Categories
Nutritional counseling

The Milky Way: Why We Encourage Inclusion of Dairy in Eating Disorder Recovery

Dairy Eating Disorder Recoveryby Shelly Bar, MD, Katie Grubiak, RDN, and Lauren Muhlheim, Psy.D.

Dairy is tasty and good for you. Despite this, there are a lot of folks who are scared of it. You may have eliminated dairy from your diet in pursuit of better health or better digestion. You may have heard that the elimination of dairy would help with weight loss. You may have experienced gastrointestinal distress following the consumption of dairy products, concluded that you are lactose-intolerant, and decided you should therefore avoid dairy-rich foods like ice cream and pizza. However, did you know that—especially if you have an eating disorder or disordered eating —this might not be necessary and might actually make things worse?

In this article, we will discuss the many dietary benefits of dairy. We will also explain lactose intolerance and various interventions to address it so that dairy can remain a part of your diet.

Why Dairy is Important

Dairy, in both solid and liquid forms, is an excellent source of macro and micronutrients. Besides providing a balanced synergy of protein, carbohydrates, and—when it has not been removed from the product—fat, dairy provides a significant source of vitamins and minerals, including electrolytes. Milk is a significant source of calcium (300 mg per cup), potassium, magnesium, phosphorus, iodine, zinc, and B vitamins. Vitamin A and D are usually added to milk during processing, making it a good source of these nutrients as well.

Calcium is a crucial mineral for all teens and all people with eating disorders due to the risk of bone loss. Four glasses of milk a day provide approximately 1200 mg of calcium, meeting the daily needs of most teens and adults. Other dairy sources—such as cheese—can have the calcium equivalency of a glass of milk. Therefore, consuming four calcium-rich food or beverage sources daily can prevent the need for calcium supplementation.

The Advantage of Dairy Milks

The U. S. Food and Drug Administration (FDA) requires standardization of products labeled as cow’s milk. This means the macro and micronutrient composition in one cup of milk must remain the same across all manufacturers.  The only variation allowed is the percentage of fat—skim/non-fat, 1%, 2%, or whole—which can in turn alter the amount of fat-soluble Vitamins A and D that are added. Thus, you can be guaranteed to know exactly what specific amount of each nutrient you are getting consistently by drinking a glass of milk.

By contrast, standardization is not required for non-dairy milks, so their nutritional content can vary widely. Each manufacturer can determine the formulation of their beverage and the amount of macro and micro-nutrients it provides. On the whole, they provide fewer nutrients than cow’s milk. Some people might even make non-dairy milks at home. These would almost certainly be deficient in nutrients compared to cow’s milk.

Bioavailability—the body’s ability to utilize a nutrient—is another concern.  Bioavailability depends not only on the specific form a nutrient takes in a food, but on the other nutrients alongside which it is absorbed. In cow’s milk, calcium appears as calcium phosphate, which on its own is 30% bioavailable. Cow’s milk also contains optimal amounts of Vitamin D, phosphorus, magnesium, and zinc, synergistically enhancing this availability. Non-dairy milks may not contain adequate calcium in a form or nutrient combination for the body to easily access it. Some manufacturers are adding these nutrients in an attempt to market the beverage as promoting bone health. If the manufacturers of non-dairy milks are trying to model their products after cow’s milk, one must ask the question: why not drink the real thing?

Other factors that make cow’s milk superior to non-dairy milks:

  • Protein: Nutritional recommendations encourage adequate protein intake. Cow’s milk contains significantly more proten that most non-dairy milks, with the exception of soy milk. Some manufacturers of non-dairy milk are seeking ways to boost their protein content in response to consumer demand.
  • Carbohydrates: It is recommended that a majority of one’s total daily calories come from carbohydrates. Cow’s milk has carbohydrates sourced from naturally-occurring lactose. Non-dairy milks have varying amounts and sources of carbohydrates. Since manufacturers often market to “health-conscious” consumers—from our perspective, unnecessarily concerned about sugar—carbohydrate amounts in these products are often much lower. The naturally occurring carbohydrates in cow’s milk, in combination with protein and fat, assist in moderating blood sugar and replacing glycogen stores in muscle. Have you ever heard of refueling after a workout with chocolate cow’s milk? We cannot rely on non-dairy milks to offer the same synergy.
  • Fat: Fat is an essential part of one’s daily intake. Whole –or 2%–cow’s milk contains vital fat. This provides an optimal amount of essential fatty acids as well as satiety. The non-dairy milk manufacturers, marketing to the “health-conscious” consumer provide lower-fat products which are less optimal for health and satiety.

Why Are So Many People Scared of Milk?

Diet culture—as well as the clever branding of alternative milk products—appears to have increased fear of dairy products. Many people succumb to the belief that dairy is somehow harmful. They may be afraid of the fat in milk products. It may be that people who are looking for a reason to justify dairy avoidance will pin the blame on lactose intolerance. It has become trendy to seek out non-dairy milk alternatives and this is often veiled under the belief that lactose is bad for health.

In this context, it is important to understand that our human ