market nowadays. The cheapest, easily available foods are junk foods that are not usually healthy. They may contain excesses of certain nutrients and may cause the body to strain a lot while trying to eliminate them.

Fernandez, M., & Calle, M. (2010). Revisiting dietary cholesterol recommendations: Does the evidence support a limit of 300mg/d. Current Atherosclerosis Reports, 12(6), 377-383.

Katz, D. (2003). Pandemic obesity and the contagion of nutritional nonsense. Public Health Review, 31(1), 33-44.

Maes, M. (1996). Fatty acid composition in major depression: Decrease ὠ3 fractions in cholesteryl esters and increased C20:4ὠ6 ratio in cholesteryl esters and phospholipids. Journal of Affective Disorders, 38(1), 35-46.

Mensink, R., Zock, P., Kester, A., & Katan, M. (2003). Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: A meta-analysis of 60 controlled trials. American Journal of Clinical Nutrition, 77(5), 1146-1155.

Strychar, I. (2006). Diet management of weight loss. Canadian Medical Association Journal, 174(1), 56-63.

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We Are What We Eat

After traveling to five different countries (Greenland, Bolivia, Malaysia, Pakistan, Crete) in search of the origins of the human diet, Matthieu Paley comes to the last stop in his journey, Tanzania.

Social Studies, World History

Kongolobe Berries

The Hadza people of Tanzania rely on hunting animals and gathering wild fruits and vegetables for food, such as these colorful kongolobe berries (Grewia bicolor)​​​​​​​.

Photograph by Matthieu Paley

I am a photographer and I take pictures for National Geographic magazine. I came to Tanzania to look for a community that doesn't get any of its food from outside sources. I wanted to take pictures of a people who get their food in an ancient way. Everything they ate either had to be gathered, hunted, grown or herded.

I decided to visit the Hadza people, who have what are probably the most ancient food customs on Earth.

The meat the Hadza eat comes only from hunting, which they do with bow and arrow. To experience a Hadza hunt, I tailed along with two hunters, named Kauda and January.

We walked for three days in search of game. We shot at a warthog ( Phacochoerus africanus ), but the arrow just bounced off its head. Other animals were too far away to shoot at.

Then, we saw a huge giraffe in the distance. January took off his sandals to avoid making noise and walked barefoot and half-bent for half a mile. When he was close enough he carefully aimed and shot off a poisoned arrow. Not for fun or because I was there, but to get food for himself and his people.

No Giraffe Meat this Time

Large animals like giraffes provide so much meat that the whole Hadza camp moves next to a kill. The camp is made up of between 20 and 30 people.

January's arrow went in near the giraffe's stomach. We then tracked the wounded animal for over an hour. It started to get "drunk" as the poison took effect. After a while, January said we needed to return to camp before it got dark. We would continue tracking in the morning. 

The next day, we set out to look for the giraffe, but the track had grown faint. The giraffe had survived the poison and moved on. 

On our way back to the camp, Kauda spotted a hyrax sitting on a rock and managed to kill the creature. It looked like a large rat, though I've read hyraxes are distantly related to elephants. That was the end of my hunting story. Instead of a large and mighty giraffe, we had to settle for a small, ratlike creature.

Don't Worry, Be Happy

The Hadza do not grow crops, herd animals or even store any food. There is nothing to eat at camp in the morning. Each day, they walk in the surrounding plain for a few hours and gather berries, honey, tubers , and baobab -fruits. And yes, sometimes they kill animals. However, they do not hunt for cruel fun or out of greed, but simply to feed themselves.

Our ancestors all had that lifestyle at some point in history. The Hadza are one of the oldest peoples on Earth, perhaps even the very oldest. Some scientists believe they have been where they are for 50,000 years.

The Hadza travel from place to place, with no fixed home. They live in camps made of twigs covered with grass, like upside-down nests. When they leave a camp behind, the twigs and grass fall off and go back into the soil. There are no graveyards, no piles of garbage, no traces left behind. Over thousands of years, the Hadza have caused no damage to their environment.

What struck me most about the Hadza is how happy they seem. In their language, there is no word for "worry." Worrying is related to either the future or to the past. The Hadza truly live in the moment. When you spend your time focusing on the here and now, on day-to-day living, there is no need for worrying about unimportant things. The Hadza may have something to teach us.

Article originally published on December 10, 2014, this material has been adapted for educational use.

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Scroll to the end of the article for a list of dishes and their origins.

• PHOTOGRAPHY

A Photographer’s Quest for People Who Eat Like Their Ancestors

Matthieu Paley traveled to remote communities around the world in search of the origins of what we eat.

These days, documenting our dinners for the Internet is a universal pastime: sharing your food means that you don’t dig into your plate until you’ve taken a picture of it with your phone and posted it to your social networks.

We embraced this form of photography for our story, “ The Evolution of Diet ” in the September 2014 issue of National Geographic magazine. Photographed by Matthieu Paley and written by Ann Gibbons, the story traces the food our ancestors ate to see what we could learn from them for feeding two billion more people by 2050.

A Bajau fisherman clutches an octopus he speared after diving from his boat. A Bajau baby (right) naps by a pan of abalone that will be his family’s dinner.

What Matthieu and I learned in our story research is that early humans adapted to live off the land regardless of how harsh the environment they found themselves in. In our quest to find some of the oldest human diets that still exist today, Matthieu traveled through ice, jungle, savannah, mountains, sea and valley in order to show the inextricable link between the unique places we live, the resulting food we eat, and how diet shapes our culture. “Food is a great source of surprises. My stomach handled it all quite well,” he says. “The trouble was more dealing with the environment that comes with the food.”

The Tsimane of Bolivia get most of their food from the river, the forest, or fields and gardens carved out of the forest.

In many of the communities we visited, obtaining enough food from the landscape to feed the family was still a matter of simple survival. Matthieu went foraging with the Tsimane people on the forest floor of the Bolivian Amazon, and he accompanied the Inuit in Greenland on seal hunts in ice-laden waters under the fading winter light. He went free-diving to spear hunt underwater with Bajau fishermen in Malaysia, and climbed trees with the Hadza people in Tanzania to harvest honeycombs and eat them on the spot, larvae and all.

An Inuit girl feeds her brother (left) a bit of liver from a seal their father has just caught. What’s not eaten right away will stay frozen in outdoor sheds; one family’s “freezer” holds the meat, ribs, and jaw of a killer whale and a foreflipper of a bearded seal

“In Bolivia and Tanzania, the kitchen was everywhere and nowhere. And no plates in sight,” Matthieu recalls. “In other countries, the kitchen is a very intimate place – like walking in someone’s bedroom. In the sacred sense, it is the place where the family’s survival is ensured, where the bounty ends up.”

The resulting images that Matthieu brought back from his journey present a global story about how the human race learned to eat and survive in the most diverse corners of the world. We are what we eat—or at least what our ancestors ate.

Wande and her husband, Mokoa, set out to find food together. The Hadza of Tanzania are the world’s last full-time hunter-gatherers.

Related Topics

• INDIGENOUS PEOPLES
• PEOPLE AND CULTURE

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Home — Essay Samples — Nursing & Health — Dieting — You Are What You Eat

You Are What You Eat

• Categories: Dieting

About this sample

Words: 508 |

Published: Jan 30, 2024

Words: 508 | Page: 1 | 3 min read

Table of contents

Body paragraph 1: physical health, body paragraph 2: mental health, body paragraph 3: emotional well-being, counter-argument and rebuttal, references:.

