“Normal” Teen Eating

Normal Teen Eating

Parents are often surprised by the high energy needs of teen girls. This is especially true for those faced with restoring a malnourished teen’s weight.

 

But even parents of healthy teens can become confused about what is “normal” in a culture where dieting is pervasive.

 

This is what normal teen eating looked for this 16 year-old teen on one day. She was out of the house, walked about 2 to 3 miles, and got to choose all of her food. This teen is healthy, has good energy, and enjoys food. She is not usually very active. Not every day of eating is the same.

 

  • Breakfast
    • 1 piece of French toast with butter and syrup, a few tablespoons of hash browns
    • 3/4 of a Belgian waffle with whipped cream and syrup
    • 2 pork sausage links
  • Lunch
    • 4 pieces of tuna on crispy rice (could not finish the 5th)
    • An order of salmon sushi
  • Snack
    • 2 scoops of ice cream
  • Dinner
    • 1 fried chicken taco in lettuce with cabbage
    • 1 steak taco in a corn tortilla
    • 1/2 serving of creamed corn
    • Horchata (beverage)
  • Snack
    • A half wedge of blue cheese with crackers

I share this because it may be difficult for parents when teens eat the foods diet culture tells us are bad. Instead, it may be a way of creating a healthy relationship with all food and getting their high energy needs met.

April 2018 LACPA Eating Disorder SIG

BermudezLA area professionals are invited to the April 2018 LACPA Eating Disorder SIG event. This event is open to non-members!

Date: Tuesday, April 24th at 7:00 pm 

Presenter: Ovidio Bermudez, MD, FAAP, FSAHM, FAED, F.iaedp, CEDS 

Title: Understanding Brain Development in the Treatment of Eating Disorders

Description: This presentation will review three concepts of the current understanding of brain development.  The first is proliferation and pruning as the brain grows via enhancement of gray matter and white matter.  The second is sequential maturation and fully coming online of different areas of the brain and how this may help us understand emotion regulation.  Third how environmental and hormonal influences may affect brain development.  In addition, how this may be applied to the treatment of eating disorders in children and adolescents will be discussed.

Bio:  Ovidio Bermudez, M.D. is the Medical Director of Child and Adolescent Services and Chief Clinical Education Officer at Eating Recovery Center in Denver, Colorado. He holds academic appointments as Clinical Professor of Psychiatry and Pediatrics at the University of Colorado School of Medicine and University of Oklahoma College of Medicine. He is Board certified in Pediatrics and Adolescent Medicine.

Dr. Bermudez is a Fellow of the American Academy of Pediatrics, the Society for Adolescent Health and Medicine, the Academy for Eating Disorders, and the International Association of Eating Disorders Professionals. He is Past Chairman and currently Senior Advisor to the Board of Directors of the National Eating Disorders Association, Co-Founder of the Eating Disorders Coalition of Tennessee (EDCT) and Co-founder of the Oklahoma Eating Disorders Association (OEDA). He is a Certified Eating Disorders Specialist and training supervisor by the International Association of Eating Disorders Professionals.

Dr. Bermudez has lectured nationally and internationally on eating pathology across the lifespan, obesity, and other topics related to pediatric and adult healthcare. He has been repeatedly recognized for his dedication, advocacy, professional achievement and clinical excellence in the field of eating disorders.

Location:  The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland)

RSVP to:  drmuhlheim@gmail.com

March and April SIG meetings are open to all professionals.   During other months SIG meetings are open to all LACPA members.  Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org

Checking Our Own Weight Biases as Parents

 

Weight bias parentingWeight bias is a preference for thinness. In the words of psychologist Ashley Solomon, Psy.D., CEDS, “Weight bias is insidiously interwoven into the fabric of our culture.”

Like many of us, I grew up in a family that possesses a great deal of weight bias. When I gained weight just before puberty my mother put me on diets. My paternal grandfather bribed me to lose weight with the offer of a car. I realize my family members meant well. They stated at the time they were worried I would not be well-liked if I was overweight. At 101 years of age, my maternal grandmother still weighs herself daily and credits the diet she started in high school as the cause of my grandfather falling in love with her.

I have already recounted how I helped my older daughter gain weight when she fell off her weight curve at the age of 12—despite her pediatrician’s misplaced admiration, “You’re just how we all want to be,” (75%ile for height and 25%ile for weight [= thin for your height])” My son and younger daughter gained weight before their growth spurts, which led to that same pediatrician warning me about weight gain and risk of obesity for the two of them. This succinctly illuminates our culture’s weight bias: obesity is a far greater concern than anorexia nervosa.

Now let’s fast-forward to 2 years after the obesity warning for my younger daughter. Nearing the end of her height growth spurt, she has fallen off her weight curve. What is an FBT-trained professional therapist and enlightened mother to do?

She is about 10 pounds below where she should be according to the weight graphs (ignoring the single spurious plot point when I got the obesity warning). She is definitely slender. She does take a medication that could reduce appetite. However, even when she doesn’t take it, she has a small appetite. She does not show any other signs of weight or body concern, eats a range of foods, and is not very active (unlike her older sister when I intervened on her behalf to restore weight).

I notice my admiration for her current shape. I notice the temptation to leave her alone and let her remain on the thin side. After all, my son has gained weight now that he is no longer in high school sports. I notice a stronger urge to react to his food choices than I did when he was thinner. And with some larger relatives in their genetic heritage, I have had the fleeting thought that I would rather keep my daughter thin. WHAT?! I caught my thoughts unconsciously falling into programmed family and societal beliefs that I do not actually agree with on an aware and conscious level.

I examine my feelings and beliefs about what weight gain means for my daughter. I quickly recognized my over-valuing of her slenderness and my own projected anxiety about her potentially being larger. After questioning her pediatrician, who is, not surprisingly, unconcerned, and obtaining a print-out of her growth and weight curves, together we (my daughter and I) settled on adding a daily liquid supplement and mild encouragement to eat more. And, my daughter seems to feel it is a fun challenge.

I do what I ask the families I work with do, which is challenge the bias that thin is better and focus on keeping my daughter on track on her own weight curve, which I know is healthiest for her long term.

Five Reasons Parents Should be Included in the Treatment of Children and Adolescents With Eating Disorders

I had the honor of presenting a workshop yesterday along with Therese Waterhous, PhD/RDN, CEDRD. and Lisa LaBorde, Outreach Director for Families Empowered and Supporting Treatment of Eating Disorders (FEAST) at the IAEDP Symposium 2016. Our workshop was entitled, From “Worst Attendants” to Partners in Recovery: Empowering Parents as Agents of Change for Children and Adolescents with Eating Disorders.

Slide1

A growing body of scientific research demonstrates that parents and caregivers can be a powerful support for a child in recovery from an eating disorder. This model of care is a radical shift from the traditional individually focused therapeutic approach and requires significant changes in how patients and families are treated within a clinical practice.

During my section of the presentation, I presented Five Reasons to Include Parents in treatment for youngsters with eating disorders. I share them here:

  1. The reason to exclude parents was based on theories that have now been debunked.

In the late 1800s Gull suggested that families were “the worst attendants” for their children with anorexia nervosa, and this set the tone for many years. More recent perpetrators of this viewpoint were Hilda Bruch and Salvador Minuchin. In the historical treatment of eating disorders, parents were blamed and the children were taken away to be fixed by professionals. When ultimately sent back home, parents were told, “Step back,” “Don’t get into a battle for independence, “ and “Don’t be the food police.”

These practices were based on early theoretical models for eating disorders that have not been supported by empirical studies. Research has not been able to identify any particular family pattern that contributes to a child’s eating disorder.

  1. Best practices now state to include parents (and not blame them).

As the following clinical guidelines demonstrate, it is no longer the appropriate standard of care to exclude families from treatment.

