In a previous post, I have discussed who is typically on an FBT team. In its traditional manualized form, the core team is a therapist, a medical doctor, and the parents. The team can also include a registered dietitian nutritionist (to guide the parents) and may include a psychiatrist.
It is not uncommon for medical providers unfamiliar with FBT and treatment centers to encourage additional individual therapy for the patient. As I have said previously, this is not always advisable. In FBT, less can be more—the work of the parents may be undermined by an individual therapist who either does not believe in or does not support FBT.
So, I thought it would be useful to describe in greater detail the situations in which I think additional therapies are warranted and which therapies are most aligned with FBT.
FBT is primarily a behavioral treatment, administered by parents. The two therapies I discuss below—Dialectical Behavior Therapy and Exposure and Response Prevention—are also behavioral treatments that can be applied consistently alongside FBT without confusion. By contrast, non-behaviorally-based therapies may create splitting or confusion when offered alongside FBT. In particular, you should be cautious about and avoid therapies that do not reinforce the parents’ authority over eating or introduce different theories about the cause of an eating disorder.
Comprehensive Dialectical Behavioral Therapy
Dialectical Behavioral Therapy (DBT) is a form of cognitive-behavioral treatment (CBT) developed in the 1980s by Marsha Linehan, Ph.D. It was developed to treat chronically suicidal individuals diagnosed with borderline personality disorder and is now considered the most effective treatment for this population. Research has demonstrated its effectiveness for a range of other mental disorders including substance dependence, depression, post-traumatic stress disorder (PTSD), and eating disorders.
DBT stands out as the treatment of choice for people with difficulty regulating emotions—those prone to outbursts of anger and impulsive behaviors such as self-harm and purging. It focuses on the teaching of skills to tolerate emotions and improve relationships.
Be aware that there are many therapists (including us!) who use DBT skills in individual therapy with clients. Some therapists also may offer a standalone DBT skills training group. However, while these individual elements of DBT treatment may be beneficial, comprehensive DBT has a powerful advantage.
For DBT to by comprehensive it must comprise the following components:
DBT skills training. This almost always occurs in a group format run like a class. Group leaders teach behavioral skills and assign homework. Groups meet weekly for 24 weeks to complete the curriculum. Skills training consists of four modules: Mindfulness, Distress Tolerance, Interpersonal Effectiveness, and Emotion Regulation.
Individual therapy. Weekly sessions run concurrently with the skills training. The individual therapist helps clients apply the DBT skills.
Phone coaching. Clients are encouraged to reach out to their individual therapists to receive in-the-moment support applying skills during times of need.
DBT Consultation Team to Support the Therapist. All the members of the DBT team (group therapists and individual therapists) support each other in managing these clients who are in high distress.
When a teen is in comprehensive DBT, there is usually a parallel track for the parents that includes a parent skills group and a parent phone coach so that the parents receive help supporting their teen who is learning to apply DBT skills.
Exposure and Response Prevention
Exposure and Response Prevention (ERP) refers to specific CBT strategies used to address obsessive-compulsive disorder (OCD) or similar symptoms. OCD is characterized by distressing and intrusive thoughts and compulsive behaviors in which a person engages to try to reduce the distress. In ERP, the patient is exposed to the distressing situation and encouraged to prevent their compulsive behavior so they can learn to tolerate the distress. Once a person feels capable of handling their distress they will no longer need to engage in the compulsive behavior.
OCD and eating disorders commonly co-occur, and eating disorders can result in compulsive behaviors that require additional attention, such as compulsive exercise or other rituals not related to eating. Patients with eating disorders who engage in these behaviors may benefit from the addition of ERP.
With the global COVID-19 pandemic shutting down not only towns and states but entire countries, our world has entered into an abnormal time. The lives of everyone have been interrupted and disrupted by a virus that can have devastating effects. During this time many people are reporting feeling levels of heightened anxiety and for those already struggling with anxious thoughts, this can be a paralyzing time.
It is natural to feel anxious during a worldwide pandemic. There is something scary out there and there are a lot of questions about what will happen, what the future will be like once we can return back to normal, and whether we can even return back to our old normal.
These thoughts and feelings remind me of when I lived in New York during the September 11th terrorist attacks. While an attack is far different than a virus, there are similarities in the feelings that arise. I, and many others living during that, questioned whether I was safe, whether this would happen again when it might happen again, and what would happen next. In the months and years to follow our style of living differed slightly. Most apparent was how the structure of airports and entering airports changed. Never again would you come off the plane to see family and friends waiting at the gate. And there were other changes that we all just adapted to which became our new norm. Life became known as living in “Post 9/11.”
I can only assume that we will one day live in a world “Post COVID-19” and move past this pandemic. But It leaves us all with numerous questions including: “Can I get sick? What will happen in the future?” Anxiety loves to live in the “what-ifs” and can cause increased fears and panic. So during this time, a time of uncertainty when many of us feel a lack of control, it is best to look at strategies to manage anxious feelings.
Limit triggering information. The news can be very triggering so try to limit your news consumption. Just as it was in 2001, the news is 24 hours a day and 7 days a week. However, now, it can be accessed not just by our computers, radio or television, but right on our phones. Too much information can be overwhelming. Try to limit your media intake to an hour a day and look at getting your information from legitimate sources. In this case, follow a single trustworthy news source or the Centers for Disease Control and Prevention (CD) or the World Health Organization (WHO). Pay attention to your local officials who are setting guidelines in the towns/cities that you live in.
