This Halloween, Serve Candy to Your Teen in Recovery

A Family-Based Treatment (FBT)-approach

Fear FoodFor teens with eating disorders, Halloween can be scary for the wrong reason: the candy! Most teens with eating disorders are only willing to eat a restricted range of foods. Expanding this range is an important goal of treatment, with the reintroduction of fear foods being a key step. Candy tends to be high on the fear food lists of many teens.

Halloween presents an ideal opportunity.

A Taste of Recovery

Most teens in America are excited for Halloween and its bounty of candy. By incorporating some candy during your teen’s Halloween week you can help them approximate the lives of teens who do not have eating disorders. This step can give them a taste of the full life you want for them—a life where they are unencumbered by food restrictions, a life where they can enjoy all foods, a life where they can travel the world confident that they will easily be able to meet their nutritional needs, and a life where they won’t feel the need to shun social events for fear of facing the foods there.

I know that I’m painting a beautiful picture and that this is easier said than done. Teens with eating disorders will deny that the disorder is driving their food preferences. Instead, they claim they simply don’t like candy anymore. Or that candy was the preference of a child and since then their palates have matured. But don’t believe them—you have crucial parental memory and knowledge. You know which foods your teen actually liked a few years back. You also probably know the foods on which he or she binged if they binged. And it is not credible that any teen really hates all candy!

Especially if your teen had a great many fear foods, you may already have experience reintroducing some of them. But once meals start going more smoothly, some weight has been restored, and binges and purges have subsided, many parents are reluctant to push further. Why rock the boat when your teen seems to be doing well? You may be wondering: Is candy really necessary?

In fact, this Halloween is exactly the right time to introduce candy.

Exposure

It is much easier to introduce fear foods before your teen is completely independent in their eating. Right now, you are still overseeing meals and your teen does not yet have their independent life back. Pushing the issue of fear foods becomes more challenging when your teen has regained most of their freedom.

When you introduce fear foods to your teen, you will probably feel anxious. Your teen will too. You may even feel like you are going back a step. This is how exposure works—it is supposed to raise your teen’s anxiety. When your teen avoids these fear foods, their anxiety decreases, reinforcing the avoidant behavior and justifying the anxiety response. This perpetuates both the emotion and the behavior. But the food is not truly dangerous—if the teen were to eat the food, they would learn that nothing catastrophic happens. In exposure, the teen is required to eat the food, and the anxiety response shows itself to be baseless. With repeated exposure, the brain habituates, learns that the food is not harmful, and loses the anxiety response.

Exposure works through repetition over a sustained period of time—not all at once. It’s likely that each food on your teen’s feared list will need to be presented several times before the thought of eating it no longer causes extreme anxiety.

You may feel that requiring your teen to eat candy is extreme. However, remember: the healthy part of your teen probably wants to eat candy, but the eating disorder would beat them up if they ate it willingly. By requiring your teen to eat candy, you are actually granting your teen permission to eat it—permission they are unable to grant themselves. After recovery, many teens report that they really wanted the fear food but were too afraid—it was only when their parents made them eat it that they were able to.

And I would argue that fearlessness in the face of candy is important for your child. So be brave about facing potentially increased resistance by your teen and model facing your own fear.

Here’s How to Incorporate Candy During Halloween:

  1. Choose a few types of candy based on your teen’s preferences about three years before they developed their eating disorder. (If you can’t remember, ask one of their siblings or just pick a few options, maybe one chocolate-based and a non-chocolate alternative.) Make your choice based on providing your teen with the typical American teen experience. (American teens will typically collect a lot of candy on Halloween, have a few pieces that night, and then have candy as snacks a few times during the following week.)
  2. You may choose to tell your teen about the candy ahead of time or not. Some families find that telling teens about exposure to fear foods ahead of time is helpful; other families find that it is better to just present a fear food without warning. But note that you are not required to ask their permission; FBT is a parent-driven treatment.
  3. Serve a single serving of candy during dessert or snack a few times during the week of Halloween. Plan carefully and be thoughtful. Do this with the same resolve that you use when you serve them any starches or proteins. You may want to introduce the candy on a day when you feel more confident, will have more time to manage potential resistance, or can be sure a second caregiver will be present. You may not want to present candy, or any fear food, before an event that you are not willing to miss in case you encounter an extreme reaction.
  4. If your teen binges or purges, make sure to sit with them for an hour after they eat the candy.
  5. Plan for what will happen if your teen refuses to eat the candy. For example, will you offer something else instead and try the candy again tomorrow? Offer a reward for eating the candy? Create a consequence for noncompletion? Whatever you decide, be consistent and follow through.

If you do this-this year, there is a good chance that by next Halloween your teen will be eating candy independently!

Is the (Eating Disorder) Treatment Your Child is Getting FBT?

When new families talk to me about Family-Based Treatment (FBT), I often find that they are confused about what it is and what it isn’t.

FBT is a type of evidence-based treatment for adolescent eating disorders. This treatment was developed at the Maudsley Hospital in London in the 1970s and 1980s; Doctors Lock and Le Grange manualized it into its current form in 2001. Because of its name, FBT is often confused with more general “family therapy.” Be careful, because these are not the same thing—while both involve the family, FBT is a very specific, behaviorally-focused therapy.

While a treatment that includes some elements of FBT—but falls short of the full manualized treatment—may work for some eating disorder cases, it may not work for more difficult cases. When FBT doesn’t work it is important to know whether the child has had an adequate course of the true treatment in its evidence-based form. This can be tricky—in the field of psychotherapy, most therapists identify as eclectic, meaning they adhere to no single therapeutic orientation but combine techniques from several (just scroll through any Psychology Today therapist profile to get a taste for how many different theoretical approaches most therapists endorse). We don’t yet know which elements of FBT are critical to its efficacy and make it such a successful treatment. This would take expensive dismantling studies in which different partial treatments are tested against each other. Except for studies documenting a separated FBT (where only the parents attend sessions), no such study has been cited in the literature. Until we have good evidence that suggests otherwise, treatments that stay true to the original, already-tested treatments are the safest bet.

I once worked with a patient with panic disorder who had had previous treatment. He told me that his previous therapist had conducted cognitive-behavioral therapy (CBT), widely accepted as the best evidence-based treatment for panic disorder. When I dug deeper, I found that his therapy had included no exposure to the sensations of panic—considered to be the core element of CBT treatment for panic disorder.  Instead, the treatment had focused on discussing his anxiety thoughts—a very different protocol. From this experience I learned to inquire carefully about the treatment my patients have previously received before accepting that it cannot work for them.

So it is with Family-Based Treatment. Sometimes parents tell me that they think they tried FBT but are not sure. If your child was treated in an academic center, it’s more likely they got the evidence-based treatment of FBT in its full form. However, some parents who tell me that FBT didn’t work also tell me:

  • They did FBT on their own, with no therapeutic support
  • They had meals with their child, but that the therapist met primarily with the adolescent alone
  • They didn’t supervise all meals because their child resisted it. 

In each of these situations, it is obvious to me that the treatment is not what I would consider FBT. And while it is true that including some aspects of FBT or even a “watered down” FBT may be better than no FBT or parent inclusion at all, it’s important to know whether your child had the real thing or not, especially if they end up needing more or different treatment.

Often, parents who tell me they struggled with renourishing a child on their own find that things go much better once they started working with me or another therapist. That’s not to say that parents should never try to renourish a teen on their own—just that supporting a child with an eating disorder is extremely hard work and best done with the support and guidance of a professional at their side.

Signs Your Child Received FBT

Accordingly, I created the checklist below for parents to determine whether the treatment their child received (or is receiving) is really FBT. To how many of the following statements can you answer “YES” (the more the better)?

