Eating Disorders and Nutrition News

Hallmarks of the adolescent eating disorder, and an effective skill-building program for parents

Dear Readers,

On this blog, Marcia and I have talked about the different ways one can interpret or understand eating disorders. Today, I have a few more for you. One of the hallmarks of a severe adolescent or adult eating disorder is a remarkable lack of joy, an inability to simply be in the moment. Instead, the anorexic or bulimic is always focused on a future outcome, such as “What will happen to me if I cave in to temptation and eat a peanut butter sandwich?” or, “If I don’t exercise every day I will feel like a pig.” Nancy Zucker, Ph.D., director of the Duke Eating Disorder Program at Duke University in Durham, N.C., brought up this singular lack of joy and a few other characteristic eating-disordered traits during a recent interview I conducted with her.  

            Another example: once on the road to recovery, both parents and those who struggled with an eating disorder will often experience what Dr. Zucker calls symptoms of “almost a PTSD [Post-Traumatic Stress Disorder] kind of trauma.” This is understandable because to be locked in the vise of an eating disorder is traumatic, resulting in a loss of identity, control over one’s life, and all too often, the will or physical strength needed to continue living. For the recovered or recovering patient, just the memory of the terrifying power of the disorder or the temptations that could trigger it once again can be disabling, leaving the patient feeling vulnerable and scared. For the parent, fear of an exacerbation of symptoms may lead them to be hypervigiliant to any slight change of eating behavior, an exhausting process for both child and parent.

            Dr. Zucker sees eating disorders as “a disorder of self-regulation, a disorder of self-parenting.” The adolescent is “unable to respond to her own needs” and must be taught how to do that, she explains. Feeling lonely, depressed, hungry, angry or sad are some of the feelings that the eating-disordered child fails to be responsive to. It remains an open question whether it is a failure to decipher these cues, a failure to respond, or both. The individual with an eating disorder knows only that she feels badly, and treats this condition with her default response of self-starvation, or bingeing and purging. 

            To help parents deal with these emotional and behavioral challenges, Dr. Zucker has developed a skills program called Off the C.U.F.F. (Calm, Unwavering, Firm and Funny) that helps them recognize and attend to their own needs, and by example, show their child how to do the same thing. It also helps them react swiftly to signs of impending roadblocks in their child’s recovery. One of Dr. Zucker’s most popular tools is recognizing and mastering the “Eating Disorder wave”. The “wave” refers to a brewing emotional tsunami, the rising wall of intense feeling that can overpower a child and knock her off her feet and back into the disorder if parents don’t intervene in time. Learning to read subtle emotional cues and react swiftly, it turns out, is a highly effective way to prevent relapse or continued self-destructive behavior.

            Dr. Zucker’s program has been so successful that it has been adopted by hospitals and eating disorder treatment centers around the world. A manualized version of Off the C.U.F.F. is also available.

Take care,

Nancy

 

Silencing the Inner Critic

Dear Readers,

The title of this article in today's Wall Street Journal says it all: "Silencing a Voice That Says You're A Fraud." It turns out that the Inner Critic that tells you on a daily basis that you are fat, disgusting, a pig, etc., isn't just a trait of those with eating disorders. Physicians, eminent scholars, and executives seemingly immune to self-doubt about their abilities, intelligence, or achievements can all suffer froma sense of inadequacy in one area of life or another. 

Kept in check, the Inner Critic can help a person achieve. The out-of-control Inner Critic, however, can be a destructive force, leading to depression and anxiety. The article, by Melinda Beck, describes how Cognitive Behavioral Therapy (CBT) can help combat this self-critical tendency. This technique is one of the most effective tools for combatting eating disorders, especially bulimia, body dysmorphic and binge-eating disorders. Try completing the 15-item self-criticism questionnare to see where you stand on the spectrum of self-critical behavior,  and see if you can apply some of the CBT techniques the article outlines to your own life!