Reach out for support. While right now we are practicing social distancing, you can still connect to people through phone calls, video calls, online game streaming services, and other social media outlets. Many therapists, dietitians, and medical professionals are offering video sessions. Many support groups have moved online as well. Support can be a click away. You do not have to sit with your thoughts all by yourself.
Practice grounding techniques. If you feel yourself having an anxiety attack try to focus on one sense (i.e sounds) and pay attention to what you hear around you. Or close your eyes and imagine a place that feels safe. Describe back to yourself this safe place and what you see, smell, hear, and feel.
Take deep breaths. Anxiety and panic can increase heart rates. Slowing down your breathing can help decrease the on-edge feelings. There are many great Apps and online videos that offer free-breathing techniques and meditations.
Focus on the present. Focus on what you are able to do right now. We do not know when things may start up again but think about the things you’d like to be ready for. A great example is if your school is paused right now, but you have access to many educational resources, that learning doesn’t need to end.
Lastly, engage in hobbies and activities that you enjoy. Allow yourself to have fun even during these trying times. Anxiety can steal our fun and relaxation so make sure you continue to do things that make you feel good.
It is okay to feel your feelings and it is okay to have anxious thoughts. The above list is a useful tool if you are finding yourself stuck in your anxiousness. While it is an unprecedented time, you can work on managing your reactions to your feelings and thoughts through these coping techniques. If you or someone you know is struggling, the clinicians at Eating Disorder Therapy LA are here to help. We are offering teletherapy sessions for those in California or New York state. For more information or to set up an appointment reach us at 323-743-1122 or e-mail Hello@eatingdisordertherapyla.com.
As of March 2020, the advent of the COVID-19 pandemic is bringing dramatic changes to all aspects of our lives.
One of the most significant impacts of social distancing is a change in the mode of delivery of psychological treatment. It appears that most outpatient therapists, dietitians, and medical doctors are moving entirely to telehealth sessions (over the computer). Even many intensive outpatient (IOP) and partial hospitalization (PHP) programs appear to be shifting to a telehealth delivery model. Further, it appears that admissions to residential treatment centers may be reduced and limited to only the most severely medically compromised patients.
As a result of more stringent admission standards as well as travel restrictions and the transition to online sessions, it appears that a larger number of eating disorder patients will be in the home. Fortunately, Family-Based Treatment (FBT) is a treatment naturally poised to fill the gap created by the Coronavirus.
FBT has emerged as a leading therapy with empirical support for the treatment of adolescents with anorexia nervosa who are medically stable. It also shows support for adolescents with bulimia nervosa and young adults with anorexia nervosa. FBT makes the role of parents central to challenging their adolescent’s eating disorder. The hallmark of the treatment is family meals which parents plan, prepare, serve, and supervise. If purging is an issue, they supervise after meals. They implement strategies to prevent purging, excessive exercise, and other eating disorder behaviors. I have often said that FBT is like providing residential treatment in your house for only your child.
FBT is a manualized treatment and usually takes place in approximately 20 weekly sessions with an FBT therapist over a period of about 6 months. A teen should also be monitored by a medical doctor and a dietitian may be involved in helping the parents with meal planning. Fortunately, FBT sessions can be delivered via telehealth.
Telehealth is the delivery of medical or mental health treatment over live video. There are numerous HIPAA-compliant platforms that treatment professionals use such as Doxy, Zoom, and Vsee. Aside from a reliable internet connection and a private setting, there are no additional requirements for telehealth delivered mental health care. Telehealth interventions have been used in various forms since 1972. In general, the research shows that therapy delivered via telehealth can be effective for a variety of problems. Telehealth has been successfully applied to both family therapy and the treatment of eating disorders.
Kristen Anderson, LCSW and colleagues did a study of FBT for adolescent anorexia utilizing telehealth. They utilized the same treatment manual utilized in outpatient studies of FBT with minor variations. For example, instead of weighing the patient in the therapist’s office prior to appointments, the parents weighed the patient at home prior to the session and shared the weight with the therapist. The structure of the sessions was the same, with all family members in attendance. The therapist initiated therapy sessions by video conference and met individually with the patient for a few minutes first, followed by a meeting with the entire family for the remainder of the therapy hour.
Anderson and colleagues found that it was feasible to deliver FBT via telehealth. There were no dropouts over the course of the study and the average number of treatment sessions attended was 18.4. Parents found the treatment to be extremely helpful and participant weight increased significantly. Meaningful improvements were also noted in eating disorder symptoms as well as depression and self-esteem. Anderson and colleagues concluded, “these findings suggest that this method of delivering FBT may be effective for meeting the treatment demands of adolescents living in areas of the country where there are inadequate treatment resources such as nonurban or rural settings.”
Little did they know that throughout the world, social distancing would create a need for FBT delivered by telehealth!
If you are looking for virtual FBT support during this time, we can support families throughout the states of California, New York, and Florida in the US, and we can also provide support for families in some other countries. We use a secure online platform. Please ensure you have a stable internet connection and try to position the video so that all members of the family are in view of the video screen. Learn more about our telehealth services.
