Dr. Nagib graduated from Wheaton College and has been actively working in this field for over 20 years. She offers intensive counseling for individuals facing this issue and for families wanting help with loved ones. Today, Dr. Nagib will define eating disorders and explore the emotional baggage that often accompanies these issues. She and Dr. Clinton will also describe the various treatment options for those who are struggling and share with them the hope that Christ offers. Here now is Dr. Tim Clinton and Dr. Margaret Nagib on this edition of Family Talk.
Dr. Tim Clinton: We've been able to bring up into our studio, Dr. Margaret Nagib, and we're going to talk about eating disorders. Margaret, thanks for joining us here on Family Talk.
Dr. Margaret Nagib: Oh, such a pleasure. Thank you so much for having me.
Dr. Tim Clinton: Hey, as we get started, Margaret, when I started out counseling years ago, I was involved at Liberty and we were in the University counseling center, and I dedicated probably the first few years of my life to working with eating disorders.
Dr. Margaret Nagib: Wow, I didn't know that.
Dr. Tim Clinton: Yeah, anorexia, bulimia. At that time we began to see that there was really an epidemic of eating disorder issues on our college campus. By the way, come to realize it's an epidemic across the country, even probably more now then, then.
Dr. Margaret Nagib: Yeah. I think we're more aware now, so we're seeing the numbers, but absolutely, it's more of an epidemic and where it used to be more of a younger disease, we're seeing it in midlife and even later. So it seems to be expanding even across age.
Dr. Tim Clinton: Margaret, let's step back and let's talk about, I guess bulimia and anorexia, those that seem to be the two most prominent disorders out there affecting women.
Dr. Margaret Nagib: Right, yeah.
Dr. Tim Clinton: Help me differentiate between the two of them. Probably a lot of families, everybody listening probably knows of someone who's wrestling with this.
Dr. Margaret Nagib: Sure, yeah. Absolutely.
Dr. Tim Clinton: Let's start with bulimia.
Dr. Margaret Nagib: Okay. So bulimia is characterized by episodes of eating a lot of food more than you normally would in one sitting.
Dr. Tim Clinton: Binge eating.
Dr. Margaret Nagib: Yeah, binge eating. But even beyond, this isn't the occasional binge that someone might have, but this is several thousand calories in one sitting, and then feeling really guilty about that, and then needing to compensate for that, usually by purging, so throwing up or using laxatives, and they're caught in a cycle, so someone can binge several times a day, and sometimes it gets so bad that anything they eat, they'll even throw up. So it might not even be classified as a binge, but then they feel so guilty about eating anything that they'll throw it up.
Dr. Tim Clinton: They struggle inside with feelings of self-worth and value. I mean, it's like this chaotic, almost insanity that they're wrestling with. Right?
Dr. Margaret Nagib: Right. Yeah. So the research shows that people who struggle with binge eating tend to be shame prone, which means they tend to just feel shame across situations, and that they're trying to deal with this internal shame that they're not quite sure what to do with. So the binge purge becomes a metaphor for, "I want good things in my life, but I don't know how to deal with my feelings." So how they treat food is a metaphor for what they're experiencing inside.
Dr. Tim Clinton: Anorexia differentiates a little bit here.
Dr. Margaret Nagib: Right. Yeah.
Dr. Tim Clinton: Tell us about what anorexia is.
Dr. Margaret Nagib: So interestingly, the behavior is different, but the core things are body image. So body image is an issue with both. Self-hatred can be an issue with both, but the behavior, the metaphor is more restrictive so they don't eat, and so they can get very low body weight. To be classified anorexic, you need to be a certain percentage below that body weight. So they just deal with life by completely shutting everything out. Food is the way that they do that. When you don't eat, you become very numb over time. It's a great way to numb yourself out to not feel.
Dr. Tim Clinton: Tend to be highly perfectionistic, right?
Dr. Margaret Nagib: Yes. Highly perfectionistic. Right.