• Hu, F. B., et al. "White rice, brown rice, and risk of type 2 diabetes in US men and women." Archives of Internal Medicine , vol. 170, no. 11, 2010, pp. 961-969.
• Lassale, C., et al. "Association between a dietary quality index based on the food standards agency nutrient profiling system and cardiovascular disease risk among French adults." International Journal of Cardiology , vol. 203, 2016, pp. 698-703.

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We Are What We Eat

Michael Pollan follows a bushel of corn through the industrial food system. What he discovers affects pretty much everything you eat. 

If you are what you eat, and especially if you eat industrial food, as 99 percent of Americans do, what you are is "corn."

During the last year I've been following a bushel of corn through the industrial food system. What I keep finding in case after case, if you follow the food back to the farm — if you follow the nutrients, if you follow the carbon — you end up in a corn field in Iowa, over and over and over again.

Take a typical fast food meal. Corn is the sweetener in the soda. It's in the corn-fed beef Big Mac patty, and in the high-fructose syrup in the bun, and in the secret sauce. Slim Jims are full of corn syrup, dextrose, cornstarch, and a great many additives. The “four different fuels” in a Lunchables meal, are all essentially corn-based. The chicken nugget—including feed for the chicken, fillers, binders, coating, and dipping sauce—is all corn. The french fries are made from potatoes, but odds are they're fried in corn oil, the source of 50 percent of their calories. Even the salads at McDonald's are full of high-fructose corn syrup and thickeners made from corn.

Corn is the keystone species of the industrial food system, along with its sidekick, soybeans, with which it shares a rotation on most of the farms in the Midwest. I'm really talking about cheap corn — overproduced, subsidized, industrial corn — the biggest legal cash crop in America. Eighty million acres — an area twice the size of New York State — is blanketed by a vast corn monoculture like a second great American lawn.

I believe very strongly that our overproduction of cheap grain in general, and corn in particular, has a lot to do with the fact that three-fifths of Americans are now overweight. The obesity crisis is complicated in some ways, but it's very simple in another way. Basically, Americans are on average eating 200 more calories a day than they were in the 1970s. If you do that and don't get correspondingly more exercise, you're going to get a lot fatter. Many demographers are predicting that this is the first generation of Americans whose life span may be shorter than their parents'. The reason for that is obesity, essentially, and diabetes specifically.

Where do those calories come from? Except for seafood, all our calories come from the farm. Compared with the mid-to-late 1970s, American farms are producing 500 more calories of food a day per American. We're managing to pack away 200 of them, which is pretty heroic on our part. A lot of the rest is being dumped overseas, or wasted, or burned in our cars. (That's really how we're trying to get rid of it now: in ethanol. The problem is that it takes almost as much, or even more, energy to make a gallon of ethanol than you get from that ethanol. People think it's a very green fuel, but the process for making it is not green at all.)

Overproduction sooner or later leads to overconsumption, because we’re very good at figuring out how to turn surpluses into inexpensive, portable new products. Our cheap, value-added, portable corn commodity is corn sweetener, specifically high-fructose corn syrup. But we also dispose of overproduction in corn-fed beef, pork, and chicken. And now we're even teaching salmon to eat corn, because there's so much of it to get rid of.

There is a powerful industrial logic at work here, the logic of processing. We discovered that corn is this big, fat packet of starch that can be broken down into almost any basic organic molecules and reassembled as sweeteners and many other food additives. Of the 37 ingredients in chicken nuggets, something like 30 are made, directly or indirectly, from corn.

Now, how do you get people to eat so much of this reengineered surplus corn? That took the ingenuity of American marketing. One example is supersizing. When I was a kid, Coke came in these lovely little eight-ounce glass containers. Today, a 20-ounce container is the standard size for soda. The idea that you could sell soda that way was an invention. It has a history, and you can find the individual responsible, an ingenious movie theater manager named David Wallerstein, who invented the idea of supersizing and sold it to Ray Kroc, founder of McDonald's.

Before you go out and sue McDonald's over the size of your waistline, consider that overproduction of cheap corn is government policy. It's done in the name of the public interest, using our taxpayer dollars. American taxpayers subsidize every bushel of industrial corn produced in this country, at a cost of some four billion dollars a year (out of a total of 19 billion dollars in direct payments to farmers).

But before you blame subsidies for all these problems keep in mind that agricultural overproduction is an ancient problem that long predates subsidies. In any other business, when the price of the commodity you're selling falls, the smart thing to do is to curtail production until demand raises prices. But farmers don't do that, because there are so many of them, and because they all operate as individuals, without any coordination. So when prices fall farmers actually expand production, in order to keep their cash flow from falling. This economically and environmentally disastrous phenomenon has resulted in an increase in the American corn harvest from four billion to ten billion bushels since the 1970s.

How do we begin to change this system? First, we all need to begin to pay attention to the Farm Bill, working to develop farm programs that allow farmers to stay in business without falling into the trap of overproduction. Most city people don't realize the stake they have in it. They assume it's a parochial concern of members of Congress from farm states, but it's not. If it were called the Food Bill , I think we would all pay a lot more attention to it, and get a saner result. The Farm Bill sets out the rules of the game that everyone is playing in, whether you're an industrial or an organic farmer, whether you're eating industrially or not.

The other thing we can do is become responsible consumers. I’ve never liked the word "consumer." It sounds like a character who’s using up the world, rather than creating anything. I was at a gathering in Italy last October where Carlos Petrini, the founder and president of Slow Food International, offered a wonderful redefinition of the word. He called the consumer a “cocreator.” I think that’s exactly right, and we’ve seen why: with the organic movement, consumers and farmers have shown how they can work together as cocreators of an alternative food system. We need to join together now, to recruit a larger and larger army of cocreators, to rewrite the rules of the game — and “cocreate” a different kind of food system.

This essay is excerpted from an article that originally appeared in The New York Times Magazine.  It is reprinted with permission from the author, a contributing writer for the magazine.

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We Are What We Eat

Poor nutrition crosses economic lines and leads to health problems caused by eating too little, eating too much, or having an unbalanced diet that lacks essential nutrients for a healthy life. "We Are What We Eat” was presented to highlight the global necessity for food and agriculture practices that are adequate, secure, and safe.

This exhibition was organized by Jack Brewer, Ambassador for Peace & Sport for the U.S. Federation for Middle East Peace, in collaboration with Aaron Levi Garvey, independent curator, with support from the Permanent Mission of Grenada to the United Nations, and the New York Liaison Office of the Food and Agriculture Organization (FAO).

Artists featured in this exhibition: Liu Bolin (China), Ed Burtynsky (Canada), Jim Draper (United States), Pepe López (Venezuela), Vik Muniz (Brazil), and Jennifer Rubell (United States).

You Are What You Eat

Origin of “you are what you eat”, meaning of “you are what you eat”, usage of “you are what you eat”, literary source.

“Tell me what you eat and I will tell you what you are.”

Literary Analysis of “You are What You Eat”

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The Problem With Saying Suicide Is Preventable

W hen I left my father’s condo for the airport on a sunny March day in 2018, I did not once think that he might kill himself. Yes, his depression had returned, dense and unsteadying. But he had just come home from a week of voluntary inpatient care at the psychiatric hospital. He had a psychiatrist, an acupuncturist, and a sunlamp. During my visit, I drove him to his outpatient group therapy. We played Scrabble and listened to 80s dance hits.

What I saw when I spent that week with my father was a man doing everything he could to shrug the mantle of depression from his shoulders. But within 48 hours of me leaving, my father ended his life.

He was one of more than 48,000 Americans who died by suicide in 2018, a then-record that has since been surpassed by steadily rising suicide rates in the midst of a mental health crisis the surgeon general called “ the defining public health crisis of our time .”

As this crisis rages on, we have made strides in fighting suicide, like the 988 lifeline and increased barriers on bridges and high structures throughout the United States. This spring, the Biden administration released a new 10-year strategy for suicide prevention . These improvements bolster the declaration that now feels ubiquitous in mental health messaging: suicide is preventable . But that phrase masks a nuanced, persistent reality of suicide that we must acknowledge.

Read More: America Has Reached Peak Therapy. Why Is Our Mental Health Getting Worse?

Though well-intentioned, the truth is that not all suicides can be stopped, even with the best efforts. But right after my father’s death, everywhere I looked I read that suicide is preventable. This instilled an immediate, unconscious conviction in me of a double failure: my father, who had not done enough to save himself, and those of us who loved him most, who had not done enough, either. Collectively we could have deterred his death. But we did not.

In the months following my father’s death, I channeled my guilt into an obsessive energy toward understanding and advocating for suicide prevention. I fundraised for the American Foundation for Suicide Prevention , lobbied for policy change in Tennessee, and charted my father’s risk factors against his protective factors , certain I would find the tipping point where he should have gone left instead of right—where I should have stayed, instead of left him.

Alongside the insistence that suicide can be stopped lie reminders for survivors not to feel guilty or blame themselves, a request that feels impossible, as you’re handed checklists of preventative measures. But it is not only for the sake of those left behind that we should add nuance to what we mean when we say suicide is preventable.

The crux of the issue with blanketing suicide as something that can be stopped is that it flattens one of the most confounding psychological, medical, and philosophical questions of being human into something simpler than its reality. Perhaps one day we will be able to say that, with the right blueprint, suicide is preventable. But we do not have the knowledge, let alone the resources, to make that true now.

Today I imagine my father on a precipice, teetering between life and death. I will never know exactly why he fell one way and not the other, in the same way we do not know what causes one person to take their life and another to not. We do not know whether the seeds of suicidality are planted moments before a person decides to die, or decades. For each individual, it is different. But it is not something we can cut open on the autopsy table, tracing its progression and tearing it out at the root.

This does not mean suicide prevention efforts are futile. One of the few, but most encouraging, empirically backed strategies to reduce suicide deaths is limiting access to lethal means —hence the importance of bridge barriers, firearms safety, and safe medication storage. But as my therapist reminded me after my father’s death, people have still found ways to end their lives while in the middle of inpatient mental health treatment. There were no guarantees that anything I might have done would have stopped my father’s death. 

At first, I interpreted his reminder as bleak. But over time, I started to see the way that my obsession with what could have gone differently dehumanized my father. It was both more painful and more honest when I began to accept that my father’s reality was different from my own. I would have given anything for him to still be alive, but I also did not want to deny what life was like for him. In a world still riddled with stigma against mental illness, those who die by and attempt suicide deserve the dignity of us acknowledging their pain as real.

This is a scary thing to admit, to both validate the severity of psychological crisis without dismissing suicide deaths as inevitable. And though I want us to add nuance to our language around suicide prevention, I do not believe the suicide epidemic is unstoppable. But we need more than better quality and access to mental health care (which, we do need)—we also must frame mental health as something inclusive of trauma, poverty, substance abuse, and economic, food, and housing insecurity. We need to intercept suicide far before the crisis moment.

Take, for instance, Italy’s community-centered Trieste model , where people in mental health crisis are directed to short-term stays in peer-managed housing that is more similar to a home than a hospital. The Trieste model also focuses on meeting patients’ basic needs, like food, clothing, housing, and jobs. In the U.S., California awarded $116 million to launch a pilot program replicating the Trieste model in Los Angeles. But the program has been stalled since it received funding in 2019, and remains under revision. More concentrated efforts, like free school lunch programs that have been shown to improve student mental health, can help address some destabilizing factors with more immediacy as larger systemic changes take hold.

We can also expand therapeutic interventions in a system that does not have enough clinicians to meet the needs of a worsening mental illness epidemic. Earlier in 2024, Alaska passed a law requiring mental health curricula in public schools, following in the wake of states like New York and Virginia. Alabama high-schoolers have been testing a self-guided pilot program to improve mental health literacy before crisis, which research has shown works .  These kinds of approaches contribute to a broader ecosystem of knowledge and resources that help reduce how many people reach a crisis point to begin with.

Acknowledging that, currently, suicide is not always preventable alleviates the burden for survivors wondering what we did wrong. It also honors that what the world is like for those who die by suicide is real to them, rather than implying that they failed in not doing more to help themselves. And it allows us to admit how much we still don’t know, giving us space to create more holistic, expansive solutions for all that mental health care can be.

When I stopped focusing over what might have prevented my father’s suicide, my perception of his life burst open into so much more than how he died. His death had made me question whether any of the joy and laughter and car sing-a-longs I’d shared with him in the days before were real. But once I accepted that his suicide was both his choice to make, and just one part of his story, I recognized that his depression did not invalidate all the other things that drove him. Like showing up for the people he loved, solving problems, and creating beauty around him. The way he died does not diminish how dedicated he was to growth and evolution, and it does not invalidate the countless ways he chose to live.

I have hope that, with continued research, interventions, and destigmatization, suicide deaths will decline. But I also have peace knowing that my father’s death is not defined by what he or I did wrong, but instead is one of the many continuing unknowns we must make space for in how we speak about mental health.

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• Open access
• Published: 03 September 2024

Clinical and scientific review of severe and enduring anorexia nervosa in intensive care settings: introducing an innovative treatment paradigm

• Joseph A Wonderlich 1 , 2 ,
• Dorian R Dodd 1 , 2 ,
• Cindy Sondag 2 ,
• Michelle Jorgensen 2 ,
• Candice Blumhardt 2 ,
• Alexandra N Evanson 2 ,
• Casey Bjoralt 2 &
• Stephen A Wonderlich 1  

Journal of Eating Disorders volume  12 , Article number:  131 ( 2024 ) Cite this article

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Anorexia nervosa is a serious and potentially lethal psychiatric disorder. Furthermore, there is significant evidence that some individuals develop a very long-standing form of the illness that requires a variety of different treatment interventions over time.

The primary goal of this paper was to provide a review of treatment strategies for severe and enduring anorexia nervosa (SE-AN) with the particular focus on treatments involving hospital care. Additionally, we wish to highlight a contemporary approach to such care and provide qualitative reactions to this model from both staff and patients.

A selective and strategic review of the treatment literature for SE-AN was conducted for the current paper. Emphasis was placed on clinical or scientific papers related to hospital-based care. Additionally, staff who work on a specific inpatient eating disorder unit with a substantial treatment program for SE-AN, along with a number of SE-AN patients were surveyed regarding their experiences working on, or receiving treatment on the unit. Importantly, the staff of this unit created a specific treatment protocol for individuals receiving hospital care. The results of the highlight both advantages and challenges of a hospital-based protocol oriented toward emphasizing quality of life, medical stability, and a health-promoting meal plan.

While there is general inconsistency with the type of treatment that is best suited to individuals with SE-AN, this is particularly true for higher levels of care that rely on inpatient hospital units or residential treatment settings. This is a highly significant clinical topic in need of further clinical and scientific examination.