If you are looking for FBT by telehealth in other states and countries, please check out the following websites:
Family-Based Treatment (FBT) is the leading evidence-based treatment for adolescents with anorexia nervosa and bulimia nervosa. One of the common misbeliefs I hear is that it’s “only for kids or younger teens.” However, I think it has a much wider applicability. In fact, I would say that my FBT training has significantly improved my effectiveness in treating eating disorder patients of all ages.
While there have not been studies of FBT that pull it apart and pinpoint the elements that drive its success, I have a few theories. One of the key underpinnings of FBT is meal support. People with eating disorders experience such crippling anxiety before, during, and after meals that it is no wonder they would do anything they can to avoid eating. When the brain is in a state of overwhelming anxiety, a person with an eating disorder cannot make logical decisions about what to eat—or even to eat. And yet, without eating there can be no recovery. Treatment centers understand this—providing regular meals has been the mainstay of residential and partial hospitalization (PHP) eating disorder treatment for some time. FBT is the in-home parallel to this treatment.
In FBT, parents are charged with nourishing their teens back to health by providing regular nutrient-dense meals and preventing purging, excessive exercise, and other eating disorder behaviors. Parents plan, prepare, serve, and supervise meals and after meals, if purging is an issue. They make all the food decisions. They sit with their struggling child during those terrifying meals and help their teens cope with eating amounts sufficient for them to get well. Over time they return control to their teens, building their capacity to fight the eating disorder on their own. It takes effort and time to change brain pathways that have made eating a scary experience. For this reason, even those patients with eating disorders who go on to higher levels of care usually don’t remain there long enough to develop the autonomous ability to eat enough to sustain recovery. They often continue to need meal support for some time after more intensive treatment.
I think FBT has applicability that spreads wider than just children and teens. There is preliminary evidence of its successful use with transition-age youth up to age 25. Many parents have reported successfully using it with their college-age children. I have used it with this age and the primary variation is that the young adult plays a bigger role in their own treatment. They must agree at least in theory to accept their parents’—or other caregivers’—support. The young adult may choose who will support them during meals. Some, for example, may have a college roommate provide support. Some parents do meal support via FaceTime when the young adult lives far away.
I should clarify that FBT is a manualized evidence-based treatment. To be done with fidelity it must comprise certain components, including a therapist who guides the parents in organizing their strategies to fight the eating disorder. Parents refeeding their child without a therapist’s oversight often state they are “doing FBT”. In this case, it is more accurate to say they are providing FBT-informed or carer-supported feeding. Regardless of the words we use to describe this support and whether or not a therapist is involved, I think it provides a core benefit that we can expand to other populations.
These principles can also be applied to adult treatment. I personally have supported an adult who was in PHP during the day and needed more support with meals outside of treatment hours. I applied the skills I learned in my FBT training to provide meal support to this person. It worked just like it did with teens. Obviously this adult was an active participant in their recovery who asked for my support. This does not mean that I did not encounter the same kind of anxiety and resistance that parents meet around meals.
Take another case —a 20-something patient who still lives with her parents. She has been doing so much better since she asked for help, trading in the restrictive foods she had been eating on her own for several years for family meals prepared by her parents. Or the case of a college student who gets support via FaceTime from her parents who live in another city. When working with young adults with eating disorders who are in loving relationships, we often work to help their significant others develop strategies to support them during meals.
My experience is not unusual. Many other FBT-trained clinicians report success with providing FBT-informed treatment to people from all walks of life. One dietitian has reported great progress working with an employed single adult who moved home to live with his parents so they could support with meals. Sadly, previous providers had pathologized his moving home as a sign of enmeshment. One therapist shared, “I am doing FBT with a 79-year old. She is now in phase 2. She can now go out on dates—she just has to send pictures of her food to her adult children who are taking charge of her recovery and have been in charge of plating her food.”
Many have realized that in-home meal support is a common need for patients, and naturally, it is starting to become a big business with several treatment programs now providing this service. Offered as a service, this individualized meal support can be very expensive. Far more convenient, cost-effective, and loving is meal support provided by parents, other family members, or significant others.
I personally see it as a sign of strength when an adult admits they need more help. There is no shame in needing meal support during your recovery no matter what your age. Moving back home to live with family for support is nothing to be embarrassed by. This disorder robs people of their ability to make decisions around food—outside support is needed by definition. If you struggle around mealtimes with deciding what to eat, only feel safe eating a narrow range of food, have been struggling to make progress in your recovery, or cannot manage urges to purge after eating, you are not alone. You may benefit from the addition of meal support. It may feel scary or embarrassing to ask for help and you may worry you are being a burden. But asking for help is a brave step and you will likely find that there are some people in your life who can do this for you. It sometimes requires a little creativity, but you may find that it makes a big difference in your recovery.
The short answer is: FBT can be for people of any age.
Chen, E. Y., Weissman, J. A., Zeffiro, T. A., Yiu, A., Eneva, K. T., Arlt, J. M., & Swantek, M. J. (2016). Family-based therapy for young adults with Anorexia Nervosa restores weight. International Journal of Eating Disorders, 49(7), 701–707.