Dr. Tim Clinton: Those who may have lives that are out of control. But the one piece that they ultimately can control is their food intake.
Dr. Margaret Nagib: Absolutely.
Dr. Tim Clinton: So, not that they aren't hungry, for example, I mean, they're starved. They often cook meals and do all kinds of elaborate things ...
Dr. Margaret Nagib: Right. Cook for other people.
Dr. Tim Clinton: ... but they deny themselves ...
Dr. Margaret Nagib: Absolutely.
Dr. Tim Clinton: ... of that food.
Dr. Margaret Nagib: Absolutely.
Dr. Tim Clinton: It's because, again, everything around them is chaotic and seemingly out of control. But here's the little piece that I can put in my box and manage. The problem is, and Margaret, isn't true, they say that this piece that they're controlling, the only piece they feel like they can control begins to control them?
Dr. Margaret Nagib: Absolutely. Absolutely. That's the key with both disorders, is they're trying to regulate, they're trying to regulate their emotions, but they do it through food. We classify binge eating as a disorder. There's binge eating disorder, and that's actually the highest percentage of people. 30% of binge eating disorder is men. So a lot of men struggle with binge eating disorder. We do see anorexia and bulimia in men, but it's a much lower percentage. But binge eating disorder is much more common with men.
Dr. Tim Clinton: Margaret, the battle or war with food here for a moment becomes so pervasive and consuming that often they drift into the use of diuretics, diet pills and more, right?
Dr. Margaret Nagib: Yeah. Drugs, stimulant drugs. Also, meth. One of my best friends has a recovery from eating disorder, and she used to use meth in order to lose weight, and it worked for her, and so she got into drugs and became dual diagnosis with an eating disorder and drug because of the effects of stimulants.
Dr. Tim Clinton: What about the whole issue of exercise too?
Dr. Margaret Nagib: Well, now we're getting into a whole another thing that gets a little touchy because we all love our exercise. We all want to eat healthy. But even there, it might not be classified as an eating disorder, but you can have disordered exercise. You can have disordered eating in what they call orthorexia, where there's an overfocus of healthy, this gluten free, everything free kind of diet, paleo, keto. So really, there's a lot of disordered eating in our culture. We really have poor boundaries around food.
Dr. Tim Clinton: Well, and when you think about, I guess I'm saying a normal diet, those who are getting lost here, let's talk about the anorexia for a moment. They don't even want to eat a 2000 calorie diet, let's say that. So they wind up doing minimal food intake, maybe 500,000 calories, and then they jump into the gym on top of it to basically try to eradicate any food consumption at all. Then it becomes a really war because once the family starts getting engaged and seeing some of these behaviors going on, they start getting worried, "Okay, hey, I found a scale. You're weighing yourself way too much, or we're going out to dinner and you won't eat. You won't eat with us." What starts happening to the family system in this journey?
Dr. Margaret Nagib: It's really hard for families because they see things like food disappearing and family members not showing up to certain events because of food. It's so hard, you see someone who's anorexic, for example, and it's hard to know what to say to them. Most people want to just say, "Just eat. So why don't you just eat? Can't you see how thin you are here?" And they can't.
Dr. Tim Clinton: "Here, have a meal with us." Yeah.
Dr. Margaret Nagib: Yeah.
Dr. Tim Clinton: The more you go there, the more intensity ratchets up in this. Really becomes a power struggle.
Dr. Margaret Nagib: It does become a power struggle. It's really, really hard. So family therapy is really important to educate spouses, parents, because it's counterintuitive. Everything that is intuitive to do with someone with an eating disorder is actually counter what we would suggest in treatment, because people really do have to take ownership. So having a team around them is so important. Taking that pressure off of the family and getting a dietician in there, getting a therapist in there to start being that, because they do, they need accountability at first. We call it automatic eating. We put them on a meal plan, and it's my job as a therapist to help them to maintain that. It's very hard. It's even hard for me as a professional. It's hard for me as someone who worked in residential treatment where we had them living with us, and we can't even control everything.