Take care,

Nancy

Eating disorders: They’re not about food and all about food

Dear Readers,

                We’ve often heard people say, “Eating disorders aren’t about food at all. They’re about depression, anxiety, or low self-esteem.” This takes away some of the stigma that an eating disorder sufferer feels because it means she’s not just self-involved and superficial for being obsessed with appearance and weight. There are deeper things going on here, which merit doctor’s visits and hospital stays, not to mention insurance reimbursements.

                Another way to telegraph what eating disorders are is a saying that Marcia sometimes uses: “Genetics loads the gun, and environment pulls the trigger.” This refers to current scientific understanding, which holds that eating disorders originate through an interplay of genetic (your mother had an eating disorder, so you are more likely to develop one) and environmental (incessant schoolyard taunting about your size led you to self-starvation) factors.

                These handy  aphorisms are true, but the reason they bear repeating is that when it comes to making an eating-disordered person better a lot of the hard work, fear, pain and suffering the patient has to go through in order to recover revolves around, well, food. Which can be confusing.

                It may help to view eating disorders through the addiction model. An alcoholic or a drug addict drinks or takes drugs as a self-soothing measure. Ingesting them can take the edge off a tragic loss, a blow to one’s confidence, even a bad day.   Walter Kaye, the highly respected director of UCSD’s Eating Disorder Research and Treatment Program, says of the anorexia patient, “These are very anxious people. Not eating is the one thing that makes the anxiety go away. Whereas most people feel pleasure when they eat, the anorexic feels uncomfortable.” Instead of taking something in order to reduce anxiety, as the alcoholic might, the anorexic’s self-soothing trick involves not taking the substance, or not eating.

                Another way to think of an eating disorder is in the context of various fears or phobias, such as fear of flying, fear of public speaking, or if you are Indiana Jones, fear of snakes. The way to overcome such fears is to make oneself face them, over and over.

                As Alicia Hirsch, Psy.D., director of clinical services at Mt. Sinai Eating and Weight Disorders Program in New York City says, there is an “exposure component” to treating eating disorders. “You’re asking a patient to do something incredibly uncomfortable,” which is eating. Repeated exposure to the feared thing, in this case something edible, makes the patient’s anxiety and discomfort level come down.  “The food is the medicine,” Dr. Hirsch explains.

            So, to sum up: It’s not about food. It’s about genetics and environment. Food makes the eating disordered person anxious. Food is the medicine. Any questions?

            Both the UCSD and the Mt. Sinai programs educate families about the complex mix of biological and environmental factors that are involved in the creation of eating disorders. This is an important component of any treatment program, so if you are in the market for one now, make sure it includes this piece. The more you learn, read and understand about eating disorders, the better armed you will be to help your child or loved one recover.

Take care,

Nancy

New York City eating disorders program accepting early onset anorexia study subjects

Dear Readers, 

            In our book and on this blog, Marcia and I have written about the Maudsely method of Family Based Treatment (FBT) for anorexia nervosa. This is a form of treatment developed at the Maudsley Hospital in London that makes parents key players in their child’s recovery, putting them in control of refeeding their child or adolescent (once the child is physically out of danger) and returning her or him to health. Families and clinicians who have tried this method swear by it and there is even a website, www.maudsleyparents.org  that offers information and support for families engaged in FBT. Marcia’s own Parent-Assisted Meals and Snacks (PAMS), is based on FBT principles.

            There are also a number of studies being conducted on how to expand the use of this effective method of treatment. One of these is an NIH-sponsored clinical trial examining the effectiveness of FBT for early onset or emerging cases of anorexia, headed by Katharine L. Loeb, Ph.D., director of research for the Mt. Sinai Eating and Weight Disorders Program.

            Dr. Loeb is seeking patients between the ages of 10 and 17 who meet at least some of the criteria to be considered anorexic, and who have one or more parents or guardians also willing to participate in the study. If your child is refusing to maintain a normal body weight, has stopped having her periods, has a fear of weight gain or poor body image, or any other symptoms of anorexia, you may be eligible for this study.    

            Although statistics are hard to come by, the conventional wisdom in the eating disorders treatment field is that the earlier anorexia is treated, the better the outcome. Dr. Loeb hopes her research will eventually lead to a version of FBT specifically targeted at emerging or atypical cases of anorexia, so that it can be used in efforts to prevent this pernicious disorder from fully unfolding or becoming chronic. 

