Cannabis is often used to increase appetite in people suffering from conditions such as cancer or AIDS/HIV. The idea of using cannabis for those with eating disorders is not exactly new, and in many ways the logic is entirely sound. However, eating disorders have several key differences to cachexia developing from other chronic illnesses, meaning that treating them requires slightly different approaches. Using cannabis for eating disorders is a subject we have written about before here at Leafwell; but, as it’s Eating Disorders Awareness Week, we thought to write about the potential of cannabis as a medication for a variety of eating disorders in a little more detail … Wellcome Library, London. Wellcome Images [email protected] http://wellcomeimages.org From the article ‘In Cas D’Anorexie Hysterique’ by Georges Gasne published in Nouvelle Iconographie de la Salpetriere. 1900 Nouvelle iconographie de la Salpêtriêre. Société de neurologie de Paris.Salpêtrière (Hospital) Published:- Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/ What is an eating disorder? One of the key defining symptoms of an eating disorder is an unhealthy attitude towards food and eating either too much or too little. Other symptoms include an unhealthy obsession with weight and body shape, over-exercising, obsessive dieting, binge-eating (sometimes followed by intentional vomiting, or “purging”), extreme dissatisfaction with one’s own appearance (Body Dysmorphic Disorder, or BDD) depression, anxiety and extreme feelings of guilt, regret and/or worthlessness. In some instances, an eating disorder may lead to “refeeding syndrome”, which is when malnourished or starved people take in food too quickly after a fasting period and develop electrolyte disorders. This leads to further pulmonary, cardiac, neuromuscular and hematological complications. Refeeding syndrome can be potentially fatal. Other long-term complications include increased likelihood of stress fractures and Raynaud’s syndrome. There are various types of eating disorders, including: Anorexia nervosa – keeping your weight as low as possible by not purposefully not eating enough food, exercising too much or both. Binge eating disorder (BED) – losing control of your eating and eating too much at once, until you are uncomfortably full. Often followed by feelings of guilt and regret. Bulimia – Binge eating in a small amount of time, then deliberately feeling sick, using laxatives or exercising too much in order to prevent weight gain. Obesity – Whilst not always considered an “eating disorder”, obesity does follow many of the same patterns as other eating disorders, including binge eating and an unhealthy relationship with food. Indeed, it is not unheard of for a person to swing between anorexia and obesity. Other specified feeding or eating disorder (OSFED) – an eating disorder that doesn’t necessarily match all the symptoms of one of the above, and/or have “mixed” symptoms from one or more of the above. OSFED can include atypical anorexia, avoidant/restrictive food intake beyond that of “picky eating”, night eating syndrome, anorexia athletica and eating disorders related to type-I diabetes (e.g. deliberate insulin under use in order to prevent weight gain). Some statistics on eating disorders Deaths from Eating disorders in 2012 per million persons. Statistics from WHO. Data from World Health Organization Estimated Deaths 2012 Vector map from BlankMap-World6, compact.svg by Canuckguy et al. https://en.wikipedia.org/wiki/File:Eating_disorders_world_map-Deaths_per_million_persons-WHO2012.svg Eating disorders affect approximately 30 million people in the US. They have the highest mortality rate of any other mental illness, and is often comorbid with mood disorders, anxiety disorders and substance misuse disorders (especially alcohol). Eating disorders affect a wide variety of people. Women aged 50 or over, women aged between 13 – 17 and women in high-pressured environments such as athletics are the highest risk groups for anorexia and bulimia. Restrictive eating is more likely to be found in boys and men. A 2015-2016 study by the Center for Disease Control and Prevention (CDC) showed that 39.6% of US adults age 20 and older were obese as of 2015-2016 (37.9% for men and 41.1% for women). Other risk factors include: Prenatal exposure to under- and overfeeding of the foetus during pregnancy. Maternal obesity and malnutrition play a huge role in the development of eating disorders amongst offspring. Adiposity rebound – the “adiposity rebound” refers to the age when the second rise in body-mass index (BMI) occurs, which is between 3 – 7 years old. An early age adiposite rebound is correlated with obesity in later life. Early life malnutrition and/or lack of breastfeeding – early nutrient deprivation can lead to a change in the body’s metabolism, leading it to store fat. This can make them vulnerable to obesity as adolescents and adults. Those who are not breastfed may suffer from stunted growth or grow too fast, leading to an earlier-onset adipose rebound. This is one reason why malnutrition, a lack of access to food and obesity are often linked and found together in impoverished parts of the world. Steroid-based medications such as prednisone can lead to weight-gain. Chemical structure of Prednisone, a corticosteroid. Cachexia Whilst cachexia (which means, “weakness and wasting of the body due to severe chronic illness”) is often associated with conditions such as anorexia, a person who is suffering from cachexia is not necessarily suffering from an eating disorder. Cachexia can be caused by many illnesses and conditions, as well as treatments and medications. Many of those with cachexia may well have a perfectly fine relationship with food, but are unfortunate enough to suffer from a condition that causes them to lose weight and muscle. Anorexia Athletica Those in highly competitive environments such as sports and athletics, where extreme fastidiousness is practised with regards to diet and exercise, eating disorders are not uncommon. Many athletes also need a high intake of calories, meaning they need to learn portion control when training slows down or ceases. Athletes of all types can potentially suffer from eating disorders. Even boxers and wrestlers, who are