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

Who Gets Treated for Eating Disorders in Los Angeles?

low cost eating disorder treatment Los Angeles County This NEDAwareness week, I’ve been thinking a lot about the theme of “Let’s Get Real.” One stubborn myth about eating disorders is that they affect primarily white, upper-middle-class females.

It would take you just one afternoon at my own Los Angeles practice to discover how untrue this is. My clients are all genders, ages, and ethnicities. I accept some private insurance and one public insurance. Among my patients with eating disorders are non-native English speakers, immigrants from low SES backgrounds, and people on public assistance.

The myth that eating disorders affect only the wealthy not only makes it more difficult for patients who don’t meet the stereotype to recognize that they have a problem but affects the entire system of treatment.

Throughout the US, there is a shortage of publicly funded specialized treatment programs for eating disorders. And specialized eating disorder treatment is expensive! The residential treatment complex only serves the economically privileged.

Carolyn Becker, Ph.D. recently brought attention to the presence of eating disorders in food insecure populations. The research on which she collaborated studied adults receiving food at San Antonio area food banks. Those who had hungry children in their households (representing higher levels of food insecurity) had higher levels of binge eating, dietary restraint, weight self-stigma, worry, and overall ED pathology when compared to participants with lower levels of food insecurity

Within Los Angeles County, eating disorders are a covered diagnosis by the Department of Mental Health (DMH). However, according to a DMH district chief, there are no specialized services for eating disorders within the DMH system. I recently led a training on eating disorders at one of the county community mental health centers and a staff member there told me, “Most patients with eating disorders are seen in primary care and none of us are trained specifically in this… What we need is training in evidence-based treatment.”

A clinical staff member at another DMH clinic said, “Honestly, we don’t have a lot of access to resources for people with eating disorders and aren’t equipped to adequately handle serious cases at this clinic. Referrals have always been difficult and there are no reliable referral sources for our patient population. We have really only been able to connect a few of our most severe cases to any treatment at all.”

I searched the Alliance for Eating Disorder Awareness list of Medicare/Medicaid providers and facilities within 50 miles of Los Angeles and came up with only one Medicare provider and no Medicaid providers or facilities.

This blog post was inspired because as a provider for Anthem Medi-Cal, I am receiving calls from county clinics with referrals of other (non-Anthem) Medi-Cal patients with eating disorders that I can’t see. So, when faced with a patient with an eating disorder and no insurance in LA County, what’s a provider to do?  Here’s what I’ve been able to find. If you have other resources, I’d love to hear about them!

Resources

Hospitals

CHLA takes California Medicaid for patients under age 25 needing medical stabilization.

UCLA takes California Medicaid for patients under age 25 needing hospitalization for eating disorders.

General low-fee counseling centers

Southern California Counseling Center

Maple Counseling Center

The Wright Institute

Cal Lutheran Low Fee Counseling Center

Treatment Scholarships

Center for Discovery and Project Heal provide treatment scholarships.

Source

Becker, Carolyn Black, Keesha Middlemass, Brigitte Taylor, Clara Johnson, and Francesca Gomez. 2017. “Food Insecurity and Eating Disorder Pathology.” International Journal of Eating Disorders 50 (9): 1031–40. https://doi.org/10.1002/eat.22735.

 

Thanks to Rosewood Center Santa Monica for help with the referral list.

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.

A More Diverse Eating Disorder Film

Eating Disorder film Tchaiko Omawale
with Tchaiko

In the wake of the premiere on Netflix of another eating disorder film, my friend, JD Ouellette, reminded me that the frustration over another stereotypical narrative about eating disorders could provide an opportunity. At the NEDA Conference in 2014, both JD and I (as well as many other attendees) were impressed by Tchaiko Omawale’s sharing of her inspiring story of recovery on the Friends and Family Panel. Later, we learned about her work (writing, directing, and producing) on Solace, a coming of age feature film inspired by Tchaiko’s journey with an eating disorder and self-harm. In April, I had the opportunity to attend a fundraiser for Solace and preview a scene. I spoke about the need for more films, stories, and images of people from diverse backgrounds with eating disorders, reading some parts of this article.