So it is. It's really tough. But as you do the therapy, as you get their brain back online, as they're nutritionally more balanced, they do want help underneath it all. They do want help. That's the thing I think I would want parents and families to see is at the end of the day, they really do want help, even though they're pushing you away so strongly around the food. The first thing I tell someone when they come to my office is, "I am not going to steal this from you. I'm not going to make you eat."
Dr. Tim Clinton: Or if they think you're going to make them gain weight.
Dr. Margaret Nagib: Make them gain weight.
Dr. Tim Clinton: Oh, you're kidding. They're mortified.
Dr. Margaret Nagib: Right.
Dr. Tim Clinton: You hear what I'm saying?
Dr. Margaret Nagib: Right.
Dr. Tim Clinton: But nevertheless, they may be in trouble.
Dr. Margaret Nagib: Absolutely.
Dr. Tim Clinton: Let's stop right here for a second. I want you to talk to the mom or dad listening right now. Really worried, concerned, and they're in the power struggle. They're trying to force their daughter to eat. You hear what I'm saying? They're worried about the bulimia thing and they're noticing a pattern. Maybe she's getting up within 10 minutes or so after eating. She's eating a normal meal, but you notice she's gone, and you know where she's going. Talk to them real quick about in that moment, to some ways to calmness for a second and what they should be thinking about doing.
Dr. Margaret Nagib: Yeah. Yeah. Well, I mean, I think the first thing is to be calm themselves, which is so hard to say to a parent. But when you come to them in your anxiety and your fear, that's not going to help. So to come to that calm place and sit down with them at some point, and to just be neutral in this, but honest and say, "Hey, I'm noticing," and then just point out the behaviors, "And I'm really scared and I don't know what to do. And I'm wondering how you are doing. I'm wondering what's really happening for you. Can we talk about what's underneath that? I'm not here to tell you what to eat or what not to eat, but can we talk about this because I'm noticing this. Can I be an ally for you?" Sometimes that can be very disarming for someone with an eating disorder because they're not expecting that, right? They're expecting you to come in, guns blazing, trying to get them to stop throwing up or whatever it is. Sometimes it takes weeks and months of that before the person's ready to get some real help.
Dr. Tim Clinton: Moving forward here for a moment, I don't want to just live on the downside here because it's horrifying. I've got a couple families in my mind right now where anorexia became a real lifelong journey for them. Margaret, let's talk about hope, first of all. People do get really afraid. Remember the old Karen Carpenter story way, way back?
Dr. Margaret Nagib: Sure.
Dr. Tim Clinton: You hear statistics, one out of four, one out of five actually die with the anorexia.
Dr. Margaret Nagib: Yeah. I mean, you're talking about a segment of the population where it's really, really severe. It's not as common as you think, but when it is, it's very scary. We do talk to them about some of the medical consequences, and then we monitor them. So sometimes the best I can do is say, "Hey, can we at least get blood tests? Can we get you seeing the doctor once a month to just make sure you're okay?" Sometimes that's a place to start, is if they're at least willing to keep up with some medical testing just to make sure that their heart's okay.
Dr. Tim Clinton: Their electrolytes, everything is completely out of whack. The body's out of whack. I noticed some debate out there about whether or not they believe anorexia is like an addiction. Okay? I know that's a whole different world, okay? I want to go there, but I want to talk about the patterns that are deeply ingrained here. Because the body, the emotion, everything is so ... It's in this type box, and it's like this rumination that's going on and they can't break out of it. It's almost like you can't talk them out of it.
Dr. Margaret Nagib: No, you can't. No.
Dr. Tim Clinton: So in those moments, when we're going into that place, where do we go?
Dr. Margaret Nagib: Yeah. That's the point when I sit down with the parent and I say, "Your daughter, your son has a mental illness. They're not thinking straight. They're not rational. This eating disorder is holding their brain captive. In fact, it's holding their spirit captive."