  • My therapist received training through the Training Institute for Child and Adolescent Eating Disorders.
    • The basic training is a 2-day workshop. Have they attended one?
    • Have they received or are they receiving clinical consultation or supervision by a staff member of the institute?
    • Are they certified in FBT by the Training Institute (meaning they have completed the 2-day training and received 25 hours of consultation by a staff member around their treatment of 5 patients)?
  • My therapist owns, seems familiar with, and refers to the FBT treatment manual.
  • My therapist refers to and acknowledges the three phases of FBT:
    • Phase 1 —full parental control
    • Phase 2 — a gradual return of control to the teen
    • Phase 3 —establishing healthy independence
  • My therapist is familiar with the work of Drs. James Lock and Daniel Le Grange, developers of the FBT treatment.
  • My therapist adheres to the five principles of FBT:
    • I was specifically told I was responsible for restoring my teen nutritionally and interrupting behaviors that interfere with recovery (including bingeing, purging, and overexercise). I was specifically told I was responsible for planning, preparing, serving, and supervising all meals.
    • I was told we don’t know for sure what causes an eating disorder and it doesn’t matter.
    • Initial attention of treatment focused solely on restoring health including weight gain and stopping eating disorder behaviors.
    • Rather than being given prescriptive tasks, I was empowered to play an active role and to discover those strategies that worked best for my family and the child whom I know best.
    • I was taught to externalize the illness and see it as an outside force that has hijacked my child, threatens his or her life, and makes my child do things he or she wouldn’t normally do. My child did not choose the eating disorder.
  • I have had a family meal at the therapist’s office.
  • My therapist spends most of the time with the full family, meeting only briefly with the adolescent alone at the beginning of the session (or in the case of “separated FBT,” all of the time with parents).
  • My therapist or another member of the treatment team tracks my child’s weight and gives me feedback after every weigh-in on how he or she is doing.
  • I was specifically told I am responsible for supervising all meals and snacks to ensure completion. If purging has been a problem, I was told to supervise the child after eating to prevent purging.
  • If my child has been exercising excessively, I was told to prevent this.
  • After weight was restored and bingeing and purging and other behaviors had ceased, my therapist guided me in gradually returning my teen control over their own eating.
  • I was told it was important to be direct with my teen about eating adequate amounts of food.
  • My therapist discusses the importance of both “state” and weight to recovery—meaning my therapist explains that weight recovery is a step towards psychological recovery, but not an end goal in itself.

Dead giveaways your child did not get FBT

Below are some indicators that your child might not have “gotten FBT” and might be receiving some conflicting messages:

  • I have been told that we, the parents, had caused the eating disorder.
  • My therapist spends the majority of therapy time alone with the teen.
  • My therapist spends a lot of time talking about the past and reasons my child wanted, needed, or otherwise developed the disorder.
  • A dietitian has met alone with my teen and given him or her nutritional recommendations.
  • My child has been given a meal plan.
  • I have been told that it is an option to not supervise all meals or prevent all purging.
  • The FBT therapist has provided individual CBT, DBT, or ACT with the teen during the weight restoration phase.
  • I have been told from the start of treatment to “not be the food police” (in FBT, this might happen toward the end of treatment, or in Phase 2 with an older teen).
  • My child has been in charge of making his or her own meals from the outset of treatment.

Summary

In conclusion, FBT has been proven to be the most effective treatment for adolescents in clinical trials. That said, not every treatment works for everyone. In my opinion, it is best to start with something that has a backing and then try something else if that doesn’t work. When you have sought out an evidence-based treatment, it’s important to make sure you’re getting the treatment in its researched form.

August 2018 LACPA Eating Disorder SIG Event

Jaye Azoff, Psy.D., Los AngelesDate: Wednesday, August 22nd at 7:30 pm

Presenter: Jaye Azoff, Psy.D.

Title: The Anatomy of a Recovery

Description: Recovery from anorexia nervosa (AN) follows an unpredictable, windy path. Rarely does it come quick; there is no single trajectory, no infallible indicators of how a treatment will play out. Opinions about the recovery process vary, depending on whose perspective is being sought. The patient—the former patient—sees it one way—but there is no guarantee that the opinions of others, therapists, partners, loved ones, will concur.

This talk addresses the question in a unique fashion. A patient: a former patient, (a doctoral level psychologist) will share her account of a treatment that unfolded over roughly twenty years.

Several points will be discussed. Importantly, the former patient will consider 1) briefly, the etiology of her illness (and we will assume a basic understanding of eating disorders here); 2) briefly, how (some) of the various treatments were directed and integrated across the multi-disciplinary teams (and throughout the years) 3) how her protests and resistances—and there were many— were met, and with what explanations 4) most importantly, looking back, what aspects of this treatment are now recalled as influential, elements seen in a positive light, elements perceived as detrimental.

Perhaps most important for the purposes of this discussion is the concept of the “power struggle” – that all too familiar war our patients learn over years of treatment with us to get into with themselves which then becomes acted out with their caregivers. How can we as treaters do better at not engaging, and shift the power and responsibility back into their hands?

Namely, how can we teach them that if they are to get well, it will be because they choose to get well? How do we teach them that they “win” nothing by restricting their snack for an evening or vomiting their dinner because they feel hurt over something we as clinicians might have said or done to them? These are complicated constructs, but not impossible ones, and by using Dr. Azoff’s past as a case vignette, we might be able to chisel away at some of the answers.

Bio: Jaye Azoff, Psy.D., has been practicing in the fields of clinical psychology and neuropsychology since 2008, when she graduated from the California School of Professional Psychology in Los Angeles, where she trained under the Health Emphasis Track. Dr. Azoff did most of her field training at Children’s Hospital Los Angeles’ Keck School of Medicine, where she practiced in the hematology/oncology neural tumors unit and trained in many roles over nearly eight years, eventually advancing to become the team’s neuropsychology fellow. It was Dr. Azoff’s own recovery from an eating disorder that propelled her forward and launched her into the eating disorders field. Currently, she is an eating disorders consultant, and she is the owner and operator of Basik Concierge, the world’s only boutique concierge firm offering wraparound services for individuals with eating disorders and their families. She is also the In-House Clinical Consultant for the Kantor and Kantor law firm, which fervently works to attain treatment for individuals with eating disorders struggling to gain access to care. Dr. Azoff is a past board member of the Eating Disorders Coalition. She is a sought-after speaker, having formally addressed the United States Congress in the Spring of 2013, and travels nationally to speak to patients and families affected by eating disorders, as well as delivers in-services to clinicians and other individuals eager to learn about various topics related to 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

SIG meetings are open to all LACPA members.  Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org

Are We Setting Recovery Weights Too Low?

 

At the recent International Conference on Eating Disorders in Chicago, I attended a plenary, Recovery from an Eating Disorder: How Do We Define It? What Does It Look Like? And Should It Always be the Focus? During this plenary, Anna Bardone-Cone, PhD spoke about the essential components of recovery from an eating disorder. She indicated that definitions of recovery should include the following three domains and proposed the following criteria for each domain of eating disorder recovery:

  • Physical — defined as BMI greater than 18.5
  • Behavioral— defined as absence of any binge eating, vomiting, laxative use, or fasting within the past 3 months
  • Cognitive — defined as EDE-Q subscales within 1 standard deviation of age-matched community norms.

Hold on a second—the weight criterion used to define recovery from anorexia nervosa in most studies is a BMI of only 18.5?

Most in the full plenary room agreed that for anorexia nervosa recovery, a BMI of 18.5 is too low a criterion to declare all people recovered. I agree with Laura Collins Lyster-Mensh, who made the following tweets:

  • Isn’t it possible that by setting target weights at the low end of the tail we are holding patients in chronic mental illness.
  • Setting low, population-based weight targets for ALL EATING DISORDERS means weight suppression and malnourishment and prevents psychiatric recovery for all but those who are genetically designed to be in smaller bodies, IMO.

I totally agree. If we now acknowledge that anorexia can occur in people of higher weights—a phenomenon often, and problematically, called “Atypical Anorexia”—then shouldn’t a BMI target as low as 18.5 be abandoned in favor of individualized recovery weights?

In fact, weight suppression researcher Michael Lowe was present at the plenary.  During the Q&A he proposed that rather than using a categorical definition of weight recovery (a single BMI number) we should use a continuum—for example, the recovered patient’s BMI relative to their pre-illness BMI.