            Getting timely treatment is difficult because the existing criteria that doctors use to diagnose anorexia are not developmentally sensitive enough to allow them to always catch anorexia in its early stages. Often the child will deny or minimize having certain symptoms, leaving the pediatrician confused about whether to label the problem anorexia. For example the child might play down symptoms for fear of being made to gain weight, quit an athletic team, or stop her excessive exercising. The difference between calling the problem “anorexia” and calling it “normal dieting behavior” could be the difference between getting the help a child needs to stop the disease in its tracks or letting it get out of hand. Dr. Loeb hopes that her study will also aid in the creation of case identification methods that enable doctors to navigate these gray areas and recognize early onset cases.

            We stress in our book the importance of prevention; Dr. Loeb’s work is the kind of research we need to allow parents to fight anorexia before it becomes entrenched, before it has begun to do irreversible damage to the child’s bones, heart or brain. 

            To find out more about this study, which involves both family-based and individual interventions, or about other treatment options, please contact Lauren Alfano: tel. (212) 659 8724, email Lauren.alfano@mssm.edu .

Take care,

Nancy

Eating disorders treatment now: Are we still in the dark ages?

I spoke recently with Dr. Julie O’Toole, founder and medical director of the well-respected Kartini Clinic in Portland, OR. Kartini treats kids up to about age 22 who have eating disorders, using a family based method that relies heavily on parent participation in the child’s recovery.

                Dr. O’Toole is on the same page as Marcia and me: “Parent’s don’t cause eating disorders,” she said, “they are no more responsible for a child getting an eating disorder than they are for a child getting diabetes. Far from being the problem, parents are the only sensible partners that you have to adequately treat a child with an eating disorder.”

                Probably the biggest obstacle that this pediatrician and her team face is that of dealing with what she calls “affected or partially affected parents,” meaning the mom or dad who either has overcome an eating disorder in the past, is still dealing with one, or is grappling with body image or eating problems that have remained untreated or even unacknowledged.

                As Dr. O’Toole points out, we know that eating disorders are highly “heritable,” meaning that kids can inherit the genetic predisposition toward an eating disorder. Yet often parents of a child with anorexia or bulimia who have eating problems of their own feel ashamed, as though they were weak-willed, or bad parents.

                As we have pointed out many times before, there is still a stigma attached to having an eating disorder. This is one reason why Kartini has been working with scientists at Vanderbilt University on a genetic study of eating disorders. “I’ve always taken extensive, detailed family histories,” Dr. O’Toole said, “and our therapists are trained to watch for [multi-generational eating problems]. In this sort of more genetic, or scientific way, we hope to de-stigmatize eating disorders.” Her hope is that one day, parents will look at their eating problem just as objectively as the parent whose child has diabetes, is screened and found unable to fully metabolize sugar: no one blames the child or parent for their condition, we feel sorry for them for having inherited these particular genetic traits.

                One day, there will be a more effective treatment for eating disorders than the mix of medical intervention, education, and family, behavioral and nutritional therapy that is now used. “Right now, it’s like we’re treating tuberculosis in the pre-antibiotic era,” said Dr. O’Toole. “We can structure the environment so [patients] don’t get sick or worse, but we can’t really change the brain chemistry yet.”

                The future holds great promise, though, when it comes to solving eating disorders. “The brain science isn’t here yet,” said Dr. O’Toole, “but it will be.”

Take care,

Nancy

  

Labs say you're fine, doctor says you're sick: What's going on?

Dear Readers,

                What are parents to do when they're pretty sure their child has an eating disorder yet all lab tests and the usual medical markers of health come back within normal ranges?

                This is a situation that Marcia sees a lot, most recently in the case of a young college-aged patient. The student reported that although she knew she had an eating disorder, she was told by her doctor that her labs, weight, blood pressure and heart rate were all fine. The girl and her parents were left baffled and confused.