Dr. Tim Clinton: They're not going to snap out of it.
Dr. Margaret Nagib: They're not going to snap out of it. So there does come a time, Tim, when you have to break out all the forces and get them into treatment, whether that's an intervention, whatever it is. But there does come a point when you have to do that and recognize that they're going to kick and scream and do all of those things.
Dr. Tim Clinton: Getting everything in the fight.
Dr. Margaret Nagib: Everything in the fight.
Dr. Tim Clinton: Hey, you're listening to Family Talk. It's a production of the James Dobson Family Institute. I'm your host today, Dr. Tim Clinton. I'm in studio with Dr. Margaret Nagib. She really is an expert, has worked for a long time in the area of eating disorders. Well, by the way, she has a great message on Hope. Margaret, thanks again for joining us. It's fascinating discussion because this is a difficult, difficult subject, it's a real journey for families. Margaret, okay. Let's talk about treating anorexia, and we'll talk about bulimia too in a moment. But most people now talk about a collaborative care where they talk about medical intervention, nutritional intervention, behavioral interventions and more. So you've got all these lanes we've got to work in. Let's talk about the medical side. You do need to start there.
Dr. Margaret Nagib: Yes. Start there with the physician-
Dr. Tim Clinton: That body going to stop.
Dr. Margaret Nagib: Absolutely. They need to see a physician. They need to get all the proper blood tests to see where their electrolytes are, where their heart's at. Please find a physician that specializes in eating disorders. Unfortunately, physicians do not get trained in eating disorders. Sometimes they do the wrong thing. They tell them they're just fine, or their BMI is fine.
Dr. Tim Clinton: The Body Mass Index.
Dr. Margaret Nagib: Body Mass Index. Yeah. Look for a physician that specializes in eating disorder. Hard to come by, but that would be the goal. If not that, then someone who is willing to do the proper test and at least understands that this is serious.
Dr. Tim Clinton: With the medical side, bring in the nutritional side because the war again is over food. You've got this body perception problem going on. In other words, she can be as skinny as can be, look in the mirror at herself, and I mean, turn sideways. She's thin and she thinks she's what?
Dr. Margaret Nagib: They can't see it.
Dr. Tim Clinton: She thinks she's heavy, that she's fat.
Dr. Margaret Nagib: Right.
Dr. Tim Clinton: She can't see it. And it's mortifying.
Dr. Margaret Nagib: Absolutely.
Dr. Tim Clinton: Now, getting the nutritional piece going, that's the battle zone, isn't it?
Dr. Margaret Nagib: Is hard. Once again, a dietician or nutritionist that specializes in eating disorders because they understand the mentality. They understand that this is maybe the hardest part of the treatment team for them to embrace. So someone who specializes in nutrition and eating disorder will be able to meet this person where they're at and slowly work them on a nutritional plan to get them back on their feet. But it needs to be someone who understands the mentality.
Dr. Tim Clinton: So dietician.
Dr. Margaret Nagib: Right.
Dr. Tim Clinton: Somebody-
Dr. Margaret Nagib: Dietician, nutritionist, registered dietician, they call it a CEDS, a Certified Eating Disorder Specialist. That's who I'd recommend. You don't want to send them to just any dietician.
Dr. Tim Clinton: We use the word behaviorism or behavioral program here. What we're trying to do is retrain them, right? So they've got some deeply ingrained habits that we're trying to break here. So there needs to be a lot of accountability going on too in this process.
Dr. Margaret Nagib: Oh, yeah.
Dr. Tim Clinton: You heard me talk earlier about bulimia Within the first 20 minutes is when that food settles and nutritional value is yay or nay, right? So you're trying to keep them inside appropriate important windows.
Dr. Margaret Nagib: Right. So food journals, keeping track of what they're eating, giving them a plan for 20 minutes after they eat, then they can't purge. So helping them with all of that, the dietician's going to be doing that.
