“Too Fat” vs. “Too Thin”

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Those of us who have had an eating disorder know firsthand that while recovery is possible, the road can sure be difficult. The eating disorder voice is powerful and can make people do and say things they otherwise would not express if their bodies and minds were in healthier places. A woman who is struggling mightily to recover from anorexia nervosa posted on a message board criticism of her treatment team for saying that being “too thin” is problematic while being “too fat” is okay. Does she have a point?

The treatments for someone who is “too thin” versus “too fat” are actually more similar than some people realize. In both cases, the etiology of the person’s size matters as well as whether or not the origin is pathological.

For example, consider two people, each of whom is “too fat.” One person has a healthy relationship with food and physical activity, no significant medical or psychological issues, has always been “too fat,” and comes from a family of people who are of similar builds. Meanwhile, the other person is “too fat” due to binge eating disorder. The former receives no treatment while the latter receives treatment for his eating disorder, not his body size.

Now consider another example of two people who are both “too thin.” One person has a healthy relationship with food and physical activity, no significant medical or psychological issues, has always been “too thin,” and comes from a family of people who are of similar builds. Meanwhile, the other person is “too thin” due to anorexia nervosa. The former receives no treatment while the latter receives treatment for his eating disorder, not his body size.

[Note: Anyone of any size can have an eating disorder, including some “too thin” people who experience binge eating and some “too fat” people who restrict. In reality, we never completely know what struggles someone might have just by looking at them.]

In both cases, whether one is “too fat” or “too thin,” any treatment is targeted at the underlying pathology, if one is present, not at the body size itself. However, for the person who is “too fat” due to binge eating disorder, we let the person’s weight take care of itself as they progress through treatment, as opposed to focusing on the weight. He may or may not lose weight as his disorder subsides, but altering his body weight is not the goal for two reasons:

(1) While being “too fat” is associated with an increased risk of medical woes, causal relationships have not been established, contrary to popular belief. In chapter six of Health at Every Size, Dr. Linda Bacon does an excellent job of explaining the correlations between body weight and the conditions for which weight is often blamed.

(2) While our bodies are relatively adept at gaining weight, they are resistant to long-term weight loss. In other words, interventions aimed at lowering body weight are most likely to result in ultimate weight gain, so in that sense even if the patient’s weight itself is the problem, he is only likely to exacerbate the condition by trying to lose weight.

In contrast, for the person who is “too thin” due to anorexia nervosa, weight restoration is an important part of his recovery. When someone becomes unnaturally thin due to restriction, overexercise, or other disordered behaviors, the body sheds not just fat mass, but also bone structure and tissue from organs, including the brain.

Dr. Ovidio Bermudez, Medical Director and Chief Medical Officer at the Eating Recovery Center, a behavioral hospital for children and adolescents, gave a talk at the 2014 Hynes Recovery Services conference in which he explained, “As a young girl starves herself, or a young man starves himself, and they knock off their sex steroid production, one of the important aspects of that, one of the downstream consequences of that, is that they may also be unintentionally impacting very important aspects of brain development, including neuronal growth.”

When discussing recovery, Dr. Bermudez noted that brain atrophy can be documented just as we can document bone demineralization, and then he continued, “If you stay underweight, your brain size does not recover. So you have to really normalize your weight in order for your brain size to recover.”

Dr. Kim Dennis, former Medical Director at Timberline Knolls Residential Treatment Center and current Medical Director at SunCloud Health, presented at the same conference and explained further, “When a patient with anorexia also says they’re depressed or a parent says they’re depressed, many times that’s not depression. That’s simply what looks like a mood disorder, but it’s based on the fact that their frontal lobes are shrunk, they can’t display affect, they have lower levels of neurotransmitters in their brain, and the cure to that, the treatment to that, is not necessarily Prozac, but it’s food and refeeding.

“Many times patients with anorexia really, really value their brains, and a lot of times you’ll tell someone with anorexia, ‘You’re not thinking straight because you’ve lost neurons. Your brain looks more like a 60-year-old with early dementia than an 18-year-old.’ And they’ll say, ‘I know a lot of anorexia patients might look that way but my brain doesn’t.'”

She then referred to a slide showing a brain with reduced volume due to restriction side by side with a healthy brain. “It’s important for us [clinicians] to realize when we’re working with a malnourished, underweight patient that there’s no amount of CBT (cognitive behavioral therapy) or DBT (dialectical behavioral therapy) or trauma work that’s really going to be effective unless that person’s brain is regrown first. So, first and foremost, food is medicine.”

Left: Normal control. Right: Patient with anorexia nervosa. (Image courtesy of Dr. Kim Dennis and SunCloud Health.)

Sometimes patients ask me to differentiate how my role, as a dietitian, differs from the roles played by other practitioners on their treatment team, namely their therapist. Oftentimes, I explain that eating disorders are mental illnesses that get played out through food. My role is to provide nutritional support during the early stages of recovery and then to help someone form a new and healthier relationship with food as the eating disorder recedes, but the bulk of the recovery happens in the therapist’s office.

For the reasons that Dr. Bermudez and Dr. Dennis explained, the brain cannot rebuild without weight restoration, and without an appropriately functioning brain, therapy – and therefore eating disorder recovery – becomes that much more of an uphill battle.

He Said, She Said: Parents

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WorldEDDay

He Said

June 2nd was World Eating Disorders Action Day, which was an important occasion that helped to cast desperately needed light on these conditions that are so common, yet receive so little attention.

Many of our colleagues shared articles, blog posts, and memes on social media to commemorate the day. One particular meme caught my attention because it read in part, “Families are not to blame, and can be the patients’ and providers’ best allies in treatment.”

To be candid, that statement is only partially true. On one hand, eating disorders can certainly arise in the midst of even the most loving and supportive family dynamics. On the other hand, environment is an important factor in the development of eating disorders, and this broad term that encompasses television, social media, print media, teachers, friends, coaches, co-workers, and many other influences also includes family.

Neither Joanne nor myself is here to pass judgment on anybody. Parenting is hard work, and all of us, parents and otherwise, make mistakes sometimes despite our best intentions. If we are to help families become the supportive allies that the meme correctly states they can be, then we must acknowledge the reality that even well-meaning and loving parents sometimes inadvertently contribute to the problem.

This month, Joanne and I discuss some of the most common mistakes parents make that can promote or exacerbate an eating disorder or otherwise hinder their child’s nutrition care, and we suggest alternative behaviors that can be more helpful. Joanne tackles the behaviors most related to eating disorders while I address others that I see in my side of the practice, although overlap certainly exists between the two.

Mistake 1: Modeling disordered behavior

“I can’t do moderation,” one of my patients insisted. She was 12 years old. With both of her parents out of the room, she explained to me how her parents oscillate between restriction and overconsumption. The former might take the shape of cleanses, clearing the house of “junk food,” enrolling in weight-loss programs, or other similar actions, while the latter might manifest itself through binges, lamenting their eating behaviors, or expressing concerns about a food “addiction” or feeling out of control.

The patient in question was well aware when one of her parents was about to transition from one state to another. “You cracked the seal!” her mother reportedly exclaims to her father (or vice versa) when a “bad” food is brought into the house. Because this is the behavior modeled in my patient’s household, no wonder she similarly feels, at such a young age, already destined for and incapable of anything beyond an all-or-nothing relationship with food as well.

Improvement: Model a healthy relationship with food

Children often learn through observation. Family meals in particular are an excellent time for parents to model their healthy relationship with food. Serve and consume a wide variety of foods. Destroy the good/bad food dichotomy by incorporating “bad” foods and showing that one is neither guilty for having them nor virtuous for sticking solely to “good” foods.

Similarly, keep a wide variety of foods in the house, as attempts to restrict the food supply typically backfire sooner or later. Children are bound to encounter “bad” food at friends’ houses, camp, and other environments, so better to help them build a healthy relationship with these foods early in life before they grow into young adults who do not know how to handle the newfound freedom that accompanies all-you-can-eat college dining halls.

In order to model a healthy relationship with food, parents must first of all have one. Be candid with yourself and realize that the best way to help your child might be to recognize and seek help and support for your own eating issues.

Mistake 2: Putting too much responsibility on the child

Encouraging autonomy and empowering children have their upsides, but parents sometimes take these actions too far. They step so far back that children are left without the parental support that they need to succeed. Parents might leave their children alone with us for more time than would be ideal, decline invitations to meet with us without the children or to check in with us between sessions, opt not to reinforce at home the ideas we discuss in session, or fail to implement action steps that necessitate parental involvement.

Improvement: Work together as a team

Just as children of all ages look to their parents for a variety of resources, everything from physical needs to unconditional love, they need similar help with their nutrition. Children have their own feeding responsibilities, but so do parents. In order to suss out who is responsible for what, parents must actively participate in the process. Initially, parents may not see eye to eye with us or have questions or concerns about our approach, and these thoughts are best expressed in private so as not to confuse the child with conflicting paradigms. In short, working together as a team tends to yield the most fruitful results.

Mistake 3: Assuming their children can lose weight because they did it themselves

Many of the children at our practice have parents who are high achievers. Through hard work, discipline, sacrifice, and other life choices and factors, they have reached the pinnacle of their respective fields. Some of these parents have applied these same traits to their own weight-loss endeavors with similar results. They assume that if their children take a similar path, they will reach the same outcome.