How Are Recovery Weights Established?

Unfortunately, there is very little consensus on how to determine whether a patient with a restrictive eating disorder is at a recovered or healthy weight. This affects research and practice. If researchers define recovery based on an 18.5 BMI and this weight is really too low for many people with anorexia, what does this mean for the research studies? For one thing, in clinical trials a lower percentage of people would be deemed “recovered”, showing our treatments to be even less successful than we believe them to be.

But it has bigger implications for the potential for patients to truly recover. If we set recovery weights higher, maybe more people will be treated to full recovery. Setting the BMI bar so low means we’re not insisting on full weight recovery for all people. As Laura Collins points out, the effect of this is that only those who are privileged enough to be in genetically smaller bodies may ever actually reach recovery.

And what are the ramifications for practitioners? There may not yet be an established way to determine a recovery weight—consequently, many patients may never recover. If we acknowledge that gaining to a healthy body weight is a prerequisite for full psychological recovery, then we are dooming many people in larger bodies to a life of purgatory in which they remain insufficiently sick to need intensive treatment, but never achieve full recovery.

In one recent paper, Jocelyn Lebow, Leslie A. Sim, and Erin C. Accurso survey 113 child and adolescent eating disorder treatment providers inquiring about the methods used to determine weight restoration in clinical practice. Their findings show:

  • 40.7% of practitioners used growth curve data
  • the remaining (nearly 60%) employed a diverse range of approaches
  • providers who specialize in Family-Based Treatment were significantly more likely to use an individualized approach versus considering adolescent preference

Lebow and colleagues concluded that:

Although there is a modicum of endorsement for using growth curves to predict expected body weight, this is not universal practice and is inconsistent with methods used in treatment studies. The lack of an evidence-based method to calculate expected body weight—or even a best practice consensus for calculating this number—is a major oversight in the field that requires empirical attention.

Why Might Providers Set Recovery Weights Too Low?

What are some of the reasons providers might be setting recovery weights too low?

  • No empirical consensus or guidelines on how to set target weight
  • Lack of available growth records data to determine an individualized recovery weight
  • Financial limitations—insurance companies reduce costs by lower treatment limits, which are facilitated by lower weight goals
  • Client resistance—pushing for higher weights requires overcoming greater resistance and anxiety from the patient and sometimes family over higher weights.
  • Weight stigma—even treatment providers may be susceptible to society’s war on obesity, and consequently may err on the side of under-restoring a teen in recovery.

Over twitter, one mother responded to my conference tweets about an 18.5 BMI recovery goal as being too low and tweeted the following:

  • We need all professionals to understand the need for higher recovery weights. Recovery is about state not weight. So many parents know this but are stuck with uneducated team members who undermine their work.
  • If professionals consider a return to pre-eating disorder growth patterns for height and weight to be weight restoration, we parents are saying wrong. Eating disorder voices are very loud at this weight. We recommend an additional 10% for the first few years of recovery at least. This quiets the eating disorder voice and patients are more likely to stay recovered.
  • I want all current professionals worldwide to understand this. There are so many parents in our international group whose professionals are not getting it. Maybe it has not been studied officially but anecdotally we are seeing this in high numbers. 
  • If it’s not part of their training, providers should at least listen to and support parents in this. We are committed to our kids’ recovery every bit as they are. 
  • It takes parents a while to get it too. It’s frustrating for professionals when parents undermine. I was horrified at the first proposed recovery weight and was afraid of my child being made fat. But I got educated pretty quickly, opened my eyes and realized I needed to take it further in order to achieve full recovery.

Stephanie Zerwas, Ph.D. (not at the conference) chimed in over Twitter and asked the parent:

  • What language helped you as a parent to “get it? Parents often have a belief that being a little underweight can help their child not worry about weight gain, not realizing that it keeps kids stuck in limbo and hypervigilant.

The parent responded:

  • What helped us parents “get it” was seeing those in our support group brave enough to take their kids to higher weights reporting their kids’ eating disorder voices finally quiet down. We keep repeating state, not weight = recovery and realized goal weights are set mostly too low 
  • Too many parents are upset that eating disorder professionals are saying their kids are recovered and not listening to them when they say their kids are still vulnerable, using behaviors, and need to be a higher weight. This is the power of parent groups. We know this needs to change. 
  • Parents also not understanding weight restoration is a moving target. They come to our group stating their child is weight restored and still struggling and often clinging to a weight goal given years ago. There is no “Weight Restored” in eating disorder recovery only “state restored.” 
  • We are seeing this extra 10% to be effective in many of our children who still struggle with eating disorder behaviors at 100% pre-illness percentile of growth. In the meantime, if patients are still struggling and parents want this, we should be supported. But yes, bring on the studies!!

What Do Parents Say About Recovery Weights?

So, believing that parents do indeed know their children best and are an untapped resource to study this further, I took to Twitter to ask parents to share their experiences about recovery weights being set too low. I got an overwhelming response. Below are some excerpts of what parents sent to me:

  • At her lowest weight, our daughter was BMI of 21.9. Our doctor told us “she is not at an anorexic weight.” She is currently BMI 31.6. We felt she was finally starting to shift her thinking when she was at around a BMI of 29.5.
  • When my daughter was 17, she lost 25 pounds. At her lowest, her BMI never fell below 20. Yet she was extremely ill. After she had regained about 14 pounds, her period returned, but her “state” was still awful. She is now in a range of BMI 25.5 to 26. The difference this last 5 pounds has made had been amazing. Her level of insight and flexibility is much higher. Amazingly, the higher her weight, the happier she is with herself and her body. Reflecting back, I am grateful that no one told us she was “recovered” when she got her period back. She needed to get and stay back up to the 80 to 85%ile as per her personal growth curve. At the age of 19.75 she grew another .25 inch. If that isn’t proof she needed more weight, I don’t know what is! I hear so many stories in our group of parents being told to stop refeeding too early. Teams are generally not comfortable pushing weights back up to or above personal growth curves. We are lucky our team was an exception! In our online support group, we have seen time and time again that higher weights make a difference. And the extra weight generally comes with little risk.
  • My daughter was diagnosed at the age of 10.5 with anorexia. The original goal was to get my daughter at a BMI of 15.5 to a BMI of 18. In the next 2.5 years my daughter needed 6000 calories a day and a very high fat diet. She grew nearly 9 inches, went through full puberty, and doubled her initial body weight. Once her growth slowed and her metabolism went down and stabilized, we were able to get her weight up to around a BMI of 22 and that is when we saw TRUE RECOVERY begin. She began to eat “extra.” She began to ask for things. She began to be able to eat independently. Over the last 4 years she has put on around 20 to 25 pounds on her own, naturally. Her BMI is now around 24 – 25 and she is in a 100% solid recovery. She eats intuitively, independently, and reports being free of the eating disorder voice. Fats, high calories, and a MUCH higher weight were essential to getting our daughter into recovery. If I would have listened to the “experts” I believe she would still be struggling.  
  • My daughter was 24.2 BMI at 13 years old when she started exercising excessively and then restricting. She lost a quarter of her body weight in 7 months and our new pediatrician told her to gain 10 pounds and come back in 6 weeks. We fed her 6 times for a total of 4000 calories a day. She finally got her period at BMI 21.8 and within a few months, her anxiety was high and the team suggested it was time to start exercising. My online support group spent a long time helping me understand my own fat phobia and really worked to help me set a higher target weight. My daughter grew another three inches. She is now BMI 23.5 and this is the healthiest I have ever seen her. If I had listened to the specialists, she would be just as sick as she was before.  
  • At her lowest weight and her sickest, my daughter’s BMI was 19.3. We saw improvements in her state once she was over 25 BMI and in the “overweight” range. Had I allowed a reduction in her food intake at 23 BMI when it was suggested to me, my daughter would have been in a perpetual eating disorder purgatory.
  • My daughter’s current BMI is 24.6. Lower than that or increasing muscle over fat, it is as if her body goes into ‘starvation mode’ and she gets all silly and cranky and her period is delayed.
  • My son was given a target BMI of 19 by his clinician. This was not from a growth chart, it was from a generic BMI chart. My son was still very unwell at that BMI. Thoughts were very strong, and the desire to restrict was high. He was living a half-life, tormented with the anorexia. He was throwing away his lunch and manipulating weight. His clinician was adamant that he did not need more weight, and did not need more food, although I could see he was actually starving. She would not support me to take his weight higher or increase his meal plan. My online support group warned me that this was a common mistake with clinicians. I got my son (with great difficulty, after the clinician had insisted lower was okay), to a BMI of 24. We have never looked back. We have our kid back, he is 16 years old, he is in very strong recovery for some time now. I know the extra weight is what he needed to see recovery. He is living a normal teen life now, is happy and fully functional. We are into year 3 now, and he still needs 3 meals and 2 snacks per day of at least 4000 calories to stay in recovery. We owe our son’s recovery to the wonderful advice from parents that had been in our situation before us. They knew from other parents before them that a generic BMI figure is not recovery. Recovery is a state and not a weight. It makes perfect sense too. After all we do not expect everybody to have the same shoe size.  
  • My daughter was diagnosed approximately 18 months ago with Atypical Anorexia and was very unwell at a BMI of 19. I joined a support group just prior to her entering into treatment. In large part due to the anecdotal advice and experience of others in the group, I was of the firm belief that we needed to weight restore my girl to her own individual weight, not to a particular BMI or any particular upper number. Fortunately, our team was happy for me to take the lead with this approach, and we encouraged weight gain to wherever her behaviors began to abate and her weight settled naturally on its own, with NO reduction in intake. This ended up being at a BMI of around 26, which I do not believe most clinicians would encourage. However, I truly do have my happy girl back and I do not regret any one of those extra kilos. Her body has settled at a weight at which her mind is very well. I believe that if we had been given an upper number that she couldn’t go above, that we would have trapped her in her anorexia needlessly for so much longer.
  • My daughter did not seem to actually begin true recovery until she was at 23.5 BMI.  This was higher than the professionals in her life seemed comfortable with, but I proceeded with semi-confidence (having seen the results of higher weights in other patients, through their carers’ stories) and was never challenged.  Before this higher BMI she struggled so much with ED thoughts and behaviors – very little could get through to her…. therapy, talking, coaching, none was very helpful… only FOOD, in larger amounts that some professionals recommend (specifically with regards to fats – avocados, ghee/butter, olive oil).  At 23.5 something seemed to just “lift”.  She began to be able to participate for herself. She still had many ED behaviors and thoughts, but could push them aside much of the time.  She lost most of her body image issues, and began asking for food outside of the meal plan – especially things she used to enjoy (chocolate, etc.).  Unbelievably, she began asking for MORE food. Consensus among carers in the groups seems to be that 22-25 BMI is where most sufferers see true strides in recovery.  It is very, very rare that BMI under 22 is successful, at least when polled on the peer-to-peer carer support groups.  Most often, it seems as though 23-24 is the “sweet spot” for many.  My daughter has remained at this BMI (just shy of 24) for almost 6 months.

Summary of Recovery BMI

One online support group did their own survey: ” at what BMI did you see real recovery?”

Here are the responses ( note that most were given a target bmi of 19 by their clinician, and had to fight against that, or had to walk away from their provider to get their child into recovery)

BMI 21-22      4

BMI 22            3

BMI 22-23      4

BMI 23            1

BMI 23-34      5

BMI 24            4

BMI 24-25      4

BMI 25            4

So out of 29 respondents,  none got their kid into recovery at BMI 19 OR 20.

Stay Tuned for A Survey For Parents

I think this is an important issue that deserves more attention. I am working with the same researchers who did the above study to more formally study parents’ perceptions of their childrens’ recovery. Stay tuned for a survey so we can continue to learn from your parental wisdom.

If you interested in learning more about this study, please click here.

Sources

Jocelyn Lebow, Leslie A. Sim & Erin C. Accurso (2017): Is there clinical consensus in defining weight restoration for adolescents with anorexia nervosa?, Eating Disorders, DOI: 10.1080/10640266.2017.1388664

How To Choose A Supplemental Nutrition Shake

Nutritional Supplements for Eating Disorder Recovery - Katie Grubiak, RDN By Katie Grubiak, RDN

In a previous post, we discussed the role of supplemental nutritional shakes in eating disorder recovery. Sometimes, patients in recovery will be unable to restore their nutrition entirely with food. In these cases, the use of supplements can be invaluable. If you or a loved one are restoring nutrition from an eating disorder, you should be under the care of a medical doctor (MD) & registered dietitian nutritionist (RDN).

In this post, we will continue the discussion about supplements, comparing different supplement brands based on caloric density per ounce, macronutrient comparison (fat, carbohydrates, protein), and label advertising. Lastly, we’ll rate them for taste and palatability.

Caloric Density

Substantial caloric density per ounce is the most important factor in the selection of a liquid supplement. To optimize replacing calories in a meal, we recommended selecting a product that delivers at least 300 calories per 8- to 11-ounce serving. Any under-300 calorie product is insufficient to replace a meal or even a majority of a meal for someone in recovery from an eating disorder, and should instead be treated as a calorically dense beverage to be added alongside a meal or snack. Alternatively, multiple shakes—2 or 3—can together replace a meal.

Serving size is important. Any product that comes in serving sizes larger than 11 ounces has the risk of being too filling—someone recovering from an eating disorder may not finish it, meaning that the precious calories will never be delivered.

Macronutrient Comparison

A comprehensive liquid supplement should be evaluated against the same dietary recommendations as a normal meal. The caloric nutrients or “macronutrients” that we hope to balance in a meal are protein, carbohydrates (carbs), and dietary fat. The goal is that supplements have a macronutrient profile similar to a balanced plate.

Macronutrients are often measured in terms of “exchanges”:

  • Fats: One dietary fat exchange equals 5 grams of fat. A recovery meal is often recommended to include at least two to four fat exchanges. Aim for 10-20 grams fat in an 8-11 ounce supplement.
  • Carbohydrates: One carb exchange equates to 15 grams of total carbohydrates. Meals in recovery are recommended to include at least two to four carb exchanges. Aim for 30-60 grams total carbs in an 8-11 ounce supplement.
  • Protein: One ounce of meat, chicken, or fish equates to one protein exchange, or 7 grams of protein. Meal building suggestions for animal or vegetarian protein sources are usually anywhere from two to four exchanges. Aim for 14-28 grams protein in an 8-11 ounce supplement serving.

I don’t advise comparing micronutrients—the trace amounts of added vitamins and minerals—among products because this is not important when the goal is increased intake. Instead, stay focused on the caloric constitution of a supplement including its macronutrient profile so that the primary objective of ensuring weight gain or maintenance is achieved.

Ingredients

Products labels can sometimes bear so much “health” messaging that it can be difficult to pull out what is truly important. One product label claims a better, more natural ingredient; another vouches it is more “non”-something than any other product…. This can get confusing!

To streamline the process, we recommend starting off with identifying whether or not the product is dairy free. This is an important concern for people who keep Kosher, are lactose intolerant, or have a milk protein allergy. Look specifically to see if the product says dairy-free, or suitable for lactose intolerance (might have dairy/lactose but in low concentrations). If you have a milk protein allergy, specifically screen for such ingredients as milk protein concentrate, casein (all forms), whey (in all forms), & milk (in all forms).

Second: identify whether or not gluten is an issue for you. You only need to do this if you have a known gluten issue diagnosed by a medical professional—for most people, gluten is a harmless component of a normal diet. If gluten is an issue, check to see whether the supplement is labeled gluten-free.

Third: check the label for any other known food allergy ingredient.

Last, check the “Nutrition Facts” on the back label for calorie and macronutrient comparison. I suggest stopping there and not diving into a deeper ingredient comparison. Any scrutinizing beyond this is unimportant and likely giving the eating disorder too much power. In the end, this kind of label attention diverts from the true function of the use of supplementation in eating disorder recovery—to replace calorically a substantial meal with a concentrated liquid when all or partial meal cannot be consumed.