Plain English summary

Anorexia nervosa is a serious illness which often persists for decades. Treatments for persistent anorexia nervosa are not well defined and there is considerable debate in the field about appropriate types of treatment strategies for these individuals. Such clinical uncertainty is particularly noteworthy in terms of the most appropriate types of care for these patients when they are hospitalized, which happens relatively frequently. Greater efforts are needed to develop inpatient programs for SE-AN that take into consideration their unique clinical needs.

Anorexia Nervosa (AN) is a serious and potentially lethal psychiatric disorder that is most typically seen in girls and young women, with a lifetime prevalence of 2–4% [ 1 , 2 ]. While AN is rare in some countries (e.g., Africa and Latin America) it is most prevalent in Europe, North America, and Australasia. AN is considered one of the most lethal psychiatric disorders with a crude mortality rate of 5% per decade and a standardized mortality ratio of around 6 [ 2 , 3 ].

Prospective longitudinal studies have consistently identified a subset of AN patients who have long-standing eating disorders, characterized by minimal improvement and significant impairment over decades (e.g. [ 4 , 5 ]). However, there has been significant variability across studies in terms of rates of remission and recovery from AN. Eddy and colleagues [ 5 ], suggested that the longer the duration of follow up in such prospective longitudinal designs, the greater the rates of recovery. Steinhausen [ 6 ] reported that in studies with follow up to four years since index diagnosis, recovery was approximately 33%, while studies with follow-ups ranging from 4 to 10 years average 47% recovered, and studies longer than 10 years in duration revealed recovery rates over 70%. Robinson [ 7 ] examined the same literature and concluded that rates of recovery after 10 years seemed to be declining compared to follow-ups ranging from 4 to 10 years. Eddy et al., [ 5 ] suggest that studies beyond 20 years of follow-up are not only limited, but the findings are even more inconsistent. For example, Theander [ 8 ] reported outcomes over 33 years of follow-up with 76% achieving recovery. However, two other studies [ 9 , 10 ] found that approximately 20 years after an initial hospitalization, around 50% of the sample of AN individuals was recovered. Ratnasuriya [ 11 ] reported that 20 years after hospitalization only 30% of the patients had a good outcome. Similarly, a study with a large sample of individuals treated for AN revealed that the longer the duration of the eating disorder, the lower the chance of recovery [ 12 ]. These findings are further supported by a recent systematic review on the treatment of eating disorders that showed that 40% of AN cases had partial or no remission of symptoms [ 13 ].

However, another important longitudinal study, by Eddy et al., [ 5 ] relied on a well-characterized and regularly assessed sample of both individuals with AN and bulimia nervosa (BN) over 22 years. In this study, the authors found that at the end of the first decade of illness, approximately 31% of the individuals with AN and 68% of the individuals with BN were recovered. Thus, BN appeared to be a much more remitting illness than AN. However, approximately two decades after the initial diagnosis, there was significant proportional change. At this point, approximately 63% of the individuals with AN and 68% of the individuals with BN had recovered. Approximately half of those with AN who had not recovered in the first decade did recover in the second decade. Interestingly, the recovery rate of BN did not change significantly over that decade. Thus, the study by Eddy and colleagues [ 5 ] suggests that recovery from AN may continue for decades after onset, but importantly, well over a third of the AN sample continued to have very significant AN moving into the third decade of the illness.

During the timeframe when many of these longitudinal studies were being conducted, clinicians were actively attempting to outline treatment strategies for long-term, persistent, and minimally remitting AN. Wonderlich and colleagues [ 14 ] summarized these clinical strategies, which were wide ranging and infrequently tested empirically. Overall, the collection of strategies reflected the informed experience of clinicians who had treated numerous patients with long-standing AN and served as a repository of clinical wisdom accrued largely during the 80s and 90s. Numerous recommendations and suggestions from these individuals still inform contemporary treatment strategies for SE-AN, such as establishing clear guidelines, the value of a team-oriented approach, the importance of meaningful treatment collaboration, inclusion of the patient’s family, avoidance of aggressive change-oriented techniques, and the potential value of psychiatric rehabilitation models of intervention. Additionally, Williams and colleagues [ 15 ] described an integrated treatment program which included staff from hospital-based eating disorder program along with a community-based mental health rehabilitation team and demonstrated some degree of efficacy.

An important point in the treatment literature for long-standing AN was the randomized controlled trial conducted by Touyz and colleagues [ 16 ]. This study compared the efficacy of 30 outpatient sessions of an adapted form of cognitive behavioral therapy (CBT) to an adapted form of specialist supportive clinical management (SSCM). Both treatments had a modified primary focus on enhancing quality of life and promoting harm reduction, rather than weight gain and symptom reduction. Both treatments had excellent retention of participants, with attrition rates under 15%. Comparisons between the two treatments revealed minimal differences in outcome. Furthermore, secondary analyses found a series of meaningful predictors of good response and revealed that quality of the therapeutic alliance was associated with positive responses, broadly [ 17 ]. Thus, this study offers support for the treatment of SE-AN and developing treatments that optimize patient engagement.

Several other empirical studies preliminarily have examined the impact of evidence-based, shorter-term treatments on SE-AN. Some of these studies suggested that treatments, such as CBT appear equally effective when delivered to individuals with AN versus individuals with SE-AN [ 18 ]. Similarly, two studies found that duration of illness was not a significant predictor of the outcome in structured treatment such as CBT and MANTRA [ 19 , 20 ]. However, in another study, which relied on practice guideline-based treatments, there was a significant difference in outcome between early stage versus SE-AN patients. Specifically, the SE-AN patients were less likely to improve in areas of work and social adjustment than the early stage patients and the SE-AN patients were more likely to access intensive services following treatment [ 21 ]. There are an increasing number of empirical studies with SE-AN patients which could ultimately impact effective treatment deliveries, however at this point in time, the number of these studies remains relatively limited and frequently constrained by sample size issues. Thus, there is a significant need for additional strategies to be tested with individuals, displaying long-standing and serious forms of AN.

Wonderlich and colleagues [ 22 ] outline a number of innovative treatment strategies which have been tested, at least preliminarily, in individuals with long-standing SE-AN. They highlight that there are new behavioral strategies (e.g., exposure paradigms [ 23 ], habit-oriented interventions [ 24 ], cognitive remediation therapy [ 25 ]), along with novel pharmacologic interventions, (e.g., ketamine [ 26 ], and dronabinol [ 27 ]) which may have potential value in treating longer standing forms of AN. Additionally, there are brain stimulation interventions (e.g., rTMS [ 28 ], DBS [ 29 ]) which continue to be tested in individuals with SE-AN and show either reasonable tolerability or preliminary efficacy. Also, there are system-oriented strategies that are being looked at, such as stepped-care treatment models [ 30 ] and novel “self-admission” approaches [ 31 ] to inpatient care. Again, preliminary data suggests these strategies may have value.

However, despite these newer developments, we agree with the general idea that the lack of understanding of SE-AN and the associated dearth of treatments represent a serious deficit in the eating disorder field. Moreover, we believe that this dearth of empirically supported treatments for SE-AN patients is even more of an urgent situation for higher levels of care in hospital based and residential treatment settings as many of these patients repeatedly utilize a higher level of care. The primary aim of this paper is to highlight that empirically informed treatments for SE-AN patients are particularly limited in higher levels of care, such as inpatient units, partial hospitals, and residential treatment centers. Furthermore, we want to highlight the significance of this dilemma and the impact it has on SE-AN patients, and the clinical teams who attempt to treat them in these environments. In the next section, we will provide an overview of this situation and describe an innovative program, which has recently been developed based on clinical need and expertise, to provide quality care for SE-AN patients and also support the treatment teams who are attempting to provide the intervention.