Improvement: Differentiate between typical and atypical results

If you have lost weight and kept it off, recognize that you are the exception, not the rule. Approximately 95% of people who attempt to lose weight will regain it one to five years down the road, and roughly 60% of these individuals will end up heavier than they were at baseline. Weight regain is common even if someone maintains the behaviors that promoted the weight loss in the first place.

Contrary to popular myth, our weight is largely out of our hands. The calories-in-versus-calories-out paradigm is a gross oversimplification of the complexities affecting weight regulation. While we might be able to manipulate our body size through behavior changes for a short while, biological mechanisms promoting weight regain almost always win out in the end.

Even genetics and behaviors together do not tell the whole story. For every Griffey or Boone family, we have hundreds of major league ballplayers whose offspring will never make it in the pros. Set aside the notion that what worked for parents will work for a child, and accept that your child may never lose weight and keep it off no matter what he or she does.

Mistake 4: Encouraging weight loss

A desire to lose weight leads to dieting, which is a predictor for eating disorders, worse health, and ultimate weight gain. Parents may understand the dangers and futility of dieting and instead encourage “lifestyle change.” Unbeknownst to them, the behaviors they have in mind, such as restricting calories or certain food groups, keeping a food journal, weighing or measuring portions, or staving off hunger by filling up on liquids or low-calorie foods, are still tricks of the dieting trade. Different packaging, but same contents.

Improvement: Promote size acceptance

Weight stigma is real and widespread. Children encounter it on the playground, on television, on social media, in the classroom, and maybe even at the pediatrician’s office, but they do not have to face it at home. Promote size acceptance and discuss the stigma they inevitably bump into as they move about the world. An additional and important lesson: Teach them not to contribute to said stigma.

Mistake 5: Talking about “health” as a euphemism for “weight”

Sometimes parents have a sense of the dangers associated with focusing on a child’s weight, so they substitute in the word “health” instead. Children are perceptive, however, and they learn about our cultural obsession with weight and size at an early age. When their parents say, “I just want you to be healthy,” they interpret this in context and hear, “I just want you to lose weight.” When they start talking to the big kid in the family about “health” and bring him to a dietitian while his skinnier siblings receive no such treatment, trust me, he knows exactly what is going on.

Improvement: Recognize that health and weight are not synonymous

Health and weight are not nearly as synonymous as we have been led to believe. Studies have shown that weight loss does not automatically lead to better health, and other research that controlled for behaviors found that health risks between groups of people of different body weights were nearly identical when engaging in similar behaviors. If health itself is indeed the priority, then apply it to everyone in the family, regardless of body size.

 

She Said

June 2nd was World Eating Disorders Action Day, during which numerous organizations and activists all over the world brought to light the prevalence of eating disorders (ED) and the need for comprehensive treatment. Jonah and I noticed a meme that was circulating on that day which outlined nine facts about EDs. While overall I felt like the meme was accurate and could be quite helpful for those unfamiliar with EDs, I felt like one of the “truths” was not completely accurate. This “truth” states, “Families are not to blame, and can be the patients’ and providers’ best allies in treatment.” My issue does not lie with the second part of the sentence, as I fully believe that parents can be wonderful allies in helping someone recover from an ED. But I do not agree with the statement that families are not to blame.

Let me be clear: I am not saying that it is solely the parents’ fault if their child develops an ED. But absolving parents of any blame doesn’t ring true to me.  As in most diseases, genetics play a large role as does environment. One way of thinking about it is this saying: “Genetics load the gun, but environment pulls the trigger.” Well, parents are part of the child’s environment, and therefore they can contribute (even unwittingly) to the development of their child’s ED.

99% of the time, parents are acting out of love for their child. They don’t want their child to suffer and only hope that he or she will be happy and healthy. But even with the best intentions, sometimes parents (and other family members) can inadvertently trigger an ED in a genetically predisposed patient. The following are some examples of how this can occur:

Example #1: The parent speaks negatively about his or her own body.

This might be surprising to some people, but children of parents who speak disparagingly about their own bodies (i.e., not their child’s body) are more likely to develop issues with eating and body image. I’ve had numerous patients whose parents only tell the patient how beautiful/handsome/perfect he or she is, or that there is nothing wrong with the child’s body. However, oftentimes the child will overhear their parent complaining about their own “love handles,” saggy body parts, or “unsightly bulges,” and even though these comments aren’t directed at the child, he or she learns to internalize these messages and can start to believe that his or her body is “wrong” too. The best way to prevent this from happening is for parents to avoid negatively talking about their own bodies, especially in the presence of their child. All bodies are good bodies, and stressing this message can help kids develop a more positive body image.

Example #2: The parent puts too much responsibility on the child and does not take an active role in his or her ED recovery.