To reiterate, your primary considerations when choosing a supplement are caloric density and macronutrient profile. Weight maintenance and weight gain comes from calories—not from the presence of more natural ingredients or the absence of processed ones. It’s understandable to want to use a supplement that checks off every box marked “healthy”—but this can add fuel to the eating disorder’s fire.

Labeling is part of the product—you can’t avoid it. But you don’t have to let the eating disorder make choices based on irrelevant labeling information that appeases its instincts. When you provide a supplement to a family member in recovery, you can always remove or cover up the label, or simply pour it into a cup, to reduce a triggering reaction.

 

EDTLA reviewed a number of supplement brands and taste-tested some of them. Taste was rated on a scale of 1 (yuck) to 10 (yum). Each brand has numerous product variations in its lineup—we were not able to review every variety. Note that many drugstore and grocery chains carry their own store brands – of these, we included Rite Aid, CVS, and Kroger in our analysis and tasting.

 

Ensure Product Family

Ensure brand nutritional supplementsEnsure Original

Product positioning: #1 doctor recommended brand, kosher, gluten-free, suitable for lactose intolerance, not for people with galactosemia

Calories: 220 calories per 8-ounce serving

Macronutrients: 6 g fat, 33 g total carbs, 9 g protein

Ingredients: Carbohydrate sources: corn maltodextrin, sugar. Protein sources: milk protein concentrate. Fat sources: canola oil, corn oil

EDTLA TASTE RATING: Not tasted

Ensure Plus

Product positioning: 50% more calories than Ensure Original, gluten-free, suitable for lactose intolerance, not for people with galactosemia, balanced nutrition to help gain or maintain a healthy weight, kosher, gluten-free, suitable for lactose intolerance

Calories: 350 calories per 8-ounce serving

Macronutrients: 11 g fat, 50 g total carbs, 13 g protein

Ingredients: Carbohydrate sources: corn maltodextrin, sugar. Protein sources: milk protein concentrate, soy protein isolate. Fat sources: blend of vegetable oils (canola, corn).

EDTLA TASTE RATING: Chocolate flavor 8; Strawberry flavor 7; Vanilla flavor 8

 

Ensure Enlive

Product positioning: designed to help rebuild your strength and energy from the inside, with an ALL-IN-ONE blend to support your health. The label claims bone, muscle, heart, digestion, & immune support, flavored-natural & artificially flavored, suitable for lactose intolerance, gluten-free, kosher, not for people with galactosemia

Calories: 350 calories per 8-ounce serving

Macronutrients: 11 g fat, 44 g total carbs, 20 g protein

Ingredients: Carbohydrate sources: corn syrup, sugar, short chain fructo-oligosaccharides. Protein sources: milk protein concentrate, sodium caseinate, soy protein isolate, whey protein concentrate. Fat sources: corn oil, canola oil.

EDTLA TASTE RATING: Strawberry flavor 8

 

Ensure Clear

Product positioning: great-tasting, clear liquid nutrition drink that contains high-quality protein and essential nutrients, fat free, gluten-free, suitable for lactose intolerance

Calories: 200 calories per 6.8-ounce serving

Macronutrients: 0 g fat, 43 g total carbs, 7 g protein

Ingredients: Carbohydrate sources: sugar, corn syrup solids. Protein sources: whey protein isolate

EDTLA TASTE RATING: Apple flavor 8. Also available in mixed berry (not tasted)

 

Boost brand nutritional supplementsBoost Product Family

Boost

Product positioning: a great-tasting nutritional drink as a mini-meal or between-meal snack with 26 vitamins & minerals, 3 g of fiber, & 10 g of high quality protein, gluten-free, suitable for lactose intolerance, not for individuals with galactosemia, kosher

Calories: 240 calories per 8-ounce serving

Macronutrients: 4 g fat, 41 g total carbs, 10 g protein

Ingredients: Carbohydrate sources: corn syrup, sugar, fructo-oligosaccharides. Protein sources: milk protein concentrate, soy protein isolate. Fat sources: vegetable oil (canola, high oleic sunflower, corn)

EDTLA TASTE RATING: Not tasted

 

Boost Plus

Product positioning: helping to achieve and maintain a healthy weight, 3 g fiber, 26 vitamins & minerals, gluten-free, suitable for lactose intolerance, not suitable for people with galactosemia, kosher

Calories: 360 calories per 8-ounce serving

Macronutrients: 14 g fat, 45 g total carbs, 14 g protein.

Ingredients: Carbohydrate sources: corn syrup, sugar. Protein sources: protein concentrate, soy protein isolate, fructo-oligosaccharides. Fat sources: vegetable oil (canola, high oleic sunflower oil, corn)

EDTLA TASTE RATING: Chocolate flavored 6; Vanilla flavored 5

 

Boost Breeze

Product positioning: a convenient source of additional protein & calories in a fruit-flavored drink, suitable for lactose intolerance, gluten-free, kosher, not for individuals with galactosemia

Calories: 250 calories per 8-ounce serving

Macronutrients: 0 g fat, 54 g total carbs, 9 g protein

Ingredients: Carbohydrate sources: sugar, corn syrup. Protein sources: whey protein isolate (milk)

EDTLA TASTE RATING: Peach flavored 7 (“like peach Snapple”); Berry flavored 6 (“like Hi-C”), Orange flavor 3 (“medicine like”)

 

Store brand nutritional supplementsStore Brands

Rite Aid Original Nutrition Shake

Product positioning: advertised compare to Ensure, natural & artificial flavors, gluten free, suitable for lactose intolerance, not for people with galactosemia, kosher

Calories: 220 calories per 8-ounce serving

Macronutrients: 6 g fat, 33 g total carbs, 9 g protein.

Ingredients: Carbohydrate sources: corn maltodextrin, sugar, sucromalt. Protein sources: milk protein concentrate, soy protein isolate, pea protein concentrate. Fat sources: soy oil, canola oil

EDTLA TASTE RATING: Chocolate flavored 6

 

CVS Nutritional Shake

Product positioning: – naturally & artificially flavored, made with real diafiltered milk, gluten free, suitable for lactose intolerance, kosher

Calories: 220 calories per 8-ounce serving

Macronutrients: 6 g fat, 33 g total carbs, 9 g protein.

Ingredients: Carbohydrate sources: sugar, brown rice syrup, corn maltodextrin, sucromalt. Protein sources: milk protein concentrate, soy protein concentrate. Fat sources: soy oil, canola oil, corn oil. Diafiltered skim milk contributes to carbs & protein amount simultaneously.

EDTLA TASTE RATING: Milk chocolate flavor (not tasted)

 

Kroger Nutrition Shake Fortify Plus

Product positioning: -advertised as to help gain or maintain a healthy weight & kosher, naturally & artificially sweetened milk chocolate

Calories: 350 calories per 8-ounce serving

Macronutrients: 11g fat, 50 g total carbs, 13 g protein.

Ingredients: Carbohydrate sources: corn maltodextrin, sugar. Protein sources: milk protein, soy protein isolate. Fat sources: corn oil, canola oil.

EDTLA TASTE RATING: Chocolate flavored 6

 

Orgain brand nutritional supplementsOrgain Organic Nutrition Product Family

Product positioning: weight management, meal replacement, or for medical needs;-also gluten-free, soy-free, non-GMO, high protein, organic & kosher.

Complete Protein Shake-Sweet Vanilla Bean

Designated as Grass Fed Dairy

Calories: 250 calories per 11-ounce serving

Macronutrients: 7 g fat, 32 g total carbs, 16 g protein

Ingredients: Carbohydrate sources: organic brown rice syrup, organic cane sugar, organic rice dextrins. Protein sources: organic grass fed milk, protein concentrate, organic whey protein concentrate. Fat sources: organic high oleic sunflower oil

EDTLA TASTE RATING: 4

 

Plant Based Protein Shake-Smooth Chocolate

Designated as Vegan & Dairy Free

Calories: 220 calories per 11-ounce serving

Macronutrients: 6 g fat, 25 g total carbs, 16 g protein.