Dimitropoulos, G., Freeman, V. E., Allemang, B., Couturier, J., McVey, G., Lock, J., & Le Grange, D. (2015). Family-based treatment with transition-age youth with anorexia nervosa: a qualitative summary of application in clinical practice. Journal of Eating Disorders, 3(1), 1.
Dimitropoulos, G., Landers, A. L., Freeman, V., Novick, J., Garber, A., & Le Grange, D. (2018). Open Trial of Family-Based Treatment of Anorexia Nervosa for Transition Age Youth. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 27(1), 50–61.
This quote has generated a lot of reaction. In this podcast, Shira—who lives in a larger body when she is not using eating disorder behaviors—details how she has suffered from fatphobia in the world and in treatment centers. She shares that she has been significantly harmed by both well-meaning treatment providers and highly-regarded treatment centers.
This blog addresses two questions:
How is fatphobia affecting therapy and patients?
When is someone well enough to treat?
Shira is my friend and colleague. I regard her above quote to be a challenge to all treatment providers who have not faced their own fatphobia, including those who seemed afraid of Shira’s weight gain, tried to reassure her she was not gaining weight or would not gain weight, tried to help her keep her weight down, and limited her portions. These actions have harmed her by making her afraid to eat enough to sustain her healthy body weight and making her unable to fully recover after a 19-year history of an eating disorder.
Weight Stigma in Treatment
One incident Shira experienced in treatment was relayed to her friend, Sam Dylan Finch who described it in a blog post:
“The dietitian said, ‘You three get two scoops of ice cream.’ She then looked at me and said, ‘You’ll get a kiddie scoop.’”
Some of you won’t understand the gravity of that comment. To be clear, a dietitian told a patient with anorexia nervosa to eat less food than her peers, because she is a patient in a larger body.
The message here being, of course, that Shira needed to eat a child-sized portion of ice cream, because she wasn’t thin enough to “safely” consume more than that.
This plays directly into the eating disorder’s conviction that she needed to tightly control her food intake and her body. Her peers could eat a “normal” amount of ice cream. But she couldn’t and was singled out, because something was “wrong” with her body.
“This was the message I received my entire damn life,” Shira told me. “That I couldn’t eat like everyone else.”
— Sam Dylan Finch
The mixed messages of “eat ice cream” but “only a tiny serving” have further strengthened Shira’s eating disorder. The message treatment providers delivered over and over again was that her body needed to be controlled in order to avoid fatness. She yearned to be able to eat freely.
Shira also acknowledges that there were times in the past when she thought she was fully recovered. She only discovered years later after a relapse that what she thought was fully recovered was only partially recovered. How is this possible? Because we live in a culture where it is considered desirable and virtuous to maintain a low weight, deny ourselves tasty foods, limit the amount we eat, and exercise intensely. No other mental illness is so unfortunately reinforced by our cultural ideals.
And in terms of who is well enough to treat people with eating disorders, is recovery from one’s own eating disorder the only criterion that matters? How would we ever be able to vet that? How do we define recovery anyway?
I agree with Shira that there are many providers in the field who have not faced their own fatphobia. Focusing exclusively on providers who have had an eating disorder and whether or not they are recovered ignores a large portion of the provider community who do not have diagnosable eating disorders but may still be casualties of diet culture, wrestling with internalized weight stigma. These providers may be doing much more harm, but their impact has unfortunately received limited attention.
Providers With History of an Eating Disorder
Research indicates that a significant number of eating disorder treatment professionals have personally experienced an eating disorder. A study by De Vos and colleagues (2015) found that 24 to 47 percent of eating disorder clinicians reported a personal eating disorder history. An unpublished 2013 Academy for Eating Disorders online survey indicated that out of 482 respondents from professional eating disorder organizations, 262 (55%) reported a personal history of an eating disorder and half of those reported working directly with eating disorder patients. If we added subclinical eating disorders and disordered eating I have no doubt the rates would be higher.
Some have suggested over the years that providers with histories of eating disorders should never work in the field. This would be a mistake. Many professionals with their own personal histories (disclosed or not) have made major contributions to the field and to our understanding of eating disorders. Carolyn Costin, MEd, LMFT, CEDS and Mark Warren, MD, MPH, FAED are two public examples of prominent recovered professionals. In the broader field of psychology, one need only look at Marsha Linehan, Ph.D., who developed the leading evidence-based treatment for borderline personality disorder and other conditions based on her own experience of recovery from a severe mental illness to see that blanket restriction like this make no sense. In various surveys, patients have consistently reported it is helpful to work with providers who have had an eating disorder.
But even more complicated is the fact that we do not have a solid definition of recovery. In eating disorder research studies, recovery is often defined by three components:
Physical—BMI higher than 18.5 or another universal marker like expected goal weight;
Behavioral—absence of binge eating, vomiting, laxative use, or fasting; and
Cognitive—EDE-Q subscales about shape and weight concerns within 1 standard deviation of age-matched peers.
With dieting widespread (a 2018 study reported 36 percent of Americans were dieting), how many providers with disordered eating and their own extreme weight control behaviors go under the radar? How many providers may be engaging in their own intermittent fasting, keto diets, counting calories, or excessive exercise? I would agree with Shira that we should be equally if not more afraid of these providers.