Dr. Tim Clinton: Margaret, everybody's thinking the same thing. The emotional issues. Why? What's going on deep down inside that's driving this? Families ask questions all the time. I've sat in the room many, many times and had these discussions, what have you found? What have you seen some common themes through the years? I know what the anorexia of perfectionism is a big one.
Dr. Margaret Nagib: Sure, sure.
Dr. Tim Clinton: Imagine this just for a moment. The ability to be that disciplined.
Dr. Margaret Nagib: This is true.
Dr. Tim Clinton: Think about that.
Dr. Margaret Nagib: Yeah. It's almost not human.
Dr. Tim Clinton: Like an extraordinary gift in a sense that they have that much willpower.
Dr. Margaret Nagib: That's true. So you're kind of hitting on something there because there's this lack of real sense of, "Am I effective in the world? Am I good enough in the world?" Then they find this behavior where they're superhuman and they can actually look around and feel excellent at something. They really are. They're excellent at it. So I would say at the core, it's emotional regulation, not knowing how to deal with the tough feelings in life, the sadness, the depression, the shame, the times when we all feel like, "Am I good enough?" Not knowing who they are in Christ, not knowing their value. This helps them feel powerful. It helps them feel accomplished. It becomes, in some ways, like a religion. This is what I need to do to feel okay in the world. That part of it can be very, very addicting because there's very clear reinforcement. Every time they lose a pound, they feel successful.
Dr. Tim Clinton: It drives it.
Dr. Margaret Nagib: It drives it. Absolutely. So that's what you're talking about. You're talking about core identity, and I need this to feel okay about myself. So the metaphor I often use is of a rickety raft, and you're out there in the storm and the eating disorder is your rickety raft, and it's keeping you alive. It's keeping you alive. So I'm not going to rip that away from you, because that's the only way you actually know how to cope in this world and with what's going on inside of you that you may not even be fully aware of. But what if there's something better? What if we can begin to look at that raft and know that ultimately you're going to die on that raft? It's keeping you alive, but it's a rickety rotten raft. So how can we slowly begin to exchange this rickety rotten raft for something much more stable? That's going to bring you life instead of hold you captive, which ultimately is not life when you're held captive to something else. That's the metaphor that I often use that can be very helpful to both family members.
Dr. Tim Clinton: There tend to be some pretty strong family dynamics going on. A lot of it, first of all, is just simply because of the chaos that's now in our family that we're in this massive tug of war. We're confused. People are hurt. But Margaret, there can also be some parent issues where there is somewhat of a disconnected times, not saying all the time, but it can be. So how do you address those kind of family issues when you're walking down this road of treatment with someone who's anorexic or bulimic?
Dr. Margaret Nagib: Yeah. I mean, think about a child who didn't know how to assert themselves or maybe got back from the parent something that wasn't helpful at the time. But ultimately, it's really hard because sometimes when parents come in, they feel a lot of shame for what's happening. But ultimately, it comes down to this person not being able to express what they really think. If they can begin to, number one, express those feelings and not feel like they're going to be overwhelmed by those feelings in a healthy way, then they can take back their life and not feel as dependent on the food or the behaviors to communicate what they're trying to communicate so desperately. So really, underneath every anorexic and bulimic. They're very tenderhearted souls. They're tenderhearted souls that don't want to disappoint you. They're people pleasers.
Dr. Tim Clinton: Then they drift right back into their world,
Dr. Margaret Nagib: Then they drift in their world. But then they use their eating disorder as a way to express their anger or whatever it is.
Dr. Tim Clinton: Margaret, then the thinking challenges, the stinking thinking is so much more that just goes with all this. It's a total spin. Margaret, one more important question. If there's a family or someone who's struggling with an eating disorder right now, what do they do? We know you've got to get the right kind of help here.