The Academy for Eating Disorders’ position paper on The Role of the Family in Eating Disorders:

  • The AED stands firmly against any model of eating disorders in which family influences are seen as the primary cause of eating disorders, condemns statements that blame families for their child’s illness, and recommends that families be included in the treatment of younger patients, unless this is clearly ill advised on clinical grounds. 

The Nine Truths About Eating Disorders consensus document, produced in collaboration with Dr. Cynthia Bulik, PhD, FAED states:

  • Truth #2: Families are not to blame, and can be the patients’ and providers’ best allies in treatment.

The American Psychiatric Association (APA) Guidelines for Eating Disorders also advises:

  • For children and adolescents with anorexia nervosa, family involvement and treatment are essential. For older patients, family assessment and involvement may be useful and should be considered on a case-by-case basis. (p.12)
  1. Research shows better and faster results when parents are included in mental health treatment for their children.

Randomized controlled trials of adolescents with anorexia nervosa and bulimia nervosa show that adolescents who receive family-based treatment, in which parents play a central role, achieve higher rates of recovery and recover faster than adolescents who receive individual adolescent focused therapy. This result is consistent with findings for other psychological disorders, including Obsessive-Compulsive Disorder (improved outcome is found when families are included in treatment) and schizophrenia (a large scale study found greater improvement when treatment included family education and support as part of more comprehensive care).

  1. Parents are often good allies in fighting eating disorders.

On the one hand, patients with eating disorders (and especially younger patients) are often significantly impacted by malnutrition. Research shows they commonly have a decrease in brain grey matter, cognitive deficits and anosognosia—a lack of awareness that they are ill. Recovering on one’s own is commonly difficult for an adolescent whose brain is not fully developed and may lack the cognitive ability to challenge negative thoughts, change behavior patterns, and resist urges. Furthermore, they commonly lack the independence adult clients have to purchase and prepare their own food.

On the other hand, parents are there to take care of their children. They can do the heavy lifting. They can be authoritative and require children to eat. It can be difficult for a therapist to develop rapport with a reluctant and resistant adolescent; it is much easier for a therapist to develop a therapeutic alliance with the parents who do want their child to recover. In situations where there are multiple treatment providers, parents can help with the communication between team members as they will likely be seeing them all. Lastly, parents typically buy the food for the household so they have the ability to execute the meal plan.

Eating disorders often take years, not months, to fully resolve. There will rarely be a scenario in which a patient leaves home for a residential setting and comes home “cured.” The reality is that any treatment is only the first stop on the road to recovery–full recovery takes sustained full nutrition and cessation of behaviors for an extended time period and the family, in many cases, can help that happen. So whatever treatment model is used, FBT principles and training are vitally important for families.

  1. Parents are powerful.

In the past, mental health treatment was primarily private; the internet has changed that. Parent support and activist groups such as FEAST, Eating Disorder Parent Support (EDPS), March Against Eating Disorders, International Eating Disorder Action,and Mothers Against Eating Disorders have connected parents, given them access to scientific information that was not available to parents pre-internet, and given them the tools to organize. Social media has increased the pace of this information. Parents have access to evidence-based information and are demanding treatment that aligns with it. If they are shut out from treatment, they will hear from other parents that this is problematic. They may change providers if they are dissatisfied with the treatment their child is receiving

There is no greater love than the love of a parent for their child. To work with parents and empower them to help their children get well is one of the most rewarding aspects of my work.

Condiments, the Final Frontier of Eating Disorder Recovery

By Katie Grubiak, RDN, Director of Nutrition Services

Katherine Grubiak is a Registered Dietitian with a focus on blending Western & Eastern philosophies regarding nutritional healing.

Condiments in Eating Disorder Recovery

In our work with clients with eating disorders, we help them to reintroduce recently eliminated and avoided foods that present as part of the eating disorder. We notice that as clients (both adult and child) reintroduce foods, it is often the condiments and sauces that are the last to be confronted. In some situations, clients never successfully spontaneously reintroduce these foods; we have to strongly encourage them.