                The same thing happened to Marcia as a young girl of 15 struggling with anorexia. In our book, we relate the story of the time when Marcia's grandmother, who was worried about Marcia's plummeting weight, took her to see their family doctor. He found no cause for alarm, despite the fact that Marcia was five-foot-six inches and 100 pounds. "He recommended that I put olive oil in my dry and brittle hair," recalls Marcia, "when he should have told me to add the olive oil to my food."

                Even though doctors are far more educated today about the hazards of eating disorders than they were when Marcia was a teen (an extreme case like hers would most likely be noticed by even an obtuse doctor now), eating disorders are still often missed. Patient and family are eager to accept this poor but reassuring advice; after all they don't really want to admit that there is a problem. The professional in the white lab coat is giving them permission to look the other way, and it's just too convenient sometimes.

                The reason this scenario -- normal lab results despite clear-cut anorexia – occurs so often­ is that the body works very hard and very effectively to compensate for starvation. The ups and downs of human evolution have ensured that the body is well-adapted to surviving famine. Usually labs will stay normal until the patient is in very serious medical trouble, and then things go downhill so fast families have no time to process what is happening.

      In the recent case of the young college-aged girl, Marcia advised her and her parents that it was vitally important to treat her eating-disordered behaviors regardless of her normal lab results. Marcia also referred the patient to a doctor who specializes in eating disorders, someone she knew would use the misleading lab results to educate their patient about the dire consequences of an untreated eating disorders.

 

Take care, and for parents, stay vigilant,

Marcia and Nancy

Intensive short-term family treatment for anorexia: a solution to inadequate medical coverage?

Dear Readers:

The Los Angeles Times published a story and audio slide show recently, Starved for Normality about a 39-year-old man living in Orange County, CA who has suffered from anorexia for the past 12 years. At 5'- 9" and 82 pounds, he is at high risk for dying of starvation, yet he is unable to get the kind of long-term residential care he and his doctors believe he needs to get well from the state Medicaid program that he depends on.

Unfortunately, the story does not touch on the equally grim travails of eating disorder patients with private health insurance, or the growing body of scientific evidence detailing the genetic and neurobiologic causes of anorexia and other eating disorders. It does not challenge the common misperception that eating disorders are the consequence of a frivilous susceptibility to America's diet-obsessed culture. Based on what we know today, refusing to treat eating disorders is equivalent to refusing to treat schizophrenia or cancer, diseases that patients were unfortunate enough to be genetically susceptible to, through no fault of their own.

Still, I noticed the story because I recently spoke with Dr. Walter Kaye and advanced doctoral candidate Roxanne Rockwell at UCSD's Eating Disorder Research and Treatment Program . They described the very high rate of success they were having with a five-day intensive family outpatient therapy program for adolescents with anorexia. Since November 2006, the program has treated 25 families, with patients ranging from ages 10 to 18. These patients had body-mass indexes (BMI) ranging from 13 to 21, meaning that on average they were severely underweight. The amazing thing is that followup checks, ranging from three months to two years after treatment, have been very positive, with patients maintaining a BMI of 19.5. And this is with little to no followup treatment. 

The program consists of a mix of family based techniques, such as coached family meals (where therapists show parents how to suport their anorexic child during mealtimes, invariably the most difficult time of day for an anorexic); psychoeducational sessions (where families learn about what causes eating disorders, why they should not blame each other or themselves for the illness, and how to separate their child from the anorexia that is controlling them), and behavior modification techniques.

One of the best indicators of the program's early success is that the last patient to enter the program, according to Rockwell, was referred by the family's health insurer. The child had been hospitalized once to no avail, and her insurer had paid for four other hospitalizations of patients who did not improve until attending the UCSD five-day intensive program. From the insurer's point of view, if a five-day intensive outpatient program could turn around what much longer inpatient programs had not been able to, they were willing to foot the bill.

Sadly, Bryan Bixler, the subject of the L.A. Times article, who lives within driving distance of UCSD and has a degree from that institution, is so far ineligible for this program, although the staff there would like to one day be able to treat older patients. Yet the work of Dr. Kaye and his team may show the way to a shorter, less costly and highly effective type of treatment that would prevent tragic insurance stories like Bryan's, or the story of Janell Smith, which we wrote about in this Los Angeles Times op-ed piece. 