Sometimes I encounter parents who want to take a step back from their child’s ED, as they believe that the child should be in charge of his or her recovery. While I agree that the patient needs to take an active role, most kids are dependent on their parents for food, as parents are the ones who go grocery shopping and who do the meal prep and planning. A child who is dealing with an ED cannot be counted on to feed himself or herself appropriately. Very few kids with EDs take the initiative to prepare a snack or meal for themselves. I had one patient that often would skip meals and snacks because she knew that her parents weren’t watching her. My advice would be that parents need to take an active role in their child’s ED recovery, especially if that child is a younger teenager. This means that parents might need to supervise meals and snacks, make sure that there are ample and appropriate food choices in the house, and hold the child accountable for food eaten outside of the house. Regarding the latter, signs may suggest that a child is not following her meal plan while at school, for example. In such instances, parents have the responsibility to arrange for a teacher or school nurse to supervise the child’s eating to ensure compliance with the meal plan.

Example #3: The parent encourages their child to lose weight.

This is a tough one. In our fatphobic and fearmongering culture, being overweight or obese is seen as a terrible fate. With the help of Michelle Obama, every parent is vigilant about their child becoming a part of the “childhood obesity epidemic.” Even if a parent feels like their child is “fine,” pediatricians can scare parents into seeing their child’s weight as a ticking time bomb. I’ve had too many patients to count whose parents bring them in because their doctor wants the child to lose weight. In some cases, these kids are encouraged to go on diets, and they receive praise for every pound lost. I had one patient in particular whose parents promised her a new iPad if she lost a certain amount of weight. Obviously, I feel that encouraging one’s child to lose weight is very problematic. Study after study has shown that kids who start dieting from an early age are actually more likely to become overweight or obese in adulthood. In other words, the end result is the exact opposite of what these parents are hoping for. My best advice is to stop focusing on your child’s weight. Instead, focus on his or her health, as we know that health and weight are not necessarily synonymous. Also, I would recommend talking with the child’s pediatrician (without the child present) to discuss taking the focus off the child’s weight, as negative messages about the child’s weight can lead to a preoccupation with food and even development of an ED.

Thus, while I really agree overall with the “truths” outlined by the meme, I would modify #2 to say that family dynamics can play a role in the development of an ED. While it is true that parents are not solely to blame for their child developing an ED, they can use some of the above strategies to make it less likely that their child will go down that treacherous path.

He Said, She Said: “Do Your Job”

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He Said

The main reason I enjoy following sports is not entertainment, but rather because I am fascinated by how athletics reflect life’s themes with such clarity that the lessons are blatantly apparent. Earlier this month, the New England Patriots won the Super Bowl behind Bill Belichick’s “Do Your Job” command. In other words, perform your role as you are taught, trust that your teammates will do the same, and as a result, the team as a whole will experience success.

This same lesson applies to health care. In fact, practitioners actually use the word “team” when describing the collection of providers who collaborate to help a given patient. This treatment team consists of a primary care physician and any number of specialists, including psychotherapists, dietitians, physical therapists, and others who are all essential to the patient’s care.

Equally essential is understanding the importance of each practitioner doing his or her own job, no more, no less. Nobody is an expert in every single facet of health care; consequently, all providers have limits to their scopes of practice. One of the traits that separates the best practitioners from their peers is recognizing where their boundaries lie and taking care not to step over them.

Unfortunately, some practitioners, who no doubt have their hearts in the right places, exceed these boundaries. Quite often, Joanne and I encounter situations where other members of a treatment team have provided the patient with nutritional advice. The result is almost always confusion and a step backward in the patient’s care.

For example, one of my patients recently told me about different pieces of nutritional advice that his primary care physician and his personal trainer had given him. In both cases, the guidance he received was off base. My poor patient, he was so confused that the result was a temporary undoing of progress he and I had achieved together.

The doctor no doubt meant well. Doctors are absolutely critical in health care. Primary care physicians are trained to be first-line responders for conditions ranging from splinters to cancer. Specialists dedicate their lives to their individual disciplines, and their unique expertise oftentimes quite literally makes the difference between life and death. Personally, I owe an unpayable debt of gratitude to my neurosurgeons, Dr. Griffith Harsh and Dr. Jean-Valery Coumans, for giving me the quality of life that I have now.

However, doctors receive a scarce amount of nutrition education in medical school. According to one study, students received only 23.9 hours on average of nutrition instruction in medical school, which amounts to basically a long weekend workshop. That is almost 24 hours more of formal nutrition education than most people, but still nowhere near what dietitians receive.

During a Google search, I came upon a blog entry a doctor wrote in which he attempted to dispel the “myth” that doctors do not receive adequate nutrition training. He cited the mountains of organic chemistry, biochemistry, and physiology that medical students take in addition to learning about the roles that various nutrients play in the body. However, his argument only serves to prove my point. The hard science is of course important, but so is having a solid understanding and appreciation for how food is complexly intertwined with other facets of life, such as social, cultural, and financial factors. Dietitians, not doctors, receive this comprehensive training, which perhaps explains why so many patients come in here having been given rigid, unsustainable, and plainly unrealistic “doctor’s orders” regarding how to eat.