Who is Fit to Treat Eating Disorder Patients?
If the field can’t decide who is recovered, who is to decide who is fit to treat eating disorder patients? Are therapists who acknowledge they have clinical eating disorders worse than fatphobic dieter providers who deny their own food issues and go on to shame patients, recommend any kind of dietary restriction, and limit the weight gain necessary for full recovery? How do we decide when someone is well enough to treat others?
The following quote from Carolyn Costin M.A., M.E.d., LMFT, FAED, CEDS and Alli Spotts-De Lazzer M.A., LMFT, LPCC, CEDS in their article for Gurze (2016), “To Tell or Not to Tell: Therapists With a Personal History of an Eating Disorder,” highlights an important point:
“Even if the field reaches its consensus on a definition of recovered—and then holds it up as the criteria for being able to be work with eating disorder patients—how would we verify a recovered status? Could standardized measuring and monitoring happen? When substance abuse facilities hire individuals who identify as recovering alcoholics or drug addicts, drug testing can verify if the person is considered clean and sober or ‘using.’ There is no similar test to determine if a person is ‘using’ his or her eating disorder symptoms. Some have suggested that therapists with personal eating disorder histories be subjected to clinical eating disorder assessments and ultrasound checks for ovarian size to determine if they are at a healthy weight (Wright & O’Toole, 2005). Without even discussing the actual merit of these as determining factors, would these tests be administered to all therapists who wish to work with eating disorders or just those who say they once had an eating disorder? And couldn’t those with an eating disorder history be able to avoid such testing by not disclosing they ever had an eating disorder?”
Costin and Spotts-De Lazzer go on to state, “It seems interesting and confusing that there could be so much proposed attention on therapists who have recovered from an eating disorder but not for therapists who have histories of depression, anxiety, post-traumatic stress disorder, or another diagnosis in their past.”
Perhaps we should be focusing on assessing providers for awareness of weight bias instead.
Further, if we shame Shira for being a provider with an eating disorder, how do we make it safe for other providers to acknowledge their own struggles and receive help if they have a lapse or relapse? Shira has reported that a significant number of providers have shared with her that they have struggled or are currently struggling. This says a lot.
So back to the question—how do we decide when someone is well enough to treat others?
I don’t have the answer to this question. The field has been unable to even define recovery.
Am I more afraid of fatphobic dieting therapists who may not be aware of their potential for harm than therapists who believe in and espouse Health At Every Size ® while acknowledging their own mental illnesses? Ultimately, yes, I am.
I think we need to look inward and address the rampant weight bias in the field. With dieting so widespread we have a lot of work to do. I believe everyone deserves treatment to full recovery and safety in their bodies. We need to address structural issues that limit access to care and safety. We need to make it safe for providers to receive help for eating disorders. I think it behooves every professional working with eating disorder patients to look at their own weight bias and work to practice from a weigh-inclusive approach. Only this way can we reduce the harm done to people like Shira.
Costin, C. & Spotts-De Lazzer (2016). To Tell or Not to Tell: Therapists With a Personal History of an Eating Disorder. Gurze Salucore, Eating Disorders Resource Catalogue.
Stych, A (2018). Percentage of Dieters More Than Doubles. Bizwomen: The Business Journals.
On September 18th, 2019 Instagram instituted an official policy that all ads promoting diet and weight loss products would only be able to be viewed by users 18 and over. Any ads that have false claims can be reported and subject to removal. This is a huge victory in the world of challenging diet culture. For years, celebrities and social media influencers have been advertising diet and weight loss products that, for the most part, are bogus, promise false results and can be just downright dangerous to someone’s physical and mental health.
Most celebrities who promote these products are doing so for a paycheck and not because they are actually finding these products useful. Unfortunately, advertisements like these can impact impressionable viewers, especially those struggling with poor body image, disordered eating and eating disorders. And while the celebrities may say, “Take this and look like me,” the reality is that these products have no true evidence that they can change anyone.
Emma Collins, Instagram’s public policy manager, made a statement after this policy went into effect, “We want Instagram to be a positive place for everyone that uses it and this policy is part of our ongoing work to reduce the pressure that people can sometimes feel as a result of social media.” While this is a great step forward, it does feel like the next step should be eliminating diet and weight loss products altogether.
There are some major problems with advertising weight loss products. As a Health at Every Size® activist and promoter of body positivity, I can tell you that these products merely reinforce the idea that your body isn’t good enough. They teach that there is only one ideal body, and usually, it is the body of the celebrity promoting the product. It can be really dangerous to tell people that tea will flatten their stomachs or a lollipop will give them curves in the “right” places.
These advertisements put people at risk for developing eating disorders. They promote the very behaviors that are symptoms of eating disorders. These products try to normalize appetite suppression or compensating for what one has eaten via a laxative pill or tea. The messages are not health-promoting. They reinforce diet culture beliefs of certain foods being bad and needing to atone for eating.
A major issue is that there is absolutely no evidence that the products being advertised actually help with weight loss, detoxing your body of toxins, or changing the shape of your body. Most of these products are not even approved by the United States Food and Drug Administration (FDA). The FDA is charged with regulating medications and while there are a few that have been approved, most that are advertised on social media are not. Most of these products carry false claims and use ingredients that can be more harmful than helpful. And that is a huge problem.