Eating Disorder film presentation
Speaking at the fundraiser

As summarized in Truth #5 of the collaborative consensus document, the Nine Truths, “Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses.” When I work with people of diverse backgrounds, they consistently tell me they are frustrated that mainstream eating disorder narratives do not portray people who resemble them. Not only the popular media — television, film, print articles, online publications — but even the marketing materials of many eating disorder treatment centers continue to depict eating disorder sufferers mostly as the common stereotype: female, white, and thin.

To those interested in supporting a film that doesn’t reinforce stereotypes, Tchaiko Omawale has made such a film. She needs additional funding to complete the film, which is in post-production. Visit Solace Film page to learn more and, if you are so inclined, join me in supporting this important project. She has a donation page.

Eating Disorder film Tchaiko Omawale and cast
Tchaiko speaking with cast members on her right

Winter 2017 LACPA Eating Disorders SIG Events

Glenys Oyston, RDN1.  Date: Thursday, January 26 at 7:30 pm

Speaker: Glenys Oyston, RDN

Title: The Dangers of Dieting

Description: Dieting for weight loss is a cultural norm – everyone does it, has tried it, or has been told to do it at one time or another. But is dieting for weight loss truly beneficial, or is it causing more harm than good? Registered Dietitian Glenys Oyston, discusses how intentional weight loss efforts are actually harmful to the physical, social and psychological well-being of people who engage in them, and what to do about it.

Bio: Glenys Oyston is a registered dietitian, size acceptance activist, eating coach, and blogger who runs Dare To Not Diet, a coaching business for long-timer dieters and weight cyclers who want to break free of food restriction and body dissatisfaction. She coaches people online or by phone through one-on-one and group coaching programs. She is based on Los Angeles, CA. You can find her at www.daretonotdiet.com.

Glenys Oyston, RDN

Dare To Not Diet

Dietitians Unplugged Podcast

@glenysoRD on twitter

Facebook

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

 

abby22. February 10 at 11 am – LACPA Office (in conjunction with Sport and Performance Psychology SIG)

The LACPA Sport & Performance and Eating Disorders SIGs are pleased to announce our jointly held meeting for February, 2017:

Date: Friday, February 10, 2017

Time: 11:00 AM – 12:30 PM

Location: the LACPA Office, Encino

6345 Balboa Blvd. Building 2, Suite 126

Topic: When an Athlete Gets an Eating Disorder

Speaker: Abby McCrea, LMFT

More about our topic and speaker:

Clinical eating disorders cause significant problems for more than 40% of athletes. Subsequently, the subtleties between “good athlete” and “eating disorder” mindsets can become particularly tricky to discern after the onset of an eating disorder. Knowing the risks, possible causes, and how to support athletes with eating problems is essential for developing and sustaining athletic wellbeing. 

This talk is designed to help you:

  1. Explain how and why athletes get eating problems
  2. Recognize the subtle differences between a “good athlete” and an “eating  disorder” mindset
  3. Create ways to support athletes with eating problems

Abby McCrea is a Licensed Marriage and Family Therapist who has a private practice in Sierra Madre, CA. She graduated from Fuller Theological Seminary with a Master’s of Science degree and a clinical focus on the integration between psychology and spirituality. 

With over 13 years of experience in a variety of mental health settings including inner city gang rehab community programs, college counseling centers, and eating disorder residential centers, she brings a depth of understanding, experience, respect, and compassion to her work. In her private practice she specializes and works to empower teens, adults, and families that recovery from an eating disorder is possible.  Additionally, she is passionate about developing research and treatment for athletes with eating problems, and helps clients, families, and coaches in her practice to navigate and manage the delicate balance between life, sport, and recovery.