considered some of the strongest athletes in the world, often dehydrate, starve and over-exert themselves in order to make weight, which can lead to all sorts of health problems. Gymnasts, dancers, figure skaters, weightlifters, bodybuilders, synchronized swimmers, and endurance runners and swimmers are other examples of athletes who may suffer from eating disorders due to the emphasis on weight and appearance. From https://pixabay.com/photos/running-runner-long-distance-1705716/ How does cannabis help? And why can it be used to treat obesity, when it makes people hungry? When it comes to using cannabis for conditions such as anorexia, people see the logic quite easily. However, when it comes to obesity (as well as diabetes), people find the concept of using cannabinoid-based medications to help treat it unusual. Yet, regular use of cannabis is actually linked to lower BMI, even when controlling for diet, exercise and alcohol consumption. Whilst these studies do not prove for definite that cannabis use can help people maintain a healthy weight, there are several sound theories as to why cannabinoids may be used to help maintain a healthy appetite for both over- and under- eaters. These include: The endocannabinoid system (ECS) plays a role in regulating appetite. Cannabinoids such as tetrahydrocannabinol (THC) stimulate appetite and food intake. There is some suggestion that those who suffer from eating disorders have a disruption and/or dysregulation in the production of the hormones leptin (which can regulate energy balance by inhibiting hunger) and ghrelin (the “hunger hormone”, which stimulates appetite). Cannabis use in HIV-infected men lead to an increase in plasma levels of ghrelin and leptin. THC in particular seems to have this effect. To quote from ‘Metabolic Effects of Chronic Cannabis Smoking’: “Cannabinoid receptors (CB1R and CB2R) and their endogenous ligands, the endocannabinoids, play an important role in regulating energy balance, appetite, insulin sensitivity, pancreatic β-cell function, and lipid metabolism (1–4). Endocannabinoids (anandamide and 2-arachidonoyl glycerol) and CB1Rs are present in peripheral tissues involved in energy homeostasis, such as adipose tissue, liver, skeletal muscle, and pancreas (1,2). CB1R activation promotes lipogenesis in the liver and adipose tissue (1,2,5), reduces insulin responsiveness in skeletal muscle (3), and impairs insulin action and secretion in pancreatic β-cells (4). Consistent with these findings, clinical interventional trials suggest that CB1R antagonism reduces body weight, improves dyslipidemia, and attenuates insulin resistance in humans (6,7).” Repeated exposure to THC may initially stimulate appetite initially, use over the long term could dampen CB1 receptor sensitivity, thus dampening hunger signals. Some suggest that cannabis “supercharges” the body’s metabolism, meaning that fat is burnt off faster and levels of fasting insulin are lower. The body may be more sensitive to the effects of sugar whilst using cannabinoids, meaning that the brain sends signals to stop eating sooner than it usually would. So, whilst cannabis users may get the “munchies”, they may also have a tendency to stop eating sooner and only till they are full, rather than over-full. There is much interest in the cannabinoid tetrahydrocannabivarin (THCV) for obesity and diabetes. THCV is a CB1 receptor antagonist, meaning that it has the opposite effect as THC when in low doses (THCV is a CB1 receptor agonist in high doses) and curbs hunger. In studies on mice: “THCV did not significantly affect food intake or body weight gain in any of the studies, but produced an early and transient increase in energy expenditure. It dose-dependently reduced glucose intolerance in ob/ob mice and improved glucose tolerance and increased insulin sensitivity in DIO mice, without consistently affecting plasma lipids. THCV also restored insulin signalling in insulin-resistant hepatocytes and myotubes.” Cannabidiol (CBD) can also help control blood-sugar levels and reduce the production of fat and reduces inflammation caused by insulin resistance. Cannabis can potentially help with the depression and anxiety often associated with eating disorders. In turn, this may lead to an easier, less stressful relationship with food. Are there any potential negatives with using cannabinoids for eating disorders? Whilst cannabis can help improve the mood for many, for some using too much THC may lead to increased anxiety or paranoia. Also, if a person has been starving themselves for too long, care must be taken not to binge on food, lest refeeding syndrome occurs. Some may also be attracted to the idea that cannabis can help lose weight, which is helpful for some but not necessarily others. Therefore, care must be taken to prevent misuse. Those suffering from eating disorders such as anorexia or bulimia may be interested in low doses of THC and CBD, whilst those who are obese (or just plain overweight) may look into a combination of low doses of THC and THCV, combined with CBD. However, this is only theoretical, and has not been tested clinically. As there are few effective medications for eating disorders, cannabinoids represent an extremely promising avenue to look at as a potential therapeutic target. There has been a look into inverse agonists of the CB1 receptor as a treatment for obesity in the past, namely Rimonabant. However, Rimonabant was not approved for usage due to its psychiatric side-effects. Rimonabant has also been reported to cause partial seizures in those who suffer from epilepsy. It must also be noted that Rimonabant is a synthetic cannabinoid. We here at Leafwell have looked at the pros and cons of synthetic cannabinoids before, and as such we recommend being highly cautious of using them. Remember: the ECS is a very powerful system, and our efforts to replicate the safety margins of phytocannabinoids has generally not been successful so far. Skeletal formula of an anorectic drug rimonabant (a.k.a. SR141716). https://pubchem.ncbi.nlm.nih.gov/compound/104850#section=Top If you are suffering from an eating disorder and think you may be helped by cannabinoid-based medications, feel free to check out our medical card page and set up an appointment with one of our physicians.