Marcia and I will be writing a longer piece on the topic of the latest in family based therapy techniques in an upcoming issue of  the newsletter Eating Disorders Recovery Today ,  so stay tuned.

Take care,

Nancy

Two new videos fight weight bias

 

Dear  Readers,

                One in five kids in America today is obese, and you can bet that there are a lot of experts trying to figure out how to stop the epidemic of overweight. Yale University has responded with the creation of The Rudd Center for Food Policy & Obesity, a non-profit research and public policy organization whose mission is to improve the world’s diet, reduce obesity and fight weight stigma.

                The issue of stigma is an especially painful one for overweight children, teens and older youths who must face the battleground of school and the taunts of peers every day. To help educate the public and offer coping strategies for parents and kids, the Rudd Center has released two videos on the subject of weight bias.

                The videos, “Weight Bias at Home and School” and “Weight Bias in Health Care”, are hosted by plus-size supermodel Emme and feature experts from the Rudd Center.  Here are some facts from “Weight Bias at Home and School”:

·         Weight bias starts among children as young as age 3

·         Weight bias tends to worsen as the child grows up, and can include social exclusion, bullying, ostracization, even violence

·         Overweight kids, bombarded by criticism about their weight at home, school, and by the diet, fashion and beauty industries, can eventually internalize socially accepted anti-fat messages

·         Self-blame and self-hate can lead to loneliness, depression, anxiety, low self-esteem, poor body image and suicidal behavior

·         Constant criticism about weight does not lead to positive changes in eating and exercise behaviors, it more often makes them worse, leading to comfort/binge eating and refusal to exercise

 

The video pulls no punches. Be forewarned, you’ll hear a lot of anti-fat comments. But it does offer a few coping strategies, most of which we discuss in our book. For parents:

·         Strive for open communication with your child, be there to listen to problems

·         Try to maintain a neutral stance

·         Be direct: tell your child he/she didn’t deserve to be teased/bullied

·         Remind your child of his/her strengths

·         Try to find positive real-sized role models for your child

For friends, relatives, teachers, outside observers:

·         Don’t make assumptions about overweight people. Genetic, environmental and psychological factors all contribute to a person’s weight.

·         Avoid contagious “fat-talk,” negative talk about one’s own weight, shape or size

·         Intervene when you see or hear someone being teased, bullied, or even made uncomfortable by subtle innuendo about weight or size

·          Make weight tolerance as important as race, gender or religious tolerance

 

Take care,

Nancy and Marcia

In defense of "fun" food

            In our book, Marcia and I talk about the importance of what we call “fun foods,” snacks, “junk food” and desserts made up of simple carbohydrates and fats. These are foods that are eaten solely for pleasure, not because they provide any particular nutrients. The idea is that once you have fulfilled all your body’s nutritional needs for the day, you can indulge, in moderation, in foods that just taste good. Normal eaters typically consume one to three servings of fun food per day, usually at the end of a meal or as a snack.

            You’ve probably gathered that we are hardly doctrinaire about eating. In part that’s because treating eating disorders is all about getting away from being “the food police” to yourself or your loved ones and showing that, despite what health food enthusiasts and anti-obesity crusaders would have everyone believe, no one food group has a moral edge over another.

            Many people view fun foods as unhealthy and fattening and therefore substances to be avoided. For people who hold this repressive world view, eating fun foods can create anxiety and guilt. Those negative feelings can then lead to I’ve-lapsed-by-eating-one-cookie-so-may-as-well-eat-the-whole-bag behavior. The notion that fun foods will trigger episodes of overeating takes hold.

            This is why eating-disordered patients avoid fun foods except as constituents of a binge. Treatment involves overcoming the fear of fun foods, which for them have become “fear foods.” Perhaps the most compelling argument for fun foods is that their judicious consumption prevents overeating and bingeing, making them important components of a healthy diet. A serving of fun food at the end of a meal puts a natural boundary around that eating episode. Once dessert is eaten, most people stop eating. Nobody wants more casserole after they have had a brownie. Several years ago, a controlled experiment of binge eaters found that after meals containing protein, binge-eaters stop further eating by consuming "sweet-tasting, palatable food."