Higher levels of care and SE-AN

Historically, there has been some debate about the most preferred treatment setting for patients with SE-AN. Some individuals clearly suggest that outpatient treatment is appropriate if medical stability is maintained [ 32 ]. However, Strober [ 33 ] advocates for inpatient hospitalization for SE-AN and suggests that comprehensive coordinated care is best provided in such a setting. Woodside [ 34 ] provides broad strategy for SE-AN patients when hospitalized, which happens relatively frequently. He notes that many SE-AN patients cannot realistically conceive of recovery but are interested in incremental improvements in their eating disorder. Others are interested in pursuing enhanced quality of life or improving their overall condition. He highlights the importance of collaborative goal setting that is realistic and tailored to each individual patient. There are no minimum standards for goals, virtually any change is promoted. Woodside does not provide high levels of detail about the operations of the program over the course of a hospital stay, but does conclude that there is an urgent need for increased dialogue about the issues regarding inpatient care and SE-AN.

Banford et al. [ 35 ] offer comments about the idea that eating disorder treatment programs, both outpatient and inpatient, often pursue treatment goals that are inconsistent with SE-AN patient motivation. Furthermore, many of these programs are oriented toward more acute cases of AN, often of younger ages than many of the SE-AN patients. Thus, the authors highlight the possible problems for SE-AN patients when they are in traditional eating disorder programs. They emphasize that when SE-AN patients are integrated into recovery focused partial hospital programs with younger, more acute patients, problems may emerge and they recommend that SE-AN patients are best treated in a separate program with individualized goals and interventions. They highlight that there are very few descriptions of SE-AN specific hospital units in the eating disorder literature, but note that such patients are frequently admitted. They highlight that in an ideal SE-AN hospital unit, goals might include harm reduction, improved quality of life, achieving stabilization, reducing medical risk and decreasing crisis hospital dependency. Overall, they highlight an approach that is characterized by clinical flexibility, creativity, and adaptability for higher levels of care for SE-AN.

A recent systematic review of treatment interventions for SE-AN suggests that hospital-based care for SE-AN is not well understood and varies significantly across studies [ 36 ]. The evidence suggests that inpatient treatment for SE-AN may have a beneficial impact on eating disorder symptoms, but the evidence is unclear about whether or not such gains are maintained. Importantly, however, the five trials that are included in this review relied on a heterogenous collection of treatment strategies for these patients. Some programs were clearly oriented around cognitive behavioral therapy (CBT) while others were only partly based on CBT. Some programs included well defined nutrition plans, while others did not. Some programs relied on antidepressants while others did not. The length of the programs varied significantly, ranging from 3 to 5 months, which is a substantial variation. We would suggest that the clinical variability reported across the hospital-based programs in this review is representative of hospital programs broadly that treat individuals with SE-AN. In fact, this review provides support for the fundamental argument in the present paper, that there is a need for increased scientific and clinical attention to treatment protocols for SE-AN at higher levels of care.

Considerations for developing a treatment of SE-AN in higher levels of care

The Sanford Eating Disorders Unit in Fargo, North Dakota, is one of a declining number of hospital-based eating disorder programs with inpatient, partial hospital and intensive outpatient programming in the United States. In this program, we provide care annually to approximately 250 patients ranging in age from early adolescence throughout the life span. Additionally, we are one of a limited number of programs that openly accepts public insurance in the U.S. As such, we regularly provide care to individuals turned away from other treatment centers due to high medical complexity or insurance policies not covered by other programs. Typically, these individuals display SE-AN. Over time, the unit has attempted to develop a humane and effective approach to care for these individuals. In the hospital setting, we were forced to grapple with several ethical questions, such as whether we should provide care focused on full-weight restoration for a given SE-AN patient, when there is evidence to suggest that this approach has not worked well with the patient previously. Alternatively, should SE-AN patients be allowed to be admitted to the hospital without an active weight restoration based treatment plan, given the long-term risks of premature death in SE-AN? Thus, we sought to develop a treatment program that provides medical stabilization, promotes quality of life, and retains the possibility that one could, in fact, recover after years or decades of serious SE-AN [ 5 ].

In developing a standardized treatment approach for individuals with SE-AN, addressing the challenges associated with hospital-based care for individuals who vary significantly in terms of their desire or ability to restore weight was crucial. The heterogeneity of individuals with eating disorders is a significant issue in general but is even more significant in the shared space afforded by hospital treatment units. Thus, the typical hospital program for eating disorders must try to develop clinical programming to accommodate a wide variety of individuals. This may become particularly challenging when we consider that there is marked variability in the age of patients, the number of previous inpatient treatment episodes, and the total length of time they have been treated. In the case of AN, hospital programs must provide treatment programming for first-episode patients who are often adolescents and have significant family involvement, as well as long-standing patients with AN who may be significantly older, without family support.

Furthermore, there may be significant differences among SE-AN patients in terms of the degree to which the primary focus should be on weight-based recovery, or one that prioritizes a goal of maintaining medical stability and promoting quality of life. Importantly, these significant differences may, at times, be complicated for treatment teams in the hospital who are actively promoting weight-based recovery in one patient and maintaining medical stability and quality of life, or palliative or hospice care in another. Clearly, the complexity of patient experiences in a hospital environment with shared treatment programming and physical space limitations between patients is noteworthy, and a significant challenge for clinicians.

Another challenge for hospital-based programs is the impact of such diversity of patient characteristics on the distribution of valuable clinical resources. Hospital staff must repeatedly, and frequently, make decisions about who will be admitted when there is an opening for care. Should the opening be allocated to more acute, recent onset cases of AN in teenagers versus individuals with long-standing AN who have been hospitalized multiple times and not established significant weight restoration?

Furthermore, as we have noted previously, all of this clinical diversity and complexity in the hospital environment is increased because there is no well-defined, structured intervention for individuals with SE-AN in the hospital setting. As a result, there is often confusion about whether treatment goals for such individuals should focus on weight-based recovery versus medical stabilization with enhancement of quality of life. There is also uncertainty about what treatment approaches may be beneficial to SE-AN patients. For example, in the hospital, what type of psychological intervention may be most beneficial for individuals with SE-AN? Should dietary interventions be modified for such individuals? What is the role of pharmacotherapy in the treatment of SE-AN?

Given these challenges, and the lack of any clear guidance in the literature, we created an active treatment program track for hospitalized individuals with SE-AN. Due to the need to capitalize on existing resources, the SE-AN track was developed entirely integrated within our traditional eating disorder inpatient program. This means that all patients, regardless of whether they are on the SE-AN track, take part in group therapy and eat in the dining room together. In an effort to reduce potential conflicts arising in treatment as a result of a mixed milieu, some adjustments to therapeutics and dining room rules were implemented. These are described in more detail below.

When developing the SE-AN track, our primary goal was to help our SE-AN patients improve their quality of life, primarily by reducing the duration and frequency of hospitalizations and creating a more personalized treatment approach. Second, we aimed to provide transparency between patients and clinical staff regarding the rationale and procedures for treating individuals with SE-AN. Third, we sought to establish a highly collaborative agreement early in treatment between a patient and clinical staff regarding structured goals to reduce future long-term hospitalizations. Fourth, we aim to actively engage with the patient regarding discharge planning at the start of treatment. The primary objectives of the program are to maintain gains established during the hospital stay, develop an outpatient treatment plan with explicit targets, and provide a clear understanding of the procedures utilized in the long-term treatment plan (which may include repeated short-term, return hospital visits).