Dr. Margaret Nagib: So do not do this alone. Seek out a mental health professional, whether it's a physician or a therapist or a dietician who understands eating disorders, has worked with eating disorders, make sure you ask them, "Have you worked with eating disorders? Is it a specialty?" Even if it's just the parent or their loved one meeting with this person first, just make sure you connect with the professional who understands and works with eating disorders.
Dr. Tim Clinton: The good news is we're making strides in these areas, and we're seeing help and hope come to individuals and families in special ways.
Dr. Margaret Nagib: My favorite saying as of late is, "Hope dies last." You can't kill that sucker. It always dies last. So to the family members. I say, "Never ever give up hope. She or he is going to give you the run of your life, and you're going to feel like you're going to give up. You're going to feel completely powerless as a parent, but hope dies last. Don't give up hope." For the person who is struggling, I would say, "There's so much more for you and God's just waiting and he's with you, and he'll sit with you while you're binging and purging. He hasn't left you. Can we talk to him? Can we begin to see what he has for you and see if there isn't another way."
Dr. Tim Clinton: There is another way.
Dr. Margaret Nagib: Absolutely.
Dr. Tim Clinton: There's a better way.
Dr. Margaret Nagib: Right.
Dr. Tim Clinton: If we can just get you started.
Dr. Margaret Nagib: Yes.
Dr. Tim Clinton: Yeah. I mean, that starts with a decision.
Dr. Margaret Nagib: Right.
Dr. Tim Clinton: Let's make a call. Let's reach out. Let's have that conversation.
Dr. Margaret Nagib: Yeah, let's get some information.
Dr. Tim Clinton: "Mom and dad, help me. Let's do this thing."
Dr. Margaret Nagib: Yeah.
Dr. Tim Clinton: Margaret, what a great program. We've got to do a lot more on this because this is so prevalent and so many families are out there and they live in shame. The silence of this trying to ... They're like kids on a bicycle. They want to close their eyes for one or two seconds and open them back up. Remember, you used to do that as a kid, and you think when you open them and you think everything's going to be different, but it isn't.
Dr. Margaret Nagib: It's not.
Dr. Tim Clinton: No.
Dr. Margaret Nagib: No.
Dr. Tim Clinton: God wants to speak into that. We really believe it. Thanks for joining us here on Family Talk. Thanks for all you're doing. We're praying for and with you.
Dr. Margaret Nagib: Thanks, Tim.
Roger Marsh: You've been listening to Family Talk. That was Dr. Tim Clinton's important conversation with Dr. Margaret Nagib about eating disorders. Now, food is a part of our daily life, of course, and struggles with food have touched many, many lives, perhaps even yours or someone close to you. But I want you to know that there is hope, there is healing and there is recovery. Using professional care and counseling and long-term, what some people would call self-care is invaluable. Now you can do so when you find your strength and confidence in God. If you are someone you know is struggling with an eating disorder, don't hesitate to seek help. Our friends at the American Association of Christian Counselors can help you find a trained professional Christian counselor in your area. Simply go to connect.aacc.net. On that page, you'll find a search tool that will help you find a directory and get started. That's connect.aacc.net.
By the way, if you'd like to learn more about Dr. Margaret Nagib, simply visit our website at drjamesdobson.org. Click on the broadcasts page, and there you'll find a link for her website. Do you enjoy listening to Family Talk? While there is still time to order your Best of 2022 broadcast collection, it contains six CDs filled with valuable content that is a great addition to your home ministry library. For a suggested donation of $50, you can order one today. You can place your order online at drjamesdobson.org or give us a call at 877-732-6825. We would love to hear from you, so please contact us with your comments, your questions, and even your prayer requests. Again, the number to call is 877-732-6825. I'm Roger Marsh, and from all of us here at the JDFI, we pray that God continues to bless you and your family. You've been listening to Family Talk, the voice you trust for the family you love.
Announcer: This has been a presentation of the Dr. James Dobson Family Institute.