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

April and May 2016 LACPA Eating Disorder SIG events

Please join us:  

Wednesday, April 20 at 7:30 PM

During April all LACPA Special Interest Groups (SIGs) and Clubs are available to non-members as a way of introducing them to some of the many FREE benefits of LACPA membership.

Presenter:  Lyn Goldring, RN, Director of Nursing, Monte Nido and Affiliates

Title:  Medical Complications in Eating Disorder Treatment

Description:  Eating disorders affect every system of the body. The physical consequences of severe food behaviors often go unseen because the body is highly adaptive. Developing an adequate “medical tool kit”allows clinicians and health care providers know what questions to ask and what physical test should be done to evaluate the severity of the Eating Disorder. With wisdom and humor, Lyn gives practical advice on understanding and addressing medical issues in a non-medical setting.

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

Bio:  Lyn practiced her nursing skills all over the world before finding her way to Monte Nido. Withconsistent compassion she helped to create our current nursing program, managing the well being of our clients’ and a team of nurses at both houses. Lyn’s wisdom and British wit are an essential element of our program, while clients find a safe haven in her kindness.

RSVP to:  drmuhlheim@gmail.com

In an effort to reach out to our community, LACPA is opening up SIGs to nonmembers for a limited time only. Take advantage of this opportunity and encourage your colleagues to attend a SIG during APRIL to experience one of the many benefits of being a LACPA member. In accordance with current policy, non-members will NOT be allowed to attend SIGs during any other months of the year.

Tuesday, May 10 at 7:30 PM

Presenter:  A. Janet Tomiyama, Ph.D., Assistant Professor,Department of Psychology, UCLA, Director, UCLA Dieting, Stress, and Health Laboratory www.dishlab.org

Title:  Dieting, stress, and weight stigma

Description:  Does dieting work to promote long-term weight loss and health? This talk will discuss evidence suggesting the answer is no, and will cover the potential negative consequences of dieting, including stress. Further research on stress and its effects on comfort eating will be presented, as well as novel research on weight stigma and its negative effects on eating, stress, and long-term weight gain.

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

Bio:  A. Janet Tomiyama, Ph.D., is an Assistant Professor in the Department of Psychology at the University of California, Los Angeles. She received her B.A. in Psychology in 2001 from Cornell University, and her M.A. and Ph.D. in Social Psychology with concentrations in Health and Quantitative Psychology in 2009 from the University of California, Los Angeles. In 2011, she completed a Robert Wood Johnson Health and Society Scholar Fellowship jointly at the University of California, Berkeley and the University of California, San Francisco. Her research centers around eating, dieting, stress, and weight stigma.  She is one of the leading researchers demonstrating the flaws of BMI as an indicator of health. http://www.nature.com/ijo/journal/vaop/ncurrent/abs/ijo201617a.html

RSVP to:   drmuhlheim@gmail.com

May event is only open to LACPA members.

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!  

OCD and Eating Disorders – LACPA ED SIG Event – March 2016

It’s the time of year when the Los Angeles County Psychological Association SIG events are open to nonmenbers.  So, come try it out.  Details on our next event are as follows:

Thursday, March 3 at 7:30 PM

Presenter: Kimberley Quinlan, LMFT

Title: When OCD and Eating Disorders Collide: Assessment and Treatment Planning for OCD and co-existing Eating Disorders 

Description: Managing Obsessive Compulsive Disorder and a co-existing eating disorder can be quite difficult and require significant attention and prioritizing. A very important goal is to ensure that improvements in the symptomology in one disorder are not due to an increase in compulsivity in another co-existing disorder.

During this presentation, Kimberley will discuss at length how to identify and assess for Obsessive Compulsive Disorder symptoms and how to then prioritize treatment goals and tools in these cases. Participants will learn how to manage clinical time with clients, specifically when their eating disorder has become a part of their OCD compulsions.

Attendees will learn important differentiations between general OCD, OCD food-related obsessions (including Symmetry obsessions and Orthorexia) and Eating Disorder obsessions.   Attendees will learn how to prioritize treatment goals and planning (specifically targeting the use Exposure and Response Prevention and other evidence based treatment tools) when managing OCD and co-existing Eating Disorders. Attendees will also be offered a Q&A for general questions.

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

Bio:

KIMBERLEY QUINLAN is a licensed Marriage and Family Therapist in the State of California. During her training and education, Kimberley dedicated much of her research to the study of Cognitive Behavioral Therapy (CBT) for the treatment of Anxiety Disorders and Eating Disorders.

Kimberley did her internship at the OCD Center of Los Angeles and went on to become the Clinical Director of the OCD Center of Los Angeles. Kimberley currently has a private practice in Calabasas, California. Kimberley provides weekly outpatient, intensive outpatient services, in addition to 2-day Mindfulness Workshops, for those with OCD, Body Focused Repetitive Behaviors’s and other OCD spectrum disorders.

Kimberley has been featured in many world known media outlets, such as LA Times, Wall Street Journal, KCRW public radio, and the Seattle Times, discussing co-existing OCD and eating disorders. Kimberley has also consulted on various mental health issues with programs such as ABC’s 20/20 and Telemundo.

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

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.”