We do not often see celebrities sharing disclaimers of potential side effects from using these products. Diet pills may increase heart rate, heart palpitations, the likelihood of a stroke, and even death. The detox teas carry the risk of dehydration, electrolyte imbalance and stripping our guts of the nutrients we need. Side effects can also include an increase in stomach cramping, bloating, and diarrhea. Our bodies were designed to naturally flush out toxins. It is why we have a liver. And for those users of the products looking for a way to lose weight, well the weight “lost” from these teas are usually just water or stool mass. These products place a huge toll on the body and put vital organs at risk.
For these reasons, we should not only be protecting social media users who are under 18. We should be protecting everyone from viewing these ads. Adults are probably more likely to purchase these products and adults are just as susceptible to false promises as adolescents. It is great that places like Instagram are giving us a choice if we want to view these ads. It is definitely a step in the right direction. But, there is nothing safe about these products. From taking a physical toll on our bodies to mentally placing shame on our bodies there is no room for diet pills, detox teas, or any other weight loss product.
If you are currently struggling with how you feel about your body, help is available through support groups, therapy, and even body-positive accounts and groups on social media. The wonderful thing about social media is that there is a community for promoting Health at Every Size® and working on self-love and acceptance. Most of these groups do not cost anything and can have to have positive effects on your mind and body.
A disclaimer: I have no vested interest in Weight Watchers’ new Kurbo app. This app will in fact create more work for me. But let me be clear: I do not want this kind of work!
I know that you mean well and are merely concerned about your child’s health, but I can assure you that Weight Watchers does not share your concern. They are a commercial enterprise interested in making money and their business model is based on preying upon insecurities.
You would only need to spend a short time in my waiting room to hear from other parents who were once like you—moderately concerned (or maybe unconcerned) about their child’s weight and happy when their child committed to “eating healthier.” The story is nearly always the same. This child has been in what I would call a larger body—you might have called them “overweight”, pediatricians might have labeled them “obese”. It starts with them giving up sweets and then progresses. They start to restrict meat and starches and exercise more. It looks healthy. Over time, some switch gets tripped, and with very little warning the kid has anorexia, a lethal mental illness.
While most cases of anorexia are triggered by dieting, unintentional weight loss can be a trigger as well. It appears that people predisposed to anorexia respond to a negative energy balance in a way that flips this switch and they cross a dieting point of no return. Many of the teens I work with have been hospitalized for life-threatening low heart rates and electrolyte imbalances.
I cannot adequately express the guilt that parents feel from having allowed their teens to start these diets. I don’t blame them. I understand the pressure they are under.
Two of my three children grew out before they grew up. They had gained the weight their bodies needed to fuel puberty and impending growth spurts. I too received the warning from my well-intentioned pediatrician about their weights and weight gain. I knew enough to ignore the implied suggestion of helping them trim down. I cringe to think what might have happened if I had followed it. My children grew just fine and became more proportional according to their genetic predisposition.
My other child was lauded by the same pediatrician for growing up before growing out. It was only years later when I plotted her growth that I realized she had totally fallen off her expected weight curve at the time the pediatrician praised her weight. Yet, I did notice that she didn’t seem to be eating enough. (For more information on the intervention I did with her, read this post.)
The Kurbo app should come with the following warning:
“This app may trigger an eating disorder
from which your child could take 22 years to recover.”
Yes, 22 years! The most rigorous longitudinal study we have of anorexia has shown that at 9 years, only 31% of individuals with anorexia nervosa had recovered. Almost 63% had recovered at 22 years. If this is the path you follow, you may be facing many long years in and out of costly treatments to help your child recover.
Incidentally, Kurbo has made my job tougher. It classifies foods as “green”, “yellow”, or “red”. “Red” foods, such as ice cream, fried chicken, and pizza are “bad” — Kurbo advises kids to avoid them.
I work with children who suffer from anorexia, may be hypermetabolic, and may require ingesting upwards of 6000 kcal per day for several years to recover. I can’t express the difficulty of convincing an anorexic child to eat highly caloric foods to recover, when they immediately parrot back all the health messages they’ve received about these foods being dangerous. It’s terribly confusing to be told that the foods they’ve learned are bad for them are in fact the medicine that will cure them. This is but one reason why we cannot take a one size fits all approach to foods.
Back in my waiting room, maybe you would hear from some of the adults with eating disorders. They might tell you that years of dieting have contributed to weight gain, weight cycling, binge eating, and misery. They will typically remember that this pattern started in childhood with a diet. Dieting disconnects people from their own internal regulatory system (as does tracking calories and exercise).
What Can Parents Do Instead? The following advice is for parents of kids of all sizes.
I suggest teaching kids that bodies naturally come in all shapes and sizes and that body size is largely genetically determined. I recommend viewing the Poodle Science video from ASDAH. This video does a great job illustrating body diversity and the risks of subjecting everyone to a single body standard. I suggest teaching kids that fat bodies are great too. We have to make it safe for people to be fat in order to prevent and treat eating disorders. Eating disorders are a more lethal problem. Parents can avoid judging or criticizing their own or other peoples’ bodies.