A description of a SE-AN treatment program at a higher level of care

In deciding to change treatment outcomes for SE-AN patients in the hospital, it became crucial to re-examine the treatment approaches generally used on the unit, given that they were designed for traditional treatment targets (e.g., full weight restoration). Changes were made across almost all therapeutic modalities (e.g., psychotherapy, psychiatric interventions, and nutritional rehabilitation). For example, our goal was no longer primarily focusing on three to four pounds of weight restoration a week in the hospital. We wondered what this would mean for dietitians working with SE-AN patients or when determining the length of hospitalization. Furthermore, in a patient’s psychotherapy, if quality of life is the outcome being measured, what should a therapist focus on in a session? Though specific quality of life interventions were not clear in the existing literature, what became clear to our team was the need to reduce the length and frequency of hospitalizations. We did not believe that a high-quality life could be achieved moving from hospital admission to hospital admission. However, SE-AN patients also often require significant time and support from providers at higher levels of care due to their high medical acuity arising from complications of their SE-AN. Thus, any quality of life focused treatment for individuals with SE-AN at higher levels of care must find a way to reduce time spent in the hospital by the patients, while also providing them significant ongoing support. This perspective (i.e., reducing frequency and length of hospitalizations while supporting the patients) became an overarching goal across all aspects of the SE-AN program. Below, we outline the fundamental procedures for the program.

Admission procedures and initiation of SE-AN treatment

As previously stated, one of the primary goals of the SE-AN program is to provide transparency and collaborative goal setting between patients and clinical staff. As such, discussing the SE-AN program goals should be started immediately, but not prescriptively. We believe the best approach for goal-setting is through collaborative formulation process among the treatment team and the patient, as this is one of the best ways to ensure adherence to treatment and improve clinical outcomes. Upon intake, patients are assessed as to whether they meet SE-AN criteria (e.g., duration of illness over seven years and multiple failed empirically supported treatment attempts) and their personal treatment goals are identified. Patients who meet these SE-AN criteria and express goals in line with improved quality of life and medical stability are informed of the SE-AN program. All new SE-AN patients are informed that their initial stay will be considered a brief evaluation stay of 2–4 weeks to achieve medical stability and assess readiness for the SE-AN program. During the first few days of the admission, patients meet with the provider to start an ongoing conversation about their therapeutic goals and receive psychoeducational materials about the SE-AN program. Patients are informed about the program’s guidelines, including working towards specific goals, SE-AN-specific interventions, length of stay, and discharge planning, all of which are presented below. If, at the end of the evaluation stay, the patient and team decide that the SE-AN program is suitable for the patient, the “ongoing admission” process is discussed. The details of the ongoing admission process will be described below. In short, this process ultimately allows the patient to return to the hospital on the SE-AN track for brief goal-oriented stabilization stays if they have adhered to their treatment plan for at least three months.

Treatment contract and goal setting

As noted by Woodside [ 34 ] collaborative goal setting that is realistic and tailored to each individual patient is crucial for treating individuals with SE-AN. While Woodside suggests that no goal is too small, we believe that at higher levels of care, goals must actively move the patient toward improved quality of life. Therefore, all patients with SE-AN in our program must set goals in three domains: quality of life improvement, ongoing medical stability, and maintaining a meal plan tailored to work with the patient’s goals (e.g., weight maintenance or varying degrees of weight restoration). Patients are asked to work with their treatment team in each domain to establish 2–3 measurable objectives that will help them move their lives forward. For example, a quality of life goal might be “going to get coffee once a week with a friend,” while an example of a goal to help a patient meet their meal plan requirements might be “establish appointments with an outpatient dietitian twice a month.” The treatment team retains measurable objectives created collaboratively to measure future progress and decide the suitability of continuing specific SE-AN programming for future admissions.

Furthermore, individuals with SE-AN often carry comorbidities that may be treatment-interfering (e.g., substance use, obsessive-compulsive disorder, post-traumatic stress disorder). If the treatment team, or patient, determine a patient’s comorbidities interfere with the SE-AN approach during the initial evaluation stay, additional goals must be set to address these ongoing issues either at the outpatient level of care or in a different treatment facility. For example, if a patient with SE-AN also experiences obsessive-compulsive behaviors, the patient and team must think through achievable goals (e.g., exposure and response prevention therapy or medication management) to reduce the impact on SE-AN treatment. These goals should be established with the treatment team and may range from traditional therapeutic interventions (e.g., exposure therapy or substance use treatment) to potentially more experimental approaches (e.g., repetitive transcranial magnetic stimulation [rTMS] or psychedelic-assisted psychotherapy) when indicated. The primary objectives regarding setting goals around comorbidities is to reduce treatment-interfering symptoms not directly related to the eating disorder outside the hospital and increase the likelihood an individual will be able to adhere to the treatment plan.

Another goal-related issue often pertains to step down and discharge planning. Following an inpatient admission on the SE-AN track, individuals may have the desire to step-down their level of care to a partial hospitalization program (PHP) or intensive outpatient program (IOP) to ensure a higher degree of aftercare compared to stepping down to outpatient therapy. As our primary goal is to improve quality of life outside of the hospital, our program has taken the stance that this is acceptable as long as there are specific, and clear goals that have been identified to work on while in the PHP or IOP. Additionally, we have occasionally utilized both PHP and IOP as the primary level of care for our SE-AN protocol; however, only for individuals who come to the hospital medically stable.

Specific interventions for SE-AN

Medical stability.

One of the immediate priorities of a SE-AN approach at a higher level of care is addressing the patients’ physical health and stabilizing any medical complications resulting from SE-AN. This includes addressing the various physical consequences of prolonged inadequate nutrition. Most crucially, medical experts should address issues such as cardiovascular complications, hypoglycemia, organ damage, electrolyte imbalances, and gastrointestinal distress that interferes with the ability to eat. While medication management of psychiatric comorbidities may also be necessary, the initial goal is to stabilize physical health so that there is a life remaining to improve.

Nutritional rehabilitation

An essential consideration for nutritional rehabilitation for individuals with SE-AN is the role of dietitians in the care team and developing simple, and achievable menu plans. While traditional goals, like improved diet variety, have been linked to sustained recovery following weight restoration treatments [ 37 ], the SE-AN program shifts away from what or how these patients eat, prioritizing only that they eat a sufficient amount. Thus, in collaboration with a dietitian, the SE-AN patient creates a meal plan based on foods they are already eating, described as “simple and doable.” While the dietitian works to ensure the patient meets their macronutrient targets (within what is possible given what the patient is willing and able to eat),, there is initially less concern about various food or meal challenges. Over time, if patients successfully adhere to their meal plan, they may choose to increase variety or do meal exposures during future SE-AN admissions. As has been discussed among our team while developing this program, some of these recommendations may challenge the traditional treatment targets utilized by dietitians in treating eating disorders. However, the concept of helping a patient find a meal plan to stabilize their weight and stop weight loss is a skill dietitians most likely already possess. Thus, this does not require extensive additional training. However, we encourage collaborative, and ongoing, discussions among the medical providers and the dietitians in determining various nutritional rehabilitation interventions, such as determining rate of increase in calories to stop weight loss while not destabilize the patient and potentially changes to the macronutrient breakdown of the diet to address medicals needs like treatment of edema. While many of the skills needed to treat SE-AN are already possessed by dietitians, specialized training for working with severely low-weighted, chronically-ill patients may want to be pursued by dietitians, or any of the team members, when it comes to how to best treat SE-AN patients nutritionally.