“Normal” eaters enjoy ketchup on French fries, mayonnaise on a sandwich, and dressing (with oil) on salads. In fine cooking, sauces such as Hollandaise are elements that complete the dish. Watch any cooking show and you will see how integral the sauces are to the meals.

In addition to adding needed flavor and creaminess to dishes, these sauces and condiments also add the necessary dietary fat that is essential to metabolic function, hormone balance, absorption of fat soluble vitamins (Vitamins A, D, E, K), nerve coating, and ultimately brain healing.  It is said that even after weight restoration, for 6 months the body & brain are still recovering.  Gray matter, which is severely compromised in anorexia, only can be re-layered through the help of essential fatty acids. Recommendations are between 30-40% of total calories coming from dietary fat. How about we rename this macro-nutrient “essential fuels” (EFs) to honor its positive and real use in recovery?

We think it is worth pushing these condiments and sauces as one step towards a full recovery for our clients. If you are a person in recovery or a parent of a person in recovery, we hope you will consider the following suggestions:

  • Try one new condiment on a sandwich or side dish per week. This may include: ketchup, mayonnaise, mustard, aioli, etc.
  • Try dipping chips or vegetables in sauces such as Ranch dressing, salsa, or guacamole.
  • Experiment with one new creamy salad dressing (not fat free) on a salad.
  • Eat a meal that has one new sauce, such as a cream sauce on pasta, a sauce on steak, or an Asian curry.

Here are some recipes:

Chimichurri Sauce-with Argentinian roots its used as both a marinade and a sauce for grilled steak. Also try it with fish, chicken, or even pasta (like a pesto). Chimichurri also makes a great dipping sauce for french bread or a yummy spread on a sandwich! 

  • Prep Time: 8-10 minutes
  • Serves 4

Ingredients:

  • 1 cup firmly packed fresh flat-leaf parsley trimmed of stems
  • 3-4 garlic cloves
  • 2 TBSP fresh or 2 TSP dried oregano leaves
  • 1/2 cup olive oil (extra virgin cold pressed)
  • 2 TBSP red or white wine vinegar-maybe a rice vinegar
  • 1 TSP sea salt
  • 1/4 TSP ground black pepper
  • 1/4 TSP red pepper flakes (amount depending on level of heat desired)

Finely chop the parsley, fresh oregano, & garlic or place all in a food processor with just a few pushes. Place in a small bowl. Stir in the olive oil, vinegar, salt, pepper, and red pepper flakes to taste. Serve immediately or refrigerate. Perishable-so avoid keeping longer than two days.

Chili Aoli

Condiments in eating disorder recoveryUse on top of meatloaf, meatballs, or on a sandwich.

Total time: 10 minutes | Makes 1 cup.

  • 1 cup mayonnaise
  • 2 cloves garlic, peeled and minced
  • 3 1/2 tablespoons canola oil
  • 1/2 teaspoon ground cumin
  • 3/4 teaspoon lemon juice
  • 1 1/2 tablespoons dark chili powder
  • 3/4 tablespoon paprika
  • Salt and pepper

In a small bowl, whisk together all ingredients until smooth. Taste and season as desired with salt and pepper.

Trader Joe’s Wasabi Mayo can really spruce up a turkey sandwich!  

For Teens With Bulimia, Family Based Treatment is Recommended

Teens With Bulimia Family Based TreatmentMy original eating disorder training began in 1991 with learning Cognitive Behavioral Therapy (CBT) for bulimia nervosa (BN) under G. Terence Wilson, the co-author with Dr. Christopher G. Fairburn, of the treatment approach that preceded CBT-E. In 2010 I underwent training in Family Based Treatment (FBT) for Adolescent Anorexia Nervosa (AN) and became certified in FBT by the Training Institute for Child and Adolescent Eating Disorders.