 Abby speaks nationally on the topics of eating disorders and athletes, eating disorder education, deconstructing social ideals of body image, spirituality and the rituals of eating problems, and identity development among teenagers in life transitions.

Please RSVP and/or direct any questions to Sari Shepphird at drshepp@msn.com

LACPA SIG Meetings are a LACPA member benefit and are open to all LACPA Members. For more information about LACPA Membership, SIG’s and other events, visit the LACPA events calendar: www.lapsych.org

Parking Information:

The LACPA office address is THE ENCINO OFFICE PARK, 6345 Balboa Blvd, Building 2, Suite 126, Encino, CA 91316 – second building from Balboa Blvd., conveniently located near ample free daytime/weekday street parking on Balboa Blvd, south of Victory Blvd.  Both sides of Balboa have all day free parking.  There is also plenty of free parking at the Sepulveda Basin Sports Complex on the west side of Balboa, south of Victory, 6201 Balboa Blvd. (2nd driveway past the Busway). 2-3 minute walk to the office door.  Wherever you park, please check the signs. 

Parking at The Encino Office Park lot between the hours of 9 a.m. – 6:30 p.m. is restricted to building tenants only.  Do not park in the lot at the building. 

 

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

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

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

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

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

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

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

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

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

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

Lauren and Katie’s college readiness checklist:

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

How to prepare a young adult for college

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

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

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

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

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

Presentation at NEDA 2015 conference

Lauren and Katie presenting NEDA 2015

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

Here are some of the key points of our talk:

Interested in Weight Loss? We CAN’T Help You. Here’s Why

Learn more about the non-diet approach at Eating Disorder Therapy LA - Health at Every Size (HAES)
Yale Rudd Center for Food Policy & Obesity

Learn More About Our Non-Diet Approach

At Eating Disorder Therapy LA, we treat eating disorders (including Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, and Other Specified Feeding and Eating Disorder or OSFED) across the weight spectrum. We often get inquiries from clients interested in help for binge eating or emotional eating, with their primary goal being to lose weight.

We always tell them that while we believe we can help them with their disordered eating, if weight loss is their real goal, we cannot help them. By contrast, we are willing to help with, and in fact are rather insistent upon, weight gain for our patients who are below their body’s healthy weight.

Many prospective clients seeking help with weight loss have completed a diet regimen (or often, in their minds, “failed” one) and are suffering from binge eating. They want to eliminate the binge eating and concurrently lose weight. While we are expert at helping clients to stop binge eating and learn to regulate eating, we will not consent to “help someone” lose weight.

Here’s why:

  1. We don’t think anyone really has the answer to help someone lose weight. The research shows that diets don’t work. We are not so grandiose as to believe that We are any different.

    • Traci Mann’s 2007 review of 31 weight loss studies showed that on average, 41% of dieters regained even more weight than they lost on the diet. In an interview about the study, Dr. Mann said, “You can initially lose 5 to 10 percent of your weight on any number of diets, but then the weight comes back. We found that the majority of people regained all the weight, plus more. Sustained weight loss was found only in a small minority of participants, while complete weight regain was found in the majority. Diets do not lead to sustained weight loss or health benefits for the majority of people.”
    • Harriet Brown, the author of Body Of Truth – a detailed analysis of the war on obesity and the diet industry – wrote in an article about the book, “In reality, 97 percent of dieters regain everything they lost and then some within three years. Obesity research fails to reflect this truth because it rarely follows people for more than 18 months. This makes most weight-loss studies disingenuous at best and downright deceptive at worst.”
  2. Dieting and weight suppression may be the major drivers of binge eating and ironically, can cause weight gain.