As a former personal trainer who still maintains my certifications even though I no longer practice as one, I can attest to the important functions that trainers serve. Great trainers can put together workout programs that increase safety, effectiveness, and enjoyment while simultaneously reducing the intimidation, confusion, and boredom that sometimes accompany exercise.

Having been through the personal training certification process and having worked in the field though, I can tell you that most trainers have no nutrition knowledge beyond what most laymen hold. Looking through the manual that I studied for one of my certifications, I see that the nutrition chapter is 15 pages long. As I have argued before, sometimes a little bit of nutritional knowledge is worse than none at all. Registered Dietitians hold degrees in the field, complete rigorous internships that include everything from chopping squash in a cafeteria kitchen to ordering intravenous feedings for intensive care unit patients, pass credentialing boards, and hold state licenses to practice dietetics. Fifteen pages versus all of that. From whom would you rather receive your nutritional guidance?

Similarly, we dietitians have limits to our expertise as well, and we must respect them. Because emotions can be so intertwined with food, strong feelings and deep-rooted issues sometimes arise during our sessions. Acknowledging these emotions and taking them into account are important parts of our work, but we cannot address them as effectively as trained therapists can. For that reason, providing the quality of care that our patients deserve sometimes means suggesting that they consider adding a therapist to the team.

Practitioners of all disciplines fill important roles in patient care, but if we want to achieve victory, which in this case means helping our patients to the best of our collective ability, then we need to follow Coach Belichick’s guidance by staying within our scopes of practice and trusting that everybody else on the team will do the same.

From the patient’s perspective, keep in mind that well-meaning practitioners sometimes reach beyond the bounds of their expertise in an effort to help, but the further he or she stretches, the less accurate the guidance is likely to be. If you want reliable expertise regarding a particular issue, then seek it from a practitioner who has dedicated his or her professional life to that specialty and let him or her do his or her job.

 

She Said

What an exciting Super Bowl that was! Jonah and I were on the edge of our seats for the entire game, and the finale was just amazing! It got us thinking about the Patriots’ motto this season: Do Your Job. It was clear that every Pats player had such an important role in that game and that each player did his job extremely well. In order to work together as a team, they needed each person to execute his job as he had been trained. And it really paid off!

The Pats slogan got me thinking about how eating disorder (ED) patients need a strong treatment team in place in order to recover. Each member of the treatment team needs to do his or her job to support the patient, and there needs to be a clear line of communication among all team members. In addition, each member needs to try to practice within his or her scope of expertise without taking on the others’ roles.

In ED treatment, the team can consist of a number of different players. If the patient is in an inpatient or residential program, the treatment team will likely include a doctor and/or psychiatrist, a nursing staff, a therapist, a case manager, residence counselors, and a dietitian. In an outpatient setting, the team ideally includes a physician, therapist and/or psychiatrist, and a dietitian who specializes in EDs. It could also include teachers, advisors, deans, coaches, and in some cases, the patient’s family as well. You know the saying that it takes a village to raise a child? Well, it takes a village to help a patient recover from an ED.

As much as we try not to do so, sometimes treatment team members will fumble the ball by giving advice that is outside of our scope of practice. I remember one of my patients had a therapist who was actually making changes to the meal plan I had developed for the patient without talking with me first. Although I am sure the therapist only meant to help, it gave the patient mixed messages about what roles the therapist and I would play. Similarly, there are times when my nutrition counseling sessions seem to take on a more therapeutic nature. Most people have a lot of feelings around food, eating, and weight, and sometimes it is difficult to know where the boundary lies between nutrition therapy and therapy! But I always strive to bring the conversation back to the food and then suggest the patient discuss his or her feelings more in depth with his or her therapist.

Another important aspect of treatment team work is that the team usually functions best when there is one quarterback running the show. In most cases, this individual is usually the ED physician or therapist, although sometimes it can be a case manager or even the dietitian. In reality, the patient is really the quarterback, but when he or she is really struggling with ED, a trained professional is the safest bet to step in and manage treatment.

Above all else, communication is the cornerstone of a successful treatment team. Clear communication, whether by phone, in person, or via email, can really make such a difference in a patient’s quality of care. If we are all on the same page, the patient will get a consistent message and hopefully feel more confident and secure that his or her treatment team is a cohesive unit that will help him or her eventually beat ED.

“Beauty Work”

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This morning I read an article on “beauty work,” the digital manipulation of actors and actresses in movies and television to alter their appearances. No matter how rampant this practice may or may not be, the larger point is that comparing ourselves to people we see in any form of media, or even in real life, is never a good idea.