Another important consideration is how individuals with SE-AN utilize the dining room. Among providers, it has often been argued that the dining room is the most therapeutic intervention for individuals with eating disorders at a higher level of care. While this remains true for individuals with SE-AN, the dining room often serves a very different purpose. The primary function of the dining room is to support SE-AN patients who are trying a different eating model than what they have tried in previous treatments. For the treatment team, this might require changing the expectations in the dining room. For example, in our program, it is understood that patients with SE-AN may engage in some behaviors in the dining room that are often considered disordered. Rather than providing redirection for any eating disorder behavior (e.g., cutting food into small pieces, overuse of condiments), only behaviors that interfere with the patient’s ability to consume their expected nutritional goals (e.g., delaying the start of their meal until the last 5 min so that they are not able to finish their meal) receive redirection. Discussions between SE-AN patients and staff should be supportive, calming, and reassuring. Calm, kind, and reassuring non-verbal messages are also encouraged. Ideally, SE-AN patients should be able to complete their meal in food, given that the patient and dietitian agreed the meal was simple and doable, and that these patients are given only the amount of nutrition needed for medical stabilization and to support their own weight goals, which often means halting weight loss and stabilizing and maintaining current weight. However if a patient does not finish their meal in food, they are expected to consume the missed nutrition immediately following the meal via a liquid supplement. Repeated refusal of planned foods or supplements suggests that the patient is not able to utilize and benefit from the SE-AN program at this time, and calls into question the utility of future admissions under the SE-AN track. The team and the patient would collaboratively discuss expectations for treatment adherence and how nonadherence may decrease the likelihood of the patient being allowed to continue treatment in the SE-AN track.

As previously noted, one of the challenges of creating a hospital-based treatment for SE-AN is the potential interaction of these patients with other patients pursuing different treatment goals. While this might not be an issue in some settings, the dining room can often create a space of conflict between individuals on a traditional restoration plan and those on the SE-AN program. To reduce interference with patients on weight restoration programs, patients on the SE-AN program eat at a designated table within the dining room. These simple modifications are essential in dealing with the heterogeneity of the eating disorder patient population.

Psychotherapeutic interventions

Psychotherapeutic strategies for patients with eating disorders at higher levels of care, in general, are extremely varied, making decisions about psychotherapy interventions for individuals with SE-AN difficult [ 38 , 39 ]. Given that the goal of our SE-AN program is to promote quality of life and increase time outside of hospital units, we have shifted the programming towards values-oriented therapies [ 40 ] and skills-based distress tolerance interventions [ 41 ]. Acceptance and Commitment Therapy (ACT) techniques, like cognitive defusion and committed action, help patients deal with ruminative thinking, a hallmark of SE-AN, while pursuing valued goals following discharge from the hospital. Meanwhile, Dialectical Behavior Therapy (DBT) distress tolerance skills help SE-AN patients more effectively cope with the distress involved in changing eating disorder behaviors and resisting eating disorder urges, in order to approach valued personal goals, even when distressed. With these simple interventions, we hope to help patients increase their treatment motivation and adherence to the treatment plan. The hope is that this approach reduces the pressure on the patient and leads to greater hope and self-efficacy, as they take steps toward recovery in achievable ways, rather than having patients see recovery as an externally imposed goal that is also an insurmountable obstacle.

Additionally, conventional relapse prevention planning, consistent with Cognitive Behavioral Therapy (CBT), is also promoted to assist patients in adhering to clinical goals regarding relapse in the SE-AN program. An essential structural treatment issue is the need to strongly promote continued collaboration with the patient’s outpatient providers following discharge from the hospital program. Such ongoing collaboration is necessary for protecting gains made during the hospitalization.

Criteria for return visits and staying in the SE-AN program

Following discharge from a SE-AN hospital stay, patients are encouraged to immediately begin working towards the goals they set at intake to improve the quality of their life, adhere to their meal plan, and stay medically stable. If, after three months, the patient has been able to meet all of their goals, the patient should still be medically stable and have maintained their weight. Thus, SE-AN patients can return to treatment for 2–3 weeks to work on potential increases in their meal plan, maintaining their progress, or identify opportunities to enhance medical stability. However, patients who are meeting their goals and feel confident in their ability to continue doing so may choose to wait longer than three months before returning. If medically stable patients wait longer than three months, the expectation is still that they can return to treatment for short term stays if they have remained medically stable and have adhered to their individualized meal plan.

While the program aims to provide a more “doable” treatment option, it is necessary to recognize that there is less of a safety net with a maintenance intervention than a full-weight restoration treatment. The likelihood that there are slips, lapses, or relapses for individuals with SE-AN is still high. However, given the slower pace of treatment, getting back on track requires less effort than when relapse happens on traditional treatment approaches. Thus, the first step for any patient who slips on the SE-AN program is simply returning to their meal plan outlined at discharge. The patient-centered meal plan was created to be doable by the patient using foods they were already eating. Returning to the meal plan, the patient can maintain their current weight and potentially drift back to their discharge weight.

If a patient lapses and cannot maintain their weight, we may request that the patient delay return admission beyond three months and begin working to get back on track with their previous discharge plan to demonstrate that they can maintain their weight and stick to their meal plan outside the hospital. For patients unable to get back on track, we advise they seek treatment for medical stabilization. Once medically stable, if they can get back on track, the patient and treatment team must discuss whether it would be appropriate to return for continuation of the SE-AN program. Just as the creation of this program arose from the ethical considerations regarding continually trying unsuccessful full-weight restoration approaches with individuals with chronic anorexia nervosa, the SE-AN program must fall under the same scrutiny. For patients for whom the SE-AN program did not work, the treatment team and patient must carefully weigh the minimal potential for benefit of continuing in a treatment that has not proven to be effective, relative to the costs of continuing a treatment that is not working, as well as the missed opportunity of pursuing other potential treatments options. The treatment team needs to be willing to discuss all alternative options, including returning to weight restoration approaches or the initiation of palliative, or even hospice, care.

Staff and patient feedback

As reviewed above, there is a dearth of research on effective treatments at higher levels of care for patients with SE-AN. Furthermore, the heterogeneity of the limited existing research impedes the ability to meaningfully synthesize this work and translate it to clinical practice. Meanwhile, patients with SE-AN frequently request admissions for hospital care, and programs must decide, with little evidence to consult, how to best serve these patients. Absent empirical guidance or professional consensus on the best way to serve these patients, we believe that exposing higher levels of care treatment programs to professional scrutiny in order to prompt more in-depth discussion of treatment issues for this population would be beneficial. Additionally, without a generalizable understanding of hospital treatment for patients with SE-AN, program evaluations should be conducted within individual treatment programs to inform strengths and shortcomings of each specific program, from the perspective of the patients and staff. We recently began a quality assessment effort to elicit feedback on our program, in order to further refine and enhance the SE-AN treatment protocol. Below, we provide an overview of staff and patient feedback. Of note, this feedback was given as part of evaluation efforts for our particular program, rather than as part of a methodologically rigorous research protocol, and as such is not intended to create generalized knowledge about hospital treatment of SE-AN.

Staff feedback

Overall, staff feedback about the SE-AN treatment model has been quite positive. Staff responses consistently indicated that the SE-AN model seemed to give a sense of hopefulness for many patients, and provided a good opportunity for us to “meet patients where they’re at.” Staff acknowledged that this can be a last resort for patients without other options, who are deemed “too sick” or noncompliant and are thus turned away from many other programs. Staff also noted that the greater autonomy given to patients in SE-AN protocol is helpful for their treatment process and progress, and appears to contribute to an increase in effective collaboration between the patient and providers. Staff believe that patients find this approach to be more tolerable, which decreases patient resistance and defensiveness. Finally, staff appreciated being able to individualize treatment around identifying realistic goals for patients to achieve incremental change outside of the hospital, and felt that in this way they were helping to set the patients up for success rather than contributing to a treatment/relapse cycle.