    • Research on “weight suppression,” which is the difference between someone’s current weight and their highest adult weight, shows it is linked to both anorexia and bulimia. Drexel University psychologist Dr. Michael Lowe, Ph.D. is one of the leading researchers on weight suppression. His research shows that the greater the weight suppression, the more severe and difficult to treat was the eating disorder. His research also shows that the more weight-suppressed a person is, the more likely they are to regain weight in the future. To me, this suggests that some bodies are naturally larger and will resist all attempts to reduce in size. Attempting to fight the body’s predestined weight may contribute to binge eating behaviors and even higher future weights.
    • Evelyn Tribole, coauthor of Intuitive Eating in a review of dieting wrote: “Dieting increases your chances of gaining even more weight in the future, not to mention increase your risk of eating disorders, and body dissatisfaction. “
  3. Weight cycling – the repeated cycle of losses from dieting followed by the usual weight gains after going off the diet – creates its own health issues, in particular, additional stress on the cardiovascular system.

  4. Weight loss can trigger both anorexia and bulimia. Research from the Mayo clinic shows that 35% of the young people who visited the clinic with anorexia started out in the “obese” or “overweight” weight range.

  5. Dieting is incompatible with Cognitive Behavioral Therapy (CBT), the treatment we provide for adult eating disorders.

    While CBT is very effective for eliminating binge eating, it relies on a non-restrictive approach to eating. The goal of CBT is to disrupt the diet-binge cycle through a pattern of regular eating and relaxation of dietary rules. Patients are encouraged to end restrictive dieting and behaviorally challenge dietary rules through behavioral experiments and exposure to forbidden foods as part of treatment.

  6. Counterintuitively, when overweight binge eaters successfully complete CBT treatment for binge eating, they do not lose appreciable amounts of weight.

    Even adding a behavioral weight loss program following completion of CBT for binge eating does not lead to additional significant weight loss. However, it is possible that long-term abstinence from binge eating may prevent future weight gain especially as compared to untreated binge eaters.

Our first responsibility as practitioners is to do no harm. Even if weight loss is a client’s stated goal for treatment, and even if their doctor is advising it, we fear that “helping” someone to diet may increase their binge eating and disordered eating. This may in turn cause greater weight gain or weight cycling – a far worse alternative than remaining at the current weight.

Here is how EDTLA can still help in the absence of weight loss:

  • We provide CBT-E for bulimia, binge eating disorder and subclinical disordered eating. I trained with one of the original developers of cognitive behavioral therapy for eating disorders. Clinical trials show 65.5% of CBT-E participants meet criteria for remission from their eating disorder. Relief from cycles of binge eating usually leads to benefits such as freedom from obsessing about food, greater productivity, decreased anxiety about food decisions, and improved self-esteem. Commonly, patients experience decreased guilt and shame around eating and food. Relationships improve as clients become more able to fully participate in meals with loved ones and friends. It also commonly leads to the expansion of other enjoyable areas of one’s life outside of dieting and body image.
  • We work with clients on challenging weight stigma (both their own internalized and in the larger community). We also work on improving body image.
  • My associates and I follow a Health at Every Size® approach. At Eating Disorder Therapy LA, we recognize and celebrate that bodies come in all shapes and sizes. We focus on creating and maintaining healthy behaviors including flexible eating and enjoyable exercise.

Many clients arrive in therapy feeling that they cannot feel better unless they lose weight. However, the majority of those who go through a full course of treatment make significant improvements in their eating behaviors and are surprised at how much better they are able to feel even without weight loss.

Suggested Reading and Viewing:

Bacon, Linda, Health at Every Size

Brown, Harriet, Body of Truth

Mann, Traci, Secrets from the Eating Lab

Saguay, Abigail, What’s Wrong with Fat

The Problem with Poodle Science (video by the Association of Size Diversity and Health)

Why Dieting Doesn’t Usually Work (TED talk by Sandra Aamodt)

Warning Dieting Causes Weight GAIN (video by Evelyn Tribole MS RD)

Why do dieters regain weight?

Additional References:

Berner, L.A., Shaw, J.A., Witt, A.A. & Lowe, M.R. (2013). Weight suppression and body mass index in the prediction of symptomatology and treatment response in anorexia nervosa. Journal of Abnormal Psychology, 122, 694–708.