CBT is the most effective treatment for adults with bulimia nervosa. It is an individual approach that focuses on reducing dieting and changing unhelpful thinking patterns that maintain the behavior. FBT is the most successful treatment for adolescents with AN. FBT encourages parental control and management of eating disorder behaviors, but does not address distorted thinking regarding shape and weight. Over the last five years, there has been no clear guideline on which treatment I should offer to adolescents with BN.

This changed in September 2015 with the online publication of “Randomized Clinical Trial of Family-Based Treatment and Cognitive-Behavioral Therapy for Adolescent Bulimia Nervosa” by Daniel Le Grange, Ph.D., James Lock, M.D., W. Stewart Agras, M.D., Susan Bryson, M.A., M.S., and Booil Jo, Ph.D. which has been published in the November Journal of the American Academy of Child and Adolescent Psychiatry.

In this study, researchers at the University of Chicago and Stanford randomly assigned 130 teens between the ages of 12 and 18 years old with BN to receive either CBT-A (CBT adapted for adolescents) or FBT-BN (FBT for adolescent bulimia). The teens received 18 outpatient sessions over the course of six months. Assessments were conducted at end of treatment and at six and twelve month follow-ups. After the completion of the treatment, bulimia abstinence rates were 39% for FBT patients and 20% for CBT patients. By the six-month follow up, these rates rose to 44% for FBT patients and 25% for CBT patients. These differences were statistically significant. By 12 month follow up, while the bulimia abstinence rate continued to rise for both populations, the difference was no longer statistically significant.

The researchers concluded,

FBT-BN is likely a better initial treatment option compared to CBT-A for those adolescents with clinically significant bulimia behaviors. FBT-BN leads to quicker and higher sustained abstinence rates that are maintained up to 12 months posttreatment…It appears that, similar to their adolescent peers with AN, adolescents with BN can benefit from an approach that actively involves their families in the treatment process. However, given that there were no statistical differences between these 2 treatments at 12 months post-treatment, CBT-A remains a viable alternative treatment for this patient population, especially for those families who would prefer a largely individual treatment or when there is no family available to be of help.

In interviews about the study, Dr. Le Grange said, “Parents need to be actively involved in the treatment of kids and teens with eating disorders.”

This study reinforces my experience. Although I have employed CBT for bulimia in working with adolescents, rarely do adolescents fully embrace the work required on their part for CBT to be successful. I have found it more effective to use FBT with their family and to supplement with some individual CBT if the adolescent appears ready and motivated for additional independent work. Bingeing and purging are serious symptoms carrying the risk of heart and esophageal problems and death. Thus administering a treatment that brings a faster rate of remission of symptoms is a priority.

Unintentional Weight Loss as a Trigger for Anorexia.

Unintentional Weight Loss as a Trigger for AnorexiaSome of the biggest misunderstandings about Anorexia Nervosa center around it being an intentional illness and related to vanity. A paper by Brandenburg and Andersen in 2007 entitled Unintentional Onset of Anorexia details case histories of 5 individuals who were deemed to have anorexia precipitated by “unintended weight loss” as opposed to the “more typical onset following intentional dieting.” In the paper the authors reported that a retrospective review of 66 consecutive outpatient evaluations at an eating disorder clinic revealed 5 (7.6%) cases of “inadvertent onset AN” (Anorexia Nervosa). They stated that this finding “calls into question whether dieting is a necessary precedent for AN; and suggests some individuals, perhaps genetically or psychosocially vulnerable, may need only weight loss from any source to result in clinical AN.”

Brandenberg and Andersen went on to say, “It was only after the unintended weight loss had occurred that the patient developed the desire to lose more weight or maintain the unsought lower weight.” Of the five cases described in the paper, the sources of weight loss included parasitic infection, medication side effects, post-surgical weight loss, and bereavement.

It is now believed that people with a genetic vulnerability to anorexia respond aberrantly to negative energy balance, allowing anorexia to develop. While it is recognized that the source of this energy imbalance could be intentional or unintentional, Brandenburg and Andersen is the only research paper I have been able to find on the topic.