Staff also noted challenging aspects of the SE-AN treatment model, and areas for improvement. Specifically, several staff noted that explaining this model can be difficult as some patients initially worry that providers are “giving up on them.” And although individualization of treatment is generally seen as a strength of the model (by staff and patients alike), staff note that this can also cause issues with consistency and clarity, and for some patients not in the SE-AN program, it can cause an increase in comparisons with others (e.g., patients questioning why other patients are allowed certain accommodations, but they are not). A third challenge noted was that some patients do not use the treatment model effectively. For example, doing it to placate family or outside providers by “doing treatment,” but without genuine collaborative intent, is inconsistent with the model. Finally, this model can lead to significant challenges when patients (and/or their families and outside providers) do not have a realistic understanding of the severity of and impairment from their disorder, which can cause disagreement between the patient and their team regarding what goals are realistic. For example, a patient who states they want to gain significant weight but is unable to adhere to even a maintenance meal plan while in the hospital, would be required to set a more realistic goal. Treatment staff indicated that patients can at times get fixated on the parameters of the SE-AN model, and consistently challenge the SE-AN model limits (e.g., on length of stay, being asked to set more realistic goals); working through this reactivity and conflict detracts from providers being able to more meaningfully work on the eating disorder itself and provide patients with the full benefit of this model.

Patient feedback

Overall, patient feedback has been positive, though somewhat more mixed than staff feedback. Generally, patient and staff feedback show good correspondence, with both groups noting similar strengths and weaknesses of the treatment model. On the positive side, patients voiced appreciation for the autonomy and individuality that this approach provided with regards to being able to tailor their goals to what is specific for them. Patients stated that they “felt heard” and that their team collaborated well with them. As one patient stated “I don’t need to have a 4-hour panic attack over…lasagna which I’m never going to eat outside treatment. It just made sense to me working on what I wanted to work on.” Patients described the program as “realistic” and “autonomy supporting” and “humane” because it is “not forcing something that’s not worked in the past. And it’s not forcing, like, the cookie cutter model on a person, because every person is unique.” One patient with a trauma history stated that being given autonomy over her own choices while being kept safe from her ED was like “nothing I’ve experienced before and I think so incredibly healing.” Another patient highlighted that “people with AN often desire a high need for control. This program helps give us some level of control while working on difficult recovery goals…. This is the first time where I feel like I am in control of my recovery. I’m no longer scared I am going to die. I am no longer going to the ER 1–2 times a week…. It really seems to be working.”

Some patients were conflicted on the theoretical approach to treatment. For example, one patient expressed appreciation that “skills are repeatedly used to help facilitate success on the outside” [outside the hospital], while another patient stated that “more of the process work could be utilized rather than skills over and over” because “if you’re on the SE-AN track you probably have learned that before and probably done those groups a million times.”

Patients struggled with the structure of the treatment model. Some stated that they “wish it was faster” though they know “this is the speed it has to be for me.” Patients also expressed a desire for even more individualization, though also acknowledged that it can be difficult to balance individualization and consistency. One patient stated that she has seen other patients “just messing around” and “not actually working…just doing your disorder in treatment.” So, while patients understand the need for structure and limitations, they tend to think those limits make sense in general and for other patients on the SE-AN model, but should be less rigid for themselves. Patients discussed feeling worried that they may not be allowed to return if they struggle and are unable to meet their goals in between hospital stays, which highlights the difficult balance between requiring patients to demonstrate that they are being helped by the treatment model (to ensure we are not enabling stagnation and continued disorder) while also making allowances for nonlinear recovery processes. Patients also expressed that the SE-AN model can feel limiting. One patient stated that as a result of the SE-AN treatment model she had “lower expectations for myself” and felt the “agenda for this stay was tainted by previous stays” and that “once labeled, no matter your willingness to move forward, regardless of want to go further, it’s shut down.” Several patients similarly commented that being “labeled” as SE-AN and being recommended to the SE-AN treatment model was originally hard as it made them feel hopeless and given up on, but that once the goals of this approach were more clearly communicated, they understood its value better. Finally, patients noted some concern about lack of community resources and understanding of this approach, with one patient stating “I am scared that other treatment programs won’t take an approach like this. It can also be hard to get my outpatient providers to understand the program.”

Staff and patient feedback takeaways

Overall, staff and patient feedback suggest that the SE-AN treatment protocol is beneficial in many ways, especially in providing a treatment option—one that has the potential to extend life and willingness to engage with treatment—for those who are “too sick” for other treatment or who feel they cannot tolerate or do not want full/traditional recovery. Areas for potential improvement have been highlighted. Specifically, further consideration should be given to balancing individualization with consistency and having clearer guidelines for when, and with whom, to hold rigid expectations and under what circumstances greater flexibility can be extended. It will be important to continue to develop better strategies to communicate clearly and collaboratively with patients around what being classified as SE-AN means and the potential benefits of the SE-AN model in a way that can instill hope rather than hopelessness. Also, greater attention should be paid to addressing patient dissatisfaction when they feel limited by the SE-AN model but may not be able or willing to do traditional treatment with full weight restoration. Finally, thorough integration of the SE-AN program with outpatient providers is critical, but it can be challenging to find outpatient providers who will accept patients with SE-AN and who will agree to work on the patient’s SE-AN goals rather than traditional recovery goals and weight restoration.

In summary, we have provided a brief overview of SE-AN both scientifically and clinically. We have also attempted to highlight the limited empirically supported treatment options for SE-AN, but wish to underscore that this dearth of treatment options is significantly pronounced at higher levels of care. Given the severity of SE-AN, it is a simple fact that these patients will often use hospital-based services, and thus, greater attention to this deficit is encouraged.

Our program developed a structured treatment program for SE-AN which highlights flexible goalsetting, high levels of collaboration between patient and clinical staff, and an emphasis on enhancing quality of life, medical stability, and adequate nutritional rehabilitation. Furthermore, the approach highlights the importance of tailoring treatment planning to a given patient and their collaboratively established goals. Explicit treatment contracts are developed with patients and include a shared understanding of targeted objectives. Additionally, there is a significant effort to develop a detailed plan for maintaining health and returning to treatment after discharge from the hospital. This may include future “booster” admissions for limited periods of time to assist patients in continuing to maintain, or incrementally advance, health related goal achievement. Presently, our survey of patients, and staff suggest that the program offers significant advantages for both the treatment team and the patient, but also the continued challenges that a program for SE-AN in a hospital environment must face. We would strongly recommend that clinicians and scientists work to establish empirically supported approaches to treating patients with SE-AN in a hospital environment. Given this is a necessary type of care for such patients and the very serious nature of this illness, it is worthy of such an investment.

Data availability

No datasets were generated or analysed during the current study.

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Wonderlich, J.A., Dodd, D.R., Sondag, C. et al. Clinical and scientific review of severe and enduring anorexia nervosa in intensive care settings: introducing an innovative treatment paradigm. J Eat Disord 12 , 131 (2024). https://doi.org/10.1186/s40337-024-01079-9

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Received : 31 May 2024

Accepted : 06 August 2024

Published : 03 September 2024

DOI : https://doi.org/10.1186/s40337-024-01079-9

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