Mann, T., Tomiyama, A., Westling, E., Lew, A., Samuels, B., Chatman, J. (2007). Medicare’s search for effective obesity treatments: diets are not the answer. American Psychologist, 62(3):220-33.

Lebow, J., Sim., L., and Kransdorf, L. (2015). Prevalence of a History of Overweight and Obesity in Adolescents With Restrictive Eating Disorders. Journal of Adolescent Health 56, 19-24.

Additional HAES articles

Various articles that are found on the ASDAH website:

“Attitudes Toward Disordered Eating and Weight: Important Considerations for Therapists and Health Professionals”, Matz, J & Frankel, E

“Obesity and Anorexia: How Can They Coexist?”, Bulik, C. and Perrin, E.

“Obesity, Disordered Eating, and Eating Disorders in a Longitudinal Study of Adolescents: How Do Dieters Fare 5 Years Later?”, Neumark-Sztainer, Dianne, et. al

“Shared Risk and Protective Factors for Overweight and Disordered Eating in Adolescents”, Neumark-Sztainer, D., et al

“Multiple Disadvantaged Statuses and Health: The Role of Multiple Forms of Discrimination”, Grollman, E.A.

“The Problem with the Phrase Women and Minorities: Intersectionality–an Important Theoretical Framework for Public Health”, Bowleg, L.

Children/Teens

“Dieting and Unhealthy Weight Control Behaviors During Adolescence: Associations With 10-Year Changes in Body Mass Index”, Neumark-Sztainer, D., Wall, M., Story, M., Standish, A.

“Helping Without Harming – Kids, Eating, Weight and Health”, Robison, Jon; Cool, Carmen; Jackson, Elizabeth and Satter, Ellyn

“Overweight and Obese Children Eat Less Than Their Healthy Weight Peers”, Hoyle, Brian

“Weight Status as a Predictor of Being Bullied in Third Through Sixth Grades”, Lumeng, J.C., Forrest, P., Appugliese, D.P., Kaciroti, N., Corwyn, R.F., and Bradley, R.H.

The Hidden Benefits of Full Fat Dairy by Katie Grubiak, RD

Galbani Whole Milk Mozzarella Cheese
full fat dairy
Galbani Whole Milk Ricotta Cheese
Greek Gods’ Greek Yogurt

History of the Low-Fat Movement

Since the 1980s, physicians, the federal government, the food industry, and popular media have championed the low-fat approach to dieting and weight control. The idea stemmed from a few studies published in the 1940s, which showed a correlation between high-fat diets and high-cholesterol levels. Because high-cholesterol levels were known to be a major risk factor for heart disease, low-fat diets were highly recommended as a preventive measure for at-risk individuals, and eventually for the entire nation. This advice became so widespread by the 1980s that reduced-fat and low-fat options dominated the diet-related product market.

The Argument for Low-Fat Dairy

Although this national preoccupation with low-fat products has waned since the 1990s, low-fat dairy products have sustained their popularity. Low-fat dairy products are lower in calories and saturated fat than their full-fat counterparts, while still boasting substantial amounts of protein and calcium. To experts worried about slowing the impending “obesity epidemic”, low-fat dairy at first seems an obvious choice – especially if choosing low-fat products can help prevent heart disease.

The Issue with the Low-Fat Dairy Argument

There’s just one problem with this logic – according to a review article recently published in the European Journal of Nutrition, there is no conclusive evidence to suggest that full-fat dairy consumption is associated with increased risk of obesity, heart disease, or diabetes. In fact, in 11 of the 16 studies reviewed, high-fat dairy intake was inversely associated with obesity risk. In a 12-year longitudinal study conducted in Sweden, researchers Dr. Sara Holmberg and Dr. Andres Thelin found that men who reported a low intake of dairy fat (skim milk, no butter, etc.) had a higher risk of developing obesity in the 12-year period than were men who reported a high intake of dairy fat.