In my practice, I have seen an adolescent who forgot to eat over a high school exam period. Only after the initial weight loss, she grew anxious about her weight and started more deliberately restricting. In today’s seemingly obese-phobic society, the most common source of energy imbalance is likely dieting, but this is clearly not the only path.

Parents on the Around the Dinner Table forum, a moderated online forum for parents and caregivers of eating disorder patients, pondered this same issue and started a poll: “What caused your child’s weight loss, precipitating AN?” The results break down as follows:

CauseCasesPercent
Dieting to lose weight77             22%
Trying to eat healthy90             31%
Overtraining for athletics38             13%
Fasting for religious event / reason2               0%
Becoming vegetarian / vegan12               4%
Illness18               6%
Other, unknown44             15%

The finding that 6% of cases were reported as due to illness is remarkably similar to the findings of Brandenberg and Andersen. Furthermore, some of the comments on the FEAST survey relating to the “inadvertent onsets” included:

  • “My daughter had pneumonia and lost at least 10 pounds. She gained it back but it became a battle after that to get the weight back off again. Daughter said at some point that weight loss was completely out of her control.”
  • “World Vision’s 30-Hour Famine to raise money for starving children in the Third World. Within a week she had decided to lose 30 pounds and off she went.”
  • “My daughter started to increase exercise/training for state selection in her chosen sport. Two month’s into daughter’s increase in her training regime she had her wisdom teeth removed and could not eat solid food for 3 weeks….And our story begins!”

Mononucleosis was mentioned. Physical growth without commensurate weight gain also rang true for several parents. While attending the NEDA conference in San Diego, I met a woman who reported that her anorexia developed after weight loss following 15 months of chemotherapy at age 11.

Brandenburg and Andersen concluded, “Physicians in all specialties should be aware that weight loss in predisposed individuals may trigger anorexia nervosa.” However, this is the only paper I have found on the subject, and it is behind a pay wall (not accessible for free to the community). The message is not reaching its intended audience. As others have highlighted, it’s important to draw attention to this issue to dispel the widespread belief that eating disorders “always” start out as a desire to be thin.

Since anorexia nervosa is an illness and not a choice, perhaps a more apt title would have been “Unintentional Weight Loss as a Trigger for Anorexia.”

Is Your Young Adult with an Eating Disorder Ready for College?

Is My Young Adult with an Eating Disorder Ready for College?

You may be wondering: is my young adult with an eating disorder ready for college? Starting college is stressful for even the most well-adjusted young adult. Young adults with eating disorders often have trouble with transitions. Add an active eating disorder on top of the college transition, and you have a potential time bomb.

College brings a multitude of new situations to navigate: living away from parents; living with strangers; loss of personal space and privacy; unfamiliar environment; unfamiliar foods; loss of structure; drugs and alcohol; pressure to fit in; academic pressure; and sororities and fraternities. If a young adult has been struggling in recovery, these additional stressors typically make life even harder.

Young adults who are not completely recovered struggle in situations that healthy adults navigate with ease. Consuming enough food in a dining hall can pose a big challenge to students with eating disorders characterized by inflexible eating. In our experience, students who are not comfortable eating with peers and not comfortable eating a variety of foods (including starches, fats, and desserts) lose weight rapidly in this environment.

The patterns of college life can make it harder to maintain a healthy weight. Students are likely much more active as they walk from place to place over a large campus. Different sleep patterns (all-nighters among them) can also increase energy expenditure. For these reasons, the caloric needs of college students are often substantial; 3000-3500 kcal per day baseline is not unusual. This would translate to needing over 100 fat grams per day. These factors should be considered when evaluating whether the young adult can eat enough calorically dense food on their own to sustain a healthy weight or refrain from bingeing and purging.

College culture brings additional pressure to a student in recovery. Roommates and peers may be dieting, there is fear of the “freshman 15,” and friendships may bond around visits to the gym and yoga classes. It can be harder to refrain from exercise when it is the place that socializing occurs.