I suggest giving kids access to a range of foods — prohibiting “fun” foods leads kids to overvalue and overeat them. We don’t need to label foods as good or bad. Parents can serve nutritious food as well as fun food and model that they are of equal moral value. They can also model that food is supposed to be pleasurable and offers the opportunity for social and cultural connections.
Parents can also help children to move in ways that are fun, rather than teaching that exercise is penance for eating.
For more specific advice on helping kids develop as strong intuitive eaters with healthy body images, I suggest the work of dietitian Ellyn Satter and my psychotherapist colleagues, Zoe Bisbing and Leslie Bloch, The Full Bloom Project.
It’s almost the first day of school and parents of students with eating disorders have additional concerns to address on top of the usual back to school frenzy. Transitions can be tough for all teens—they are especially difficult for those with eating disorders. However, there are some preparations you can make to help things go more smoothly.
If you have been supervising most meals your teen has been eating over the summer, the shift to a school day brings a significant change in schedule. A considerable portion of your teen’s day will be spent at school. You may need to increase the size of the breakfast your teen will consume before a long day away from home. Practice the breakfasts you will plan to prepare during the school year. Also be mindful that there may be less time for breakfast when you have to get your teen out the door—to ease the transition, have them practice eating within a reasonable time.
During the school day, your teen will typically need lunch and at least one snack. Now is the time to consider how you will handle these meals and snacks. If your teen is early in recovery it may be important to for them to remain under the full supervision of parents for all meals and snacks. If this is the case, you should speak to the school staff now and make arrangements. Most schools will allow a parent to come and have the teen come out and eat lunch in the car and then go back in. Other parents make arrangements for a staff person at the school (favorite teacher, school nurse) to supervise lunch. You may need to do the same thing with a morning snack. You may even consider only sending your teen for part of the school day until meals are going more smoothly.
If your teen is able to eat a meal and or snack on their own, don’t assume that doing so at school will be easy. Any change in location or schedule can increase the challenge for a teen with an eating disorder. I always suggest letting your teen know that if they can’t finish what you’ve packed, they should pack it up and bring the remainder home. It is important for you to know what they couldn’t finish so that you can add food later to make sure they don’t end up with a deficient intake which could lead to relapse. Let them know they won’t be in trouble!
Practice now with the foods you will send to school for lunch. If your teen is accustomed to hot lunches at home, have them practice eating the very foods you will pack in a school lunch to make sure they are comfortable eating those foods. I always suggest packing foods that are easiest for your teen to eat while being adequate nutritionally; save the fear foods for the meals they will be eating at home with you.
If your teen will be eating without supervision, discuss with whom they will eat. Do they have friends they feel most comfortable with? Even better if they have a friend who knows about their eating disorder and they can talk to ahead of time about making plans to eat lunch together. Encourage them to eat with friends who are good eaters.
If your teen will need to have restrictions from physical education, get a note from your treatment team and deliver it to their school.
Finally, I suggest watching closely during times of transition. This means weighing your teen regularly to guard against a significant weight change. Sometimes you can hit a bump and catching a problem early can go a long way in preventing a serious decline.
Have you been tracking your food via a calorie-counting app?
Maybe you’ve been tracking your exercise through a wearable or other system. Did you know such tracking:
May encourage a disordered relationship with food and your body?
May actually be jeopardizing your health rather than helping you to monitor it?
If you’ve noticed that you’re becoming obsessive about what you eat or how you move your body, it might be a good idea to examine your relationship with any tracking devices you are using.
People may track their weights, food consumed, and workouts in the name of health. But for many people, tracking such data can actually be detrimental. Preliminary research shows that the use of MyFitnessPal can contribute to eating disorder symptoms in undergraduates (Simpson & Mazzeo, 2017), adults with eating disorders (Levinson et al., 2017) and men (Linardon and Messer, 2019).
The research is not clear about exactly why these devices can be so detrimental. In my experience working with patients with eating disorders who track, tracking cuts people off from their bodies and their own regulatory systems. People who track become reliant on objective measures and data for making decisions about how much to eat and how hard to exercise. They lose awareness of their own bodies’ signals. Perfectionistic traits may drive them to eat fewer calories, take more steps, and increase their distance or pace during a workout. Even those who don’t struggle with a diagnosable eating disorder can be negatively impacted by these tracking devices and apps, with individuals who previously had a perfectly normal relationship with food suddenly feeling completely consumed with thoughts about what they’re putting into their mouths.
This was brought home to me when working with a patient who was obsessively tracking his workout metrics. As we discussed doing a bike ride without his fitness monitor–just as an experiment to see how it felt—he argued passionately with me, with one telling objection being, “How will I know when to take a drink?” He had been timing his consumption of water according to time and distance.
I asked him the same question back: “How will you know when to take a drink?” Hearing it from a third party, he realized how strange the question sounded and how disconnected he had become from his own body.
Similarly, patients who count calories and carefully dole out lunches of specific caloric allotments become frightened when faced with a lunch of unknown (and likely higher) caloric value. Knowing that restaurant portions are larger and more calorically dense then the meals they make at home, they ask me how they can possibly avoid overeating. And then they are amazed when they find that they are sometimes satisfied with less than the entire portion of the restaurant meal, precisely because it’s more calorically dense and satiating.