Ingredients: Carbohydrate sources: organic rice dextrins, organic cane sugar. Protein sources: organic brown rice protein concentrate, organic hemp protein concentrate, organic chia seeds, organic flax powder. Fat sources: organic high oleic sunflower oil

EDTLA TASTE RATING: 4

 

Kate Farms Product Family

Product Positioning: certified gluten free, free of common allergens (no milk, wheat, soybeans, peanuts, tree nuts, eggs, fish, shellfish), corn-free, 18 g plant based protein, MCT oil in some varieties, 29 superfoods, kosher. Contains organic ingredients. Kate Farms is a family start-up company based on the love and re-nourishment of a daughter with Cerebral Palsy. This is a great choice if looking for a multi-tiered caloric supplement company that is non-dairy and has alternative macronutrient sources than the mainstream brands. Kate Farms Core Essential Formulas may be covered by insurance for oral use and tube feeding. Coverage depends on the patient’s diagnosis and insurance plan.

 

Komplete

Calories: 290 calories per 11-ounce serving

Macronutrients: 8 g fat, 41 g total carbs, 16 g protein

Ingredients: Carbohydrate sources: brown rice syrup solids, organic agave syrup. Protein sources: organic pea protein, organic rice protein. Fat sources: organic high oleic sunflower oil

EDTLA TASTE RATING: Available in Chocolate/Coffee/Vanilla (not tasted).

 

Core Essentials Standard Formula 1.0 cal/mL:

Calories: 325 calories per 11-ounce serving

Macronutrients: 10 g fat, 41 g total carbs, 18 g protein

Ingredients: Carbohydrate sources: brown rice syrup solids, organic agave syrup. Protein sources: organic pea protein, organic rice protein. Fat sources: organic high linoleic sunflower oil, medium chain triglycerides (MCT) derived from coconut oil.

EDTLA TASTE RATING: 4 chocolate flavor, 2 vanilla flavor “chalky”

 

Core Essentials Peptide Plus 1.5 cal/mL:

Calories: 500 calories per 11-ounce serving

Macronutrients: 25 g fat, 41 g total carbs, 24 g protein

Ingredients: Carbohydrate sources: brown rice syrup solids, organic agave syrup. Protein sources: organic hyrolyzed pea protein, organic rice protein. Fat sources: organic sunflower oil, medium chain triglycerides (MCT) derived from coconut oil, organic flax seed oil.

EDTLA TASTE RATING: Plain flavor 1 (perhaps best not to drink alone but add to a shake or mix in foods for extreme nutrient density or just use in tube feedings)

 

Other Brands/Products

Benecalorie brand nutritional supplementsBenecalorie

Product positioning: calorie and protein food enhancer, mixes easily into most foods & beverages including milkshakes/yogurt/hot cereal/mash potatoes, unflavored, suitable for lactose intolerance, gluten-free, kosher, not for people with galactosemia, not recommended for tube feeding (not a liquid)

Calories: 330 calories per 1.5-ounce serving

Macronutrients: 33 g fat, 0 g total carbs, 7 g protein

Ingredients: Carbohydrate sources: no carbohydrates but does contain the artificial sweetener sucralose. Protein sources: calcium caseinate from milk. Fat sources: high oleic sunflower oil

EDTLA TASTE RATING: By itself: not tasted. Mixed into oatmeal as suggested 7 (“not a significant change in taste or texture of oatmeal”)

 

I hope this review is helpful and provides encouragement to venture into supplements if recommended by your treatment team.

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

The Use of Supplemental Shakes in Eating Disorder Recovery

By Lauren Muhlheim, PsyD and Katie Grubiak, RDN

Nutritional supplements in eating disorder recovery - shakes

Restoring nutritional health is an essential part of recovery from any eating disorder, including anorexia nervosa, bulimia nervosa, and binge eating disorder. The process of nutritional rehabilitation involves eating sufficient food at regular intervals, which reestablishes regular eating patterns and allows the body to recover. In this post, we will discuss the role of supplemental nutritional shakes in eating disorder recovery. In our next post, we will taste-test the different brands and formulations of nutritional shakes on the market, share our opinions, and help you decide which to buy if you are considering using shakes in your or a loved one’s recovery.

Nutritional Rehabilitation

Since many eating disorder patients – even those who are not at low weights – can be malnourished, renourishment is an important step. Ideally it should take place under the guidance of both a medical doctor and a registered dietitian nutritionist (RDN) who can develop a meal plan uniquely suited to the needs of the patient.

Repairing a depleted body can require a very high caloric intake. The recommended rate of weight gain is usually one to two pounds per week – for many of our clients, this translates into required dietary intakes of 3000 to 5000 calories per day. However, it can be unsafe to increase intake to this level immediately due to the risk of refeeding syndrome, a serious condition caused by introducing nutrition to a malnourished person. Calories need to be increased incrementally under a doctor’s supervision and with an RDN’s guidance.

Getting Sufficient Intake

Many people with eating disorders will be able to restore their nutrition entirely with food. And while we always think it is best for patients to eat real food, and that is the ultimate goal, there are many situations in recovery in which the use of supplements can be invaluable. Sometimes, especially early in recovery, it can be hard for patients to get in enough calories via food alone.

During early recovery, when early fullness is a common issue, fortified shakes may be easier both physically and mentally to consume than food. And when getting in enough calories by eating calorically dense foods is too tough, we think the use of supplements is a perfectly good alternative. It is always better than not eating enough.

Supplement Products

Nutritional supplements, made by a number of different companies, contain nutrients in a calorically dense liquid or “shake.” Six to eight ounces of these products typically have between 200 and 350 calories, depending on the brand and formulation. Many large supermarket and drugstore chains sell shakes under their own names, some of which we tested as well. The best-known brands sold commercially in the US are Boost and Ensure, which come in different flavors and are usually sold in plastic bottles. The main lines are dairy based, but there are non-dairy versions known as Boost Breeze and Ensure Clear, which are packaged in juice boxes and may be ordered online. There are formulations with even higher caloric density (e.g. Boost Plus). In hospital settings, these products are used for patients who are unable to eat – following a stroke, for instance – or need extra nutrition. They can also be used in tube feeding.

In recent years, additional companies have emerged to compete with the Boost and Ensure brands. Several companies are developing products emphasizing organic and natural ingredients. Not all of these products are designed with the same goal in mind. Some are in fact marketed to a clientele that is concerned about losing or maintaining weight through low-calorie, “healthy” meal or snack replacement. These products could inadvertently displace foods, beverages, and other liquid supplements that would be much better suited for appropriate weight gain and eating disorder recovery, all the while delivering messages that could reinforce eating disorder thinking. We recommend thinking carefully about your objectives, researching the products you plan to buy, and proceeding with caution.

How to Use Supplements

Supplements taste better chilled than at room temperature. They can be added to a meal in lieu of a lower-calorie beverage, drunk as a standalone snack, or used in the preparation of oatmeal, smoothies, or milkshakes. They can be consumed more quickly than solid foods and can serve for quick convenient nutrition, especially on the go.

They can also be used as replacements. In some eating disorder residential treatment centers, three supplements would be considered the nutritional equivalent of a meal. A patient who refused to eat altogether would be offered three nutritional drinks; one who ate half the meal would be asked to drink two; one who ate most of the meal but didn’t finish would be asked to top off with a single supplement. Parents refeeding children at home can decide whether to offer an alternative meal or liquid replacement when a child refuses to eat or finish a meal or snack.

Instead of bringing home a multitude of varieties, select one supplement brand in perhaps one or two flavors. Limiting unnecessary choice will head off an opportunity for the eating disorder to assert itself in the form of pickiness.

Take Home

The take-home message: supplemental shakes can be a great tool for ensuring adequate nutrition during the refeeding process in eating disorder treatment. Finding the supplement best suited to you or your loved one from among the available options can be overwhelming. Substantial caloric density is your first concern – but finding one that suits your palate is essential to making sure it goes down. Fortunately, the major brands have made a variety of flavors and textures from which you can choose.