Many parents want to send their young adults to school so as not to have them miss out on common milestones and universal experiences. However, the reality is that attending school while still plagued by intrusive eating disorder thoughts and behaviors will rob them of the very aspects of the experience you want them to have. Returning to a “normal” life too soon is a common cause of relapse, further delaying their ability to live a “normal” life.

From our experiences with the preparation of high school seniors to go off to college and the reception of incoming freshman from other eating disorder teams, we have developed the following list of questions for parents to ask when deciding whether a young adult is prepared for a healthy transition to college:

Six months of solid recovery is needed, meaning the young adult has consistently displayed the behaviors included in the checklist over that period of time.

Lauren and Katie’s college readiness checklist:

  • Has your young adult maintained a steady weight in the healthy range (according to childhood growth records) and menstruated consistently (if female-bodied) for six months?
  • Has your young adult been free of eating-disordered behaviors such as bingeing, purging, laxative use, and excessive exercise for six months?
  • Is your young adult able to independently and consistently prepare/choose meals (in a variety of settings) that contain enough energy-dense foods to maintain this weight?
  • Is your young adult able to serve themselves snacks and desserts?
  • Does your young adult consume beverages other than water (juice, milk, lattes)?
  • Is your young adult able to eat at a variety of restaurants, ordering and eating a balanced meal that is not simply the lowest calorie item on the menu?
  • Is your young adult able to go into a cafeteria and eat from the different food stations comfortably (sandwich bar, grill, etc.) and not just from the salad bar?
  • Is your young adult comfortable eating hot breakfasts (other than oatmeal)?
  • Does your young adult use condiments comfortably (dressing with fat, ketchup, mayonnaise, etc.)?
  • Is your young adult comfortable eating with friends?
  • Does your young adult eat at a normal pace?
  • Has your young adult reincorporated the majority of previously feared and avoided foods?
  • Is your young adult able to go without exercise at least every other day, or not at all if medically contraindicated?
  • If your young adult has returned to exercise, do they understand the need to add additional fuel following exercise?
  • Is your young adult able to eat in front of other people who aren’t eating? (There is no guarantee roommates will not be eating disordered – so taking care of one’s own needs and handling the self-consciousness inherent in doing so is an important recovery skill.)
  • Will your young adult be able to cope with potentially having a scale in the room and roommates who weigh themselves and discuss weight/dieting?
  • If your young adult misses a meal for any reason at all, are they able to make it up that day or the next day at the latest? Making it up may mean having larger portions at other meals, two extra snacks, or the equivalent of an extra meal across a 24- to 36-hour period.
  • Is your young adult able to increase their daily calories substantially to account for mileage logged when walking around campus?
  • Can your young adult be restful? Does he or she sit when everyone else is sitting?
  • Is your young adult able to be alone around processed and highly-palatable foods without having an urge to binge?
  • Has your young adult demonstrated an ability to tolerate anxiety without resorting to restriction, bingeing, or purging?
  • Does your young adult openly acknowledge their eating disorder and have insight about the need to construct a life and schedule that supports recovery?
  • Have you discussed with your young adult that any situation that puts them in a state of negative energy imbalance or weight loss could trigger a relapse?
  • Does your young adult understand that alcohol calories “do not count” towards energy needs?
  • Are temperamental traits (perfectionism, rigidity, comparing, etc.) acknowledged and appropriately managed?

How to prepare a young adult for college

If your young adult meets most of the above criteria and there is still time before they are expected to leave for college, there are things you can do to prepare them.