Why Whole Dairy?

Much of this research may come as a surprise to those familiar with the calories-in, calories-out model of weight maintenance. How could eating dairy products that are significantly higher in calories help people avoid weight gain?

Researchers aren’t certain why full-fat dairy may aid in healthy weight maintenance, but there are a few ideas gaining traction in the field: 

  • Fullness 
    • To produce low-fat dairy products, “excess milk fat” is separated out of whole dairy. Much of this “excess milk fat” is made up of fatty acids found in milk, which are thought to make people feel full sooner and stay full longer. Thus, low-fat dairy products simply don’t keep you as full as whole dairy products do.
    • The fatty acids in whole milk also make whole dairy products richer, thicker, and more satisfying, which can add to the experience of fullness, and keep you full for longer.
  • Role in Gene Expression & Hormone Regulation.
    • The fatty acids found in whole milk may be involved with gene expression and hormone regulation in the body. Though these relationships are unclear, it is possible that fatty acids speed up metabolism or limit the body’s storage of fat.
  • Real Food, Not Just Nutrients.
    • Though macronutrient content can tell us a lot about the health benefits of food, whole fat dairy is more than just the sum of its (major) parts. Real food is a complex mix of macro (fat, carbohydrates, protein) and micro (vitamins and minerals) nutrients. Absorption of all of these macro and micronutrients is dependent upon several factors, so altering the macronutrient breakdown of dairy products (by removing fat) changes the way these products are metabolized by the body.For instance, Vitamins A, D, E, and K are fat soluble nutrients, which means that absorption of these nutrients is compromised when no fat is present.

When I have helped my clients with eating disorders to add full fat diary products back into their diet after a period of having avoided them, positive changes take place.  They often notice a decrease in food obsession and a reduction in volume of intake. Although most clients fear overeating whole full fat (and higher calorie) products, this does NOT happen. Instead, portion control often occurs more naturally since satiety comes from the taste, texture, & actual full fat macronutrient presence.  Clients recognize that they CAN feel in control but still go to their favorite real full fat foods which they previously feared and avoided. In reality, the low fat foods were the ones that they could not limit.   I have only seen satiety benefits as well as metabolic benefits of a diet higher in fat, 30-35% of total calories. To try it for yourself, I suggest:

Some recipes incorporating whole fats

  • *Maple Hill Creamery 100% Grass-Fed Organic Milk Creamline Yogurt-Lemon flavored with granola & banana for breakfast
  • *The Greek Gods Greek Yogurt-Honey Strawberry flavored with cut up pear for a snack
  • *Toasted Caprese Open Faced Sandwich-
    • French Sandwich Roll-cut in half
    • Expeller Pressed Extra Virgin Olive Oil
    • Fresh Basil Leaves
    • Heirloom Tomatoes Sliced
    • Galbani Fresh Whole Milk Mozzarella or Galbani Whole Milk Low-Moisture Mozzarella Cheese

    • Pink Himalayan Salt

  1. Drizzle the olive oil over each half of the sliced French roll
  2. Place sliced Whole Milk Mozzarella Cheese over the French roll with olive oil
  3. Lay Basil Leaves on top of the Mozzarella
  4. Lay sliced Heirloom Tomatoes over the Basil
  5. Grind & sprinkle Pink Himalayan Salt over the Tomatoes
  6. Opened faced-Toast in toaster oven for 3-5 minutes or heat in oven 350 degrees F for 5-8 minutes

Sources:

  • The full article from European Journal of Nutrition can be found here.
  • The full article from the Scandinavian Journal of Primary Health Care can be found here.
  • For a through and clear explanation of this topic, refer to this TIME Magazine article.
  • An additional study in the American Journal of Clinical Nutrition can be found here and is summarized here.
  • Another article is here.

Research Assistant, Erin Standen contributed to the writing and research of this post.