We look forward to sharing further recommendations on the nutritional aspects as well as the results of our taste test. We taste-tested many so you don’t have to. Stay tuned as our follow-up blog will delve into further supplement guidance.

November 2017 LACPA Eating Disorder SIG Event

Jamie Feusner, M.D.Date:  Thursday, November 30th at 7:30 PM 

Presenter:  Jamie Feusner, M.D.

Title: Body Image in Anorexia Nervosa and Body Dysmorphic Disorder: Clinical and Neurobiological Features

Description: Anorexia nervosa (AN) and body dysmorphic disorder (BDD) share clinical features related to body image distortion, including distorted perception of appearance and overemphasis on appearance in one’s self-evaluation. In addition, they share obsessive and compulsive tendencies, poor insight, and are frequently comorbid with each other. Despite this, few studies have directly compared the phenomenology or neuropsychological functioning in AN and BDD and even fewer have compared their neurobiology. In this talk I will describe the overlapping and distinct clinical features of these disorders, as well as the neurobiological substrates of visual and emotional processing from our recent lines of research. In our research, we have used functional neuroimaging (electroencephalography – EEG – and functional magnetic resonance imaging – fMRI) to probe the neural basis of visual processing and to uncover the dynamics of brain connectivity related to fear processing. We additionally have used structural neuroimaging to understand white matter network connectivity patterns. I will also discuss our ongoing study in AN of how brain systems involved in anxiety interact with those involve in reward and how this relates to clinical trajectory. Finally, I will discuss ongoing and future studies to develop visual modulation strategies to address dysfunctional neural systems involved in visual processing, as potential tools to remediate perceptual distortions in disorders of body image.

Bio:  Jamie Feusner, M.D. is professor of psychiatry and biobehavioral sciences at UCLA. He obtained his medical degree and completed his psychiatry residency training at UCLA. He then completed a psychopharmacology fellowship followed by a research fellowship in neuroimaging, and joined the UCLA faculty in 2006. Dr. Feusner’s research program seeks to understand phenotypes of perceptual and emotional processing across conditions involving body image and obsessions/compulsions, including body dysmorphic disorder (BDD), eating disorders, OCD, and gender dysphoria. Dr. Feusner published the first functional neuroimaging studies in BDD, and the first studies to directly compare the neurobiology of BDD to anorexia nervosa. He is currently funded by the NIH to study anorexia nervosa, BDD, and gender dysphoria. His clinical work includes Directorship of the UCLA OCD Intensive Treatment program. He teaches cognitive-behavioral therapy and pharmacotherapy, and is a research supervisor for postdoctoral fellows and students.

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

SIG meetings are open to all LACPA members.  Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org

A Viewing Guide for “To The Bone”

Ten Things I Want Viewers of To the Bone to Know

Eating Disorder Film Guide“To The Bone,” Marti Noxon’s semi-autobiographical film about her experience as a young adult living with anorexia, was released today on Netflix and has already stirred up much controversy within the eating disorder community. As a general rule, I do not see things in black and white. As with anything, I see this film in shades of grey – it handles some things well and some things poorly. Many concerns have already been aired widely in both mainstream and social media.  Foremost among these concerns is the movie’s reinforcement of the anorexia nervosa stereotype by portraying an emaciated white female and the weight loss that lead actress Lily Collins underwent to play the role. I will not rehash these here; instead, I hope to shed light on some other important issues and to provide an educational piece to accompany the film.

  1. This film may be triggering. It shows images of severe emaciation and may either be upsetting to those vulnerable to eating disorders, or inspire a competitive desire to be “as skinny”. Often, people with eating disorders don’t feel “sick enough”; anorexia nervosa can be a competitive illness. (Reports are that pro-ana sites are already using images of Lily from the film. While it’s concerning that the film adds to the available library of these sorts of images, this library is already huge – if they didn’t use this image, it would be easy to find another.) Those susceptible must exercise caution when viewing this film and if they are triggered, they should contact their treatment team or contact an organization such as the National Eating Disorders Association for help.
  2. It is difficult to make a film that accurately portrays eating disorders. To depict eating disorders on film, behaviors must be shown. Yet much of the suffering from an eating disorder is internal and harder to depict. This film is not an educational film – it is a piece of entertainment. Nevertheless, I think it does bring eating disorders into the mainstream. The film portrays some things accurately – with others it takes great liberties. Even with these departures, I do think it has virtues that can do some good. I will discuss these more below.
  3. This is one person’s story. Marti Noxon’s aim is to tell her story and she has a right to do so. She has been public that many years ago she suffered from an eating disorder and wanted to both shed light on and draw more attention to the issue. And that she has done! Based on the talkback I attended with Marti Noxon and actors Lily Collins and Alex Sharp, Marti recognizes that she can neither represent the diversity of all people with eating disorders nor speak for the range of people affected. She hopes that her work will open the door for others to tell their own stories, a hope I share. For those interested in a more diverse story about eating disorders, check out the work of Tchaiko Omwale, who is working to complete her film Solace. If you are committed to helping bring more diverse voices forward, you can contribute to help her complete her film.
  4. To The Bone accurately portrays some of the aspects of living with an eating disorder. I do not believe the film overly glamorizes anorexia. It illustrates the mindset and some of the mental anguish of someone with an eating disorder. The film displays a number of common eating disorder behaviors. We see Ellen and her peers engaging in behaviors such as calorie-counting, dietary restriction, overexercise, bingeing and purging, and chewing and spitting. Chewing and spitting is displayed in a restaurant scene in which Ellen goes out to eat with Lucas, her friend from treatment. Chewing and spitting is a lesser-known, but significant eating disorder behavior that is not commonly talked about or assessed by professionals. It is a frequently associated with more severe eating disorder symptoms and suicidal ideation. However, the behavior is more likely to occur in private than in public. It can occur in the context of anorexia nervosa as well as bulimia nervosa or other disorders.
  1. Eating disorders are serious mental illnesses and can be life-threatening. The movie shows Ellen and some of her peers needing medical attention and carefully balances showing the gravity of their situation with building hope for recovery.
  2. To the Bone paints a very Hollywood picture of recovery. While the movie adequately portrays Ellen’s ambivalence about treatment, it implies that things shift when Ellen “decides” she wants to recover. It disturbs me greatly that Dr. Beckham tells Ellen, “I’m not going to treat you if you aren’t interested in living.” Many people with anorexia nervosa have anosognosia, a symptom that causes patients to deny their illness and refuse treatment as a result. We now know that enough food, weight gain, and a cessation of eating disorder behaviors are prerequisites for recovery from anorexia nervosa. Usually some physical restoration is required before a patient can really want to recover – Dr. Ovidio Bermudez calls this a “brain rescue.”
  3. The movie does not model modern eating disorder treatment practices. But realistic treatment would probably not make a good Hollywood story. For starters, I would never suggest a therapy patient change his/her name! More seriously, in eating disorder treatment we prioritize nutritional recovery. This refers not to specific nutrients, but to the development of healthy eating habits including regular meals and adequate amounts of food. This applies to people with all eating disorders, not just anorexia nervosa. People with eating disorders need as a primary element of treatment food – balanced, sufficient, and regular eating. The movie portrays the patients in the residential treatment center as each able to choose their own food. While some patients eat some portion of the meals served, other patients eat nothing (or the one character with BED repeatedly eats only peanut butter out of the jar). I know of no treatment setting that would not have a primary focus on structured regular meals and patients having requirements for meals that can become less restrictive as they progress in treatment.
  4. I worry that the portrayal of Ellen’s family reinforces old myths about eating disorders being caused by families. To reiterate, families do not cause eating disorders. Ellen’s father is unavailable (and never even appears), her mother has had mental health problems (and is involved in a new relationship) and no one is really there for Ellen, except her stepmother who takes her to treatment and her half-sister. I do love the portrayal of the relationship between Ellen and her half-sister. I think this relationship captures the mixture of love, concern, and anger experienced by siblings.
  5. The movie misses the opportunity to depict the family as important allies in treatment. No one is really involved in Ellen’s treatment beyond the family session, and Dr. Beckham states there is no need for any future family sessions on the basis of how badly it went. None of the young people in this house have their parents involved in their treatment (at least that we see). This is very unrealistic in this day and age. Almost every treatment center involves family members to a greater or lesser degree. In reality, parents can play a central role in the treatment of adolescents and young adults, are usually included in treatment, and can even drive the treatment when their youngsters are incapable of seeking treatment on their own or have anosognosia. Parents can also help with nourishing their youngsters back to health (but not in the dramatic way it was portrayed in the film…with a baby bottle). Family-based treatment (also referred to as the Maudsley method and mentioned in passing in the scene where the moms are in the waiting room waiting for their daughters to have an intake with Dr. Beckham as something they have tried) is actually the leading treatment for adolescents and is also effective for many young adults. It focuses on empowering the family to be an important part of the treatment team and able to fight for recovery on behalf of an unwilling or unmotivated youngster and also provide meal support.
  1. Three Things I really like about the film:
    1. I love that Dr. Beckham says, “There is never one cause.” This is true.
    2. I love that it builds hope for recovery by showing Lucas as doing well and actively working on recovery.
    3. I love that it shows a male and an African-American with eating disorders.