  1. Practice eating with them in different self-serve cafeteria-type settings including a variety of restaurants for breakfast, lunch, and dinner. Good options include Souplantation, Indian restaurants that have lunch buffets, and hospital cafeterias. Have them practice building a meal that will meet their dietary needs. Revisit the same places again with the expectation that they will choose different options.
  2. Have them practice walking five miles per day for a week (to simulate the amount of physical activity they’re likely to have on a college campus) and adding sufficient calories to keep weight steady.
  3. Do ‘surprise’ food exposures for a few months – at random times take your young adult to unexpected food locales/situations and make sure they can tolerate it. For example, make a spontaneous stop at Cold Stone Creamery and offer them a snack.
  4. Do a week of sauces and butter on everything.
  5. It is a good idea to have a college contract in place. This is an agreement between the parents and the student that specifies criteria required for staying in college (things like maintaining a healthy weight, not engaging in eating disorder behaviors, and having regular weigh-ins) and what the parents will do if these things are not met (for example, increase supervision, bring the child home, etc.).  A sample college contract can be found here.
  6. Make sure they have a meal plan that includes three meals per day in the dining hall.

If your young adult does not meet the criteria listed above, then please consider having them defer college or start at a local college while living at home. It is better to delay their starting than to have them start and get overwhelmed by their symptoms and need to drop out. Life is not a race. College can wait. Your young adult will get more out of the experience when she or he is fully recovered. By contrast, sending them to college when they are not ready may reduce their chance for a full recovery.

Thanks to Rebecka Peebles, MD, Therese Waterhous, PhD/RDN, CEDRD, and JD Ouellette for their helpful feedback and contributions to this piece.

Download copy of article here: Is your young adult ready for college?

Presentation at NEDA 2015 conference

Lauren and Katie presenting NEDA 2015

Katie and I had the honor of presenting in the Individual, Family, and Friends track at the National Eating Disorder Association Conference in San Diego yesterday.  The title of our talk was:  Family Based Nutrition Therapy:  Creating A Supportive Environment.  It was a chance to share the way we work to support families who are helping children with eating disorders.

Here are some of the key points of our talk:

FBT Insights from the Neonatal Kitten Nursery

Parents feed children in FBT Kitten CollageI recently began volunteering at the Best Friends Neonatal Kitten Nursery. Best Friends Los Angeles opened its neonatal kitten nursery in February 2013.  The nursery is staffed with a dedicated coordinator and supported by volunteers who sign up for two hour feeding shifts 24 hours a day to help the kittens grow and thrive.

If you were an abandoned kitten in the Los Angeles area, or even a kitten with a mother, you’d be lucky to make your way to the Best Friends Neonatal Kitten Nursery.

The most vulnerable animals in the Los Angeles shelters are newborn kittens, often abandoned at birth, or turned into shelters from accidental litters. Because the kittens cannot feed themselves, they will die without someone to bottle feed them.

In the mommy and me section of the nursery, mothers nurse their kittens. In the other sections, kittens are bottle-fed, tube-fed, or syringe-fed until they are able to eat gruel on their own. Kittens are weighed before and after each feeding. If their weights are not steadily going up, the interventions increase. They are very fragile at this age.

The other night, the nursery coordinator, Nicole, was tube-feeding some kittens who were ill. As she explained, they were feeling too sick to eat on their own. Although acknowledging that her tube feeding was making them angry, Nicole was resolute. No kitten would starve to death on her watch. Of course, I connected this back to my families working to re-feed their children with anorexia.

In the neonatal nursery, we don’t spend time thinking about why the kitten is not nursing or eating in the expected fashion. If they are sick, they are treated for that, but in the meantime, every kitten is fed around the clock and those who don’t have mothers are bottle fed, those who won’t nurse from their mothers (often when they are too congested) are tube-fed, and those who won’t eat gruel independently are syringe-fed.

How does this relate to parents doing Family Based Treatment (FBT) for Eating Disorders with children who have Anorexia?

Of course, parents do not literally force food down human children’s throats, but they do set up contingencies to require eating even if the child doesn’t feel well and even if they rail and resist and are angry about it.

This is the heart of FBT Phase 1. When children are not able to eat on their own (due to an eating disorder) parents are instructed to nourish their starving child back to health. Parents need to step in and help their children make steady weight gains until they are able to eat on their own. Parents need to be resolute and not worry about their children being angry at them. They also should not spend time exploring why their child is not eating.

For further information on parental direction over eating in FBT, check out this prior blog post.