Joanne and I love the town in which we practice. She grew up here while I grew up just one town over and used to work at a sporting goods store a block from where our practice now stands. One of the challenges of our town, however, is the widespread focus on appearance and the negative fallout that this behavior spawns. Because the latter often shows itself in the form of eating disorders and disordered eating, we set up shop here in order to fill the need for help.

Quite often, patients come into my office and compare themselves to others, but the points of comparison go beyond actors and actresses and more often focus on fellow residents they see in the community. No digital manipulation there, but still, what are they really seeing?

Unless someone is completely candid with us, we never really know what he or she does or does not do to look a certain way. How do you know that the person who just lost a tremendous amount of weight is not battling a serious disease? Are you really sure that the friend you admire for being supposedly naturally slender is not struggling with anorexia, or that the co-worker you praise for eating the perfect little lunch is not later secretly bingeing on pizza and cupcakes before purging? Do you ever consider that the super buff weight lifter might be on steroids, or that the gym rat who can seemingly go for hours on the stair climber might be ignoring a slew of overuse injuries?

How sure are you that the person whose body you wish you had is any more happy, satisfied, comfortable, or confident with his or her body than you are with your own? Do you recognize the very real possibility that he or she is looking back at you with envy as well?

We never really know what is going on with someone, whether they are on a movie screen or walking down the sidewalk. Given that someone’s appearance tells us nothing about the person other than what he or she looks like, and given the negative consequences that frequently arise from comparing ourselves to others, how is it ever a good idea to make such comparisons?

HAES® and Eating Disorder Workshops

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Geographical fortune afforded me opportunities to recently attend two fantastic workshops right in my backyard: the Association for Size Diversity and Health’s (ASDAH) half-day workshop on Health at Every Size® (HAES) at the Multi-Service Eating Disorders Association, and the Hynes Recovery Service’s symposium on eating disorders in adolescent and young adult patients.

These conferences offered me chances to meet and learn from some brilliant colleagues, including, but not limited to, Ellen Glovsky, Lisa Du Breuil, Marsha Hudnall, Dawn Hynes, and Kim Dennis, some of whom I have known for years and others with whom I have been connected virtually but had never before met in person.

Dr. Glovsky’s talk, in particular, was terrific. They always are. She and I first met in 2007 when she gave a talk at the Beth Israel Deaconess Medical Center, where I was a dietetic intern. As soon as she finished speaking that day, I went up to the front of the room and introduced myself. We have stayed in touch ever since.

For lack of a better term, Dr. Glovsky just gets it. Having been a dietitian for approximately 40 years, she has evolved her counseling approach away from a classical directive style to the more effective motivational interviewing model that Joanne and I learned from her and use at our practice. Although Dr. Glovsky probably does not realize it, nobody has been a greater influence on my career than her.

Over the course of these two workshops, Dr. Glovsky and the other speakers shared many interesting points and anecdotes. The nuggets that really struck me are below.

  • Research indicates that 95% of people who intentionally lose weight regain the weight within five years. Of those 95%, 60% of them will end up heavier than they were at baseline. Said differently, if 100 people attempt to lose weight, five of them will keep it off, 38 will return to baseline, and 57 will end up heavier than when they started.
  • Because outcomes are only somewhat in our control, our goals are better constructed around performance and behaviors, not outcomes. For example, instead of saying we are going to lower our cholesterol by a certain number of points, we are better off setting goals to perform certain behaviors that may lead to lowered cholesterol with the understanding that some influential factors, such as genetics, are out of our hands.
  • Parents and doctors often miss the signs of eating disorders or incorrectly explain away said signs with other conclusions. Joanne asked one of the speakers how much of a dip in the growth charts should be considered a red flag. The speaker said a drop of five (for example, a patient’s body-mass-index-for-age drops from the 50th to the 45th percentile) or more indicates that something serious, such as an eating disorder, is likely at play. That reminded me of a patient’s mother who literally laughed in my face and never brought her daughter back to see me when I expressed concern that her daughter might be suffering from a yet-to-be-diagnosed eating disorder. In addition to the other reasons for concern that I saw, over the course of the last eight months her daughter’s body-mass-index-for-age had dropped by almost 20.
  • People suffering from an eating disorder or disordered eating frequently use the elimination of certain foods (“carbs,” dairy, gluten, animal products, etc.) as a means to restrict under the guise that the choice is supposedly about health, an allergy/sensitivity, or ethics.
  • A lawyer I spoke with between sessions told me she is working on using occupational safety laws to implement regulations for models in the fashion industry. According to her, the World Health Organization defines starvation as having a body mass index below 16.0 kg/m2, while the average runway model has a body mass index of 14.0 kg/m2.
  • Websites and social media groups that encourage eating disorders and offer tips to further their destructive behaviors are prevalent and easy to find. After a quick Google search that I did myself, I was shocked and saddened by what I saw in just the first few seconds. As one of the speakers explained, individuals with these conditions often seek out like-minded people online and isolate themselves from others. Pretty soon, these online communities become their entire world.
  • For some people, the term “fat” is an insult loaded with unfair and inaccurate stereotypes. For others, the word is nothing more than a neutral adjective describing body shape or size. Practitioners need to pay close attention to the language that our patients use and the intended meanings behind their words.
  • Every once in a while, I get someone who erroneously believes that HAES is just an excuse that larger people use to justify their size. As I looked around the room at the ASDAH event, I could not help but wish that those same people were there with me to share what I was seeing: People of all sorts of shapes and sizes were there, including many slender folks.

Warning Bells

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The following piece was written by KC, the mother of one of our patients.

I heard the faint warning bell early but didn’t really want to believe it. When she got in the car after a trip visiting a friend and asked if I noticed that she had lost weight, when she started to eat “healthy,” when she became “lactose intolerant” (really? since when?) and couldn’t eat ice cream, when chicken repulsed her– all of these behaviors I noticed. The running and working out increased but it was under the guise of getting ready for fall practices. I started to get nervous, but I kept waiting for her to get tired of the running, to get tired of reading labels. This was my daughter who never considered her size– who would happily try on any clothes– and only knew her weight when she went to the pediatrician. It was not until she told me her weight one morning, at which point I said, “Enough!” and then a week later told me, with what I thought at the time was a rather smug smile, that she had dropped another four pounds that I heard the cathedral bells tolling loud and clear.

I spent the next six weeks taking her to the pediatrician in the practice who was the most knowledgeable about eating disorders– mistake #1– I should have taken her directly to a specialist. She also began therapy with a psychologist who was finishing up her doctorate and had “some experience” with eating disorders– mistake #2. Being referred to Joanne as her nutritionist was the only step she made towards recovery in those first six weeks. I remember clearly my daughter’s initial visit to Joanne because it was the first time I felt I had an ally in the battle against the eating disorder. My daughter sat perched on the end of a chair with a sweatshirt and a down coat on clutching a cup of black coffee while I sat there sweating because it was so hot in the office. Joanne was extremely patient and kind while explaining her meal plan in spite of my daughter’s overt hostility. My daughter contained herself until she reached our car and then started to sob. Uncontrollably sob. Crying was nothing new in our house– she had been doing it daily for months– but looking back I realize it was the first time someone challenged the eating disorder, and it was angry.

The six weeks prior to my daughter entering a treatment facility were incredibly painful. I ate every meal and every snack with her when she was home. And it took her forever. Plus it drove me crazy the way she ate each meal– veggies first then protein then the grain. There were many forbidden topics in our house. No one could discuss exercise or bodies or food. What went on the plate had to be eaten. No one could say that he or she was full halfway through the meal. The list went on. And again, she cried all the time. At one point she confessed that prior to the meal plan, if she ate two apples and a bowl of soup as her food for the day she could tell herself at night that she had done a good job. I learned later that it was actually the eating disorder praising her. After she showered, I would find fistfuls of hair in the drain. She had a bald spot in the front of her head. We took the full length mirror out of her room. I packed up all the clothes that she used to body check and gave them to the Red Cross. She wore pajama pants, baggy shirts, and sweatshirts. Her behavior became child-like– she wanted to sit on my lap, sleep with me, wouldn’t leave my side. We could no longer go out for dinner as a family or a couple. It was far too stressful. When I was not with her, I worried that she was throwing her food into the garbage disposal– when she did come, no one could enjoy his meal– the tension and anxiety emanating from her was palatable. When my husband and I were finally able to get an appointment at Children’s for an evaluation, he expressed concern about her being taken out of school– not to be a part of the peer group. I had to bluntly tell him that our daughter was already gone, and the only hope we had to get her back was residential treatment.

It was frankly a relief when she finally entered treatment. I can honestly say that I could not handle her disorder on my own, and she needed good professional care. Picking the treatment facility is a personal choice, but I am very glad she landed where she did. Her case worker was incredible, and the women who managed her daily were loving but firm. She stayed for a period of time, and we began to measure the success of a day by how many boosts she had to drink or not. I’d like to say that she came out of treatment fully recovered but that was, of course, not the case. I was extremely lucky to be able to put together a post-treatment team for my daughter whom she embraced and respected. Her school was incredibly supportive, but I have heard horror stories where schools have not been. Families who have been told that no allowances would be made– it was either sink or swim. I will be forever grateful to her school administrators for working with and not against my daughter. An acquaintance whose child was a recovering anorexic visited with me while my daughter was in treatment. She imparted some wisdom which I found to be extremely helpful. One, it is not her fault. Two, following the meal plan and finishing her meals is non-negotiable. There is no negotiating with the eating disorder. And finally three supports, love, prayer (if that is one’s thing), and food will help to battle against the eating disorder.

It helped me to think of the eating disorder as a separate entity from my daughter. A few months after she got home from treatment, I made a flippant comment, and she laughed, really laughed. It was her first spontaneous expression of joy in months. I am so proud of her because she has worked incredibly hard to separate herself from the eating disorder. She has listened to her team, gone to therapy, followed her meal plan, and found books on her own to study. She has also developed a spiritual side to her personality which in our barely-go-to-church-on-Christmas family is a wonder to see. She has embraced her treatment and truly wants to get well. Does all this mean she has fully recovered? No, she has not. There have been setbacks, but I am extremely hopeful that she will live a full joy-filled life which has no room for an eating disorder.

Body Image and Self-Acceptance

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Between the blogs Joanne and I have written, as well entries by others that we have shared, we have posted quite a bit lately about body image and self-acceptance. While the link between these topics and nutrition is likely obvious to some readers, it occurs to me that it might not be so apparent to others and an explanation is probably in order.

The driving force behind our food choices is multifaceted. When I gave a talk to the FDA last month, the participants and I brainstormed a list of factors that influence our eating: perceived nutritional value, health concerns, availability, cultural norms, emotions, ethics, allergies, culinary expertise, previous experiences, finances, taste, time, and personal goals, just to name a few.

Within personal goals often lies a desire to look different. Consider the following examples: A model severely restricts his or her eating, becoming anorexic in the process, in order to gain a certain look. A naturally-slender man, convinced that his lean frame is responsible for him still being single, forces himself to overeat in hopes of gaining weight and finding a partner. A husband tells his wife that she is “not ready for that dress yet” and so she diets, convinced that he will not be attracted to her until she loses four more pounds. A young lifeguard, self-conscious about being in a bathing suit all day, becomes bulimic.

Those are all real people who we know, either through our work or our personal lives, and they are all examples of individuals adapting unhealthy eating behaviors because of how they feel about their appearances. Therein lies the problem: More often than not, dissatisfaction with how we look leads not to healthier lifestyles, but to harmful behaviors.

Oftentimes, a deep issue is being displaced and playing itself out through one’s food choices. Therefore, in addition to working together with us on their eating, we encourage our patients, when appropriate, to work with a qualified therapist on severing any link they may have between their appearance or weight and their self-worth, and to love and accept themselves the way they are regardless of their size or shape.

As these issues fade away, space is created for a healthier, simpler, and more satisfying relationship with food.

What Not to Say to Someone With an Eating Disorder

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It’s National Eating Disorder Awareness Week, so to stay with that theme, I thought it might be worthwhile to write about one of the most common questions I get from parents of my eating disorder (ED) patients: “What should I not say to my daughter/son who has an active ED?” Working with hundreds of ED patients and their families, I have compiled a list of “what not to say to or around your loved one who is struggling with an ED.” Here are three comments that could be triggering to your loved one.

1) “You look so healthy! How could you possibly have an ED?”

On the surface, this seems to be an innocuous and even positive comment. But, all the ED patient hears is: “You don’t look emaciated enough to have an ED. So therefore, you are fat.” Clearly, this is not what the speaker intended, but someone with an ED has a very distorted view of themselves and how others perceive him or her. It’s important to remember that people with EDs come in all shapes and sizes and it really isn’t possible to determine the severity of someone’s ED just by looking at him or her.

2) “I can’t believe how fat I’ve gotten! That’s it, no more carbs ‘til Christmas!”

I can’t tell you how many times my patients tell me that one of their parents has uttered the above. A parent might think that since the comment is about himself or herself, it shouldn’t be triggering to the child. This is incorrect. Kids learn by example and if they hear you talk badly about yourself and be critical of your body, they will think it’s okay for them to talk badly about themselves and criticize their bodies. This just fuels the ED even more.

3) “I know she needs to gain weight to be healthy. But we don’t want her to gain too much weight, right?”

Yes, I have heard these words from a number of parents and in front of their kid, no less. Weight gain is often a requirement in the recovery for anorexia nervosa. But weight isn’t the only factor that needs to be measured. Vital signs such as heart rate and blood pressure both lying down and standing up are very important indicators of health. Other measures of health include blood tests to look at nutrition status, whether or not a menstruating female has lost their period, and bone density. EDs take a toll on the entire body, not just weight. By keeping the focus on weight, we are fueling the idea that weight is the end all and be all. This is just not true.

Obviously, none of the above comments are meant to be malicious – we all want the best for our loved ones. But, it’s important to think about how your comment might be perceived by your son/daughter/sister/friend. We can’t edit ourselves every minute of every day, but by being aware of your words, you could spare your loved one (and yourself) a lot of unnecessary grief.