            Marcia also explains to her patients that the healthfulness of one's diet is best assessed by looking at its total nutrient composition, not by assessing the nutritional quality of each food that is consumed. It’s like Nancy’s son’s argument that he can be a well-rounded and intelligent person and still enjoy playing video games.

            We are not saying that fun foods should take the place of other foods you need to meet your body’s nutrient requirements. Try this and you are likely to run into health problems, such as the brittle hair, dry skin and frequent colds that would result if you, say, replaced protein with fun foods.  But it’s not the fault of donuts, or ice cream, or whatever your fun food choice might be. If you replaced protein in your diet with more fruits and vegetables, you’d run into other health problems, such as feeling sluggish and constantly fatigued.

            The bottom line is that if you meet your nutrient needs with well-chosen foods at meals, whether or not you eat several moderate servings of desserts or snack foods each day is of no health consequence.

            Hard as it may seem to believe, most people with normal metabolisms will, after fulfilling their daily nutrient needs for essential protein, fat, carbs, fibers, vitamins and minerals, still have caloric needs to fill in order to maintain enough energy throughout the day. These needs can be met through choosing additional nutrient-rich foods or by adding fun foods. For instance, after eating a well-chosen meal that takes care of nutrient needs, you could choose to eat either more dinner, three apples, or a bowl of ice cream to meet your caloric needs.

            Marcia’s eating-disordered patients find including fun foods in their food plans one of their most difficult tasks. She reminds them that consumption of these foods is standard protocol in hospital and residential eating-disorder treatment centers and cautions patients against approaching fun foods as special treats to be consumed infrequently. Sporadic consumption of these foods makes them seem even more enticing, and like other forbidden foods, more likely to trigger a binge when eaten. Consuming fun foods twice a day every day effectively destigmatizes them, making them less desirable. When fun foods are consumed every day, most people report that they do not taste as good as they had imagined; they have become a normal, but still enjoyable, part of daily life.

 

 Take care,

Marcia and Nancy

Two new eating disorders films

Dear Readers,

                I’m just back from viewing two very good new films about eating disorders that I would like to recommend to you. Swept is a short film about a brother visiting his sister while she is in a residential treatment center for an eating disorder.  Beauty Mark is a documentary about former champion tri-athlete Diane Israel, whose obsessive drive for athletic perfection, eating disorder and work as a psychotherapist led her on a journey to understand the drive for physical perfection at any cost that lies at the bottom of so many eating disorders. Both of these films were part of a National Eating Disorders Awareness Week event at Pace University in New York City, sponsored by NEDA (the National Eating Disorders Association).

              Swept depicts a difficult confrontation between an anorexic and her brother. The sister, in typical anorexic fashion pushes away food, connection with others, even an expression of love and concern by her own brother. Hints of parental discord, of family problems being “swept” under the carpet (hence the title) point to possible factors in the disorder, and the sister’s distaste at becoming a ‘project” for her well-meaning brother may seem familiar to some of you.

                Some of Beauty Mark too, will make those of you battling eating-disorders cringe with recognition: the frenzied spinning class, led by a former body builder who tearfully admits she hates her body, the male tri-athlete whose obsessive exercise leads to hospitalization, where he bench-presses his bed.  Israel is a compelling guide, leading the viewer on a tour of these driven athletes, through her own lifelong quest for approval and perfection, and through interviews with various experts. She even visits a seriously burned and disfigured mother and son who have learned the hard way that beauty is more than just skin deep.

                Moderator Sondra Kronberg, a nutritionist and well-known lecturer on eating disorders, offered these insights:

·         Eating disorders are not about food, but involve food.

·         An eating disorder is a creative adaption for survival

·         “I’m not good enough,” is a feeling that is a running theme one encounters among those battling eating disorders

Take care,

Nancy