Although I was a consultant for the film, I had no influence on the story.

In conclusion, please View the Nine Truths PSA the cast and crew of To the Bone produced for World Eating Disorders Action Day. While aspects of the film veer far from reality, the filmmakers are committed to the cause and, to support eating disorder education, they made this PSA which aligns with the best current evidence on eating disorders. Most of the messages I would want viewers of the film to come away with would be covered in this fabulous video. You can also read the Nine Truths About Eating Disorders:

Truth #1: Many people with eating disorders look healthy, yet may be extremely ill.

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

Truth #3: An eating disorder diagnosis is a health crisis that disrupts personal and family functioning.

Truth #4: Eating disorders are not choices, but serious biologically influenced illnesses.

Truth #5: Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses.

Truth #6: Eating disorders carry an increased risk for both suicide and medical complications.

Truth #7: Genes and environment play important roles in the development of eating disorders.

Truth #8: Genes alone do not predict who will develop eating disorders.

Truth #9: Full recovery from an eating disorder is possible. Early detection and intervention are important.

Produced in collaboration with Dr. Cynthia Bulik, PhD, FAED, who serves as distinguished Professor of Eating Disorders in the School of Medicine at the University of North Carolina at Chapel Hill and Professor of Medical Epidemiology and Biostatistics at the Karolinska Institutet in Stockholm, Sweden. “Nine Truths” is based on Dr. Bulik’s 2014 “9 Eating Disorders Myths Busted” talk at the National Institute of Mental Health Alliance for Research Progress meeting.

2017 Spring LACPA Eating Disorder SIG Open (to non-LACPA members) events

Michael Levine, Ph.D., FAED Date: Tuesday, March 7 at 7:30 pm.

Title: Thinking Critically and Cautiously About the Phrase “Eating Disorders Are Biologically-Based Mental Illnesses

Presenter:  Michael Levine, Ph.D., FAED

Description: It has become a foundational “truth” among many clinicians, researchers, patients, family members, and advocates that, in accordance with the 2009 position statement of the Academy for Eating Disorders (AED), eating disorders are “biologically-based mental illnesses.” In fact, number 4 of the AED’s “Nine Truths about Eating Disorders” is “Eating disorders are not choices, but serious biologically influenced illnesses.”

Dr. Michael Levine has for many years studied sociocultural factors and their relationship to the prevention of eating disorders and disordered eating. In this talk, Levine offers a critical evaluation of this contention, in so far as one meaning of “critical” is “exercising or involving careful judgment or judicious evaluation” (Mirriam-Webster On-Line Dictionary; www.m-w.com).

Levine begins by addressing important general concepts, such as “illness” and “biologically-based,” as well as “scientific,” “evidence-based,” and “risk factor.” This sets the stage for a description of the Biopsychiatric/Neuroscientific paradigm in the eating disorders field. He will then consider the evidence for “biological causes” in the development of eating disorders, and its implications for two important challenges in the field: prevention and talking with patients, families, and the media. Throughout his presentation, Levine will compare and contrast the Biopsychiatric/Neuroscientific paradigm with the Sociocultural paradigm. Thus, his concluding remarks will consider what if anything is gained (and/or lost) by applying phrases such as “biopsychosocial” and “gene-environment interactions.”

Bio: Michael P. Levine, Ph.D., is Emeritus Professor of Psychology at Kenyon College in Gambier, Ohio, where he taught 33 years (1979-2012). In the field of eating disorders, his commitment to research, writing, and activism focuses on the intersection between sociocultural risk factors, prevention, community psychology, and developmental psychology. He has authored two books and three prevention curriculum guides, and he has co-edited three books on prevention. In August 2015, as co-editor with his long-time collaborator and colleague Dr. Linda Smolak, he published a two-volume Handbook of Eating Disorders (Wiley & Sons Publishing). He and Dr. Smolak are currently working on a second, updated edition of their 2006 book The Prevention of Eating Problems and Eating Disorders (Erlbaum/Routledge/Taylor & Francis). In addition, he has authored or co-authored approximately 110 articles and book chapters, and he has presented his work throughout the United States, as well as in Canada, England, Spain, Austria, and Australia. He is a member of the advisory councils of The National Eating Disorders Association (NEDA), the Center for Study of Anorexia and Bulimia (CSAB, NY), the Center for Balanced Living (CBL, Columbus, Ohio) and Monte Nido & Affiliates—Eating Disorder Treatment Centers.

Dr. Levine is a Fellow of the Academy for Eating Disorders (AED), which has awarded him their Meehan-Hartley Award for Leadership in Public Awareness and Advocacy (2006), and their Research-Practice Partnership Award (2008). Dr. Levine is also a member of the Founders Council of the National Eating Disorders Association, which awarded him the Lori Irving Award for Excellence in Eating Disorders Prevention and Awareness (2004) and the Nielsen Award for Lifetime Achievement (2013). After living for 37 years in Mount Vernon, OH, with his wife, Dr. Mary A. Suydam, a retired (as of May 2015) Kenyon religious studies and women and gender studies professor, they moved to California in late June 2016, to live near UC Santa Barbara, where they both obtained all their degrees.

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.  Non-members wishing to attend may join LACPA by visiting our website www.lapsych.org


Date: Thursday, April 20 at 7:30 pm.

Title: Medical Complications of Eating Disorders

Presenter:  Margherita Mascolo, MD, ACUTE Medical Director

Description:  Dr. Mascolo is the medical director of ACUTE. She will discuss the medical complications of severe restricting as well as purging. The presentation will include a broad review of the pathophysiology of starvation as well as the organ systems affected. There will be case-based discussion and presentation based on real patients seen on the ACUTE unit. Target audience is mental health professionals, dietitians, and allied professionals who need a broad understanding of the medical complications of restricting and purging.

Bio: Dr. Mascolo is the Medical Director at the ACUTE Center for Eating Disorders at Denver Health, where she has been a member of the ACUTE team since its beginning in 2008. She has trained under Dr. Philip S. Mehler for the past 8 years to become one of the country’s leading experts in the medical care of patients with severe eating disorders and served as Associate Medical Director under Dr. Jennifer Gaudiani for the past 3 years.

Dr. Mascolo completed her undergraduate work at the University of St. Thomas in Houston, Texas and earned her medical degree at the University of Texas Health Sciences Center. She completed her residency in Internal Medicine at the University of Colorado in Denver. She is board certified in Internal Medicine, is an Associate Professor in the Department of Medicine at the University of Colorado. Dr. Mascolo has published multiple peer-reviewed articles on the medical complications of eating disorders and is currently working to complete her Certified Eating Disorder Specialist certification.

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.  Non-members wishing to attend may join LACPA by visiting our website www.lapsych.org