Once they are no longer eating according to self-imposed strictures, eating becomes a different experience. They gain the capacity to tune in to how they feel while eating the food, rather than just eating to completion of their allotment–and they find that their bodies tell them when to stop eating. Life without tracking can become a freeing and enjoyable experience in which you can be fully present during meals and exercise and engage with the people around you and your surroundings—having deep conversations without intrusive thoughts and becoming mesmerized by beautiful surroundings when you exercise outdoors, for example.
Our bodies are wonderful, self-regulating mechanisms. Our bodies tell us when we need to urinate or have a drink of water or when it’s time to eat and when it’s time to stop eating. When we succumb to diet or wellness culture and stop trusting our bodies and start relying on external systems to tell us when to drink or how much to eat, we become disconnected from our bodies and we lose the ability to recognize these signals.
How to Stop Tracking
If you find that you are obsessively tracking your food or workouts, I invite you to try the following experiment:
Fitness tracking: do one workout without your monitor. During and after your workout, rather than looking at your metrics to evaluate the workout, ask yourself instead how your body feels/felt during the movement and afterward.
Food tracking: eat a meal where you do not know the caloric content. Tune in to how you feel while eating it. How does it taste?
Levinson, C. A., Fewell, L., & Brosof, L. C. (2017). My Fitness Pal calorie tracker usage in the eating disorders. Eating Behaviors, 27, 14-16.
Linardon, J., & Messer, M. (2019). My fitness pal usage in men: Associations with eating disorder symptoms and psychosocial impairment. Eating Behaviors, 33, 13–17.
Simpson, C. C., & Mazzeo, S. E. (2017). Calorie counting and fitness tracking technology: Associations with eating disorder symptomatology. Eating Behaviors, 26, 89-92.
A difficult concept in recovery is knowing when to let go of an activity or even a job that could potentially re-ignite the eating disorder. As a therapist I find myself guiding my clients towards the realization that the sport or career path they had loved so much might be the very thing that holds them back and sets them back up for relapse. It isn’t always an easy decision.
Letting go of something that may have predated the eating disorder can lead to questions as to why it cannot remain in someone’s life in recovery. Many clients in the early stages of eating disorder treatment have to face the fact that they have to stop their sports if they are trying to regain weight or are working on eliminating behaviors that could leave the body physically weak. It is no surprise that once stabilization begins there is an urge to return to previously enjoyed activities. However, returning to these activities could potentially hinder full recovery.
Sports like gymnastics, running, figure skating, wrestling, and dancing are incredibly wonderful. As a figure skater myself, I can attest there is no greater feeling than gliding over the ice. But these same sports, especially at the elite level, can be incredibly demanding on the body. Behaviors required for full recovery can go against what a coach may be preaching to athletes to be in top physical form. What is expected of top athletes could look like disordered eating and poor body mentality from an outside perspective. The eating disorder itself may take what is used to condition a top athlete and manipulate it for its own gain.
It can be difficult to find the balance between a recovered mindset and meeting the demands of a sport or career. With some of my clients in the entertainment industry, there are pressures to look a certain way and fit a mold that their bodies may not be meant to fit. It can be difficult to navigate knowing they need to eat a certain amount of times a day and then have an agent say, “Lose five pounds for this role.”
The hardest decision is when there is a realization that staying in either the sport or career is just too detrimental to your health. It is certainly not easy to walk away from something you’ve put work into. And that can also be said about your recovery. Are you willing to give up a healthy body and mind for a potential chance at a gold medal or lucrative career even if it means killing yourself along the way? I’ve worked with a client who was a dancer who recognized as she was going through treatment that going back into a dance studio would be too triggering. She knew that staring at herself in a mirror and comparing herself to her classmates would lead to restricting her meals. It wasn’t an easy decision to walk away, but she knew there was no way she was in a place to be able to dance without being triggered.
In some circumstances, you may not have to completely quit your previous passion. You might be able to approach the activity differently. You may not be able to return to a sport as an elite athlete, but you could still engage in the activity at a more recreational level. I’ve seen some of my clients shift from being an athlete to being a coach. Actors going from television and movies to doing local theater. Sometimes you can still do what you love but it just needs to be re-configured to fit into your recovery lifestyle. For many, it can be comforting to know they can still act or model or run, but just do it less intensively.
You may also have the option of challenging what a sport or career emphasizes as far as body image and diet pressures. There are many models and actors who are embracing bigger bodies and not letting the pressures to lose weight define them. With this option, there is a risk of rejection along the way as we do still live in a culture that overvalues thinness. With that being said, this may be a safe option primarily for those who feel stable in recovery and are able to actively use coping skills to fight urges. If your recovery has reached a place of advocacy this definitely could be a path to take.
Leaving a passion behind or re-defining how it fits into your life can be a huge change. You may feel sad or mad. That’s okay. Ultimately, the decision you make will be the one that supports you in your recovery. If staying in the activity is going to trigger calorie counting, weekly weigh-ins or criticism for not looking a certain way, is it worth it? If you know where the eating disorder thrives then why play with fire? Ultimately, the decision will be based on what will make you healthy and happy and not allow you to compromise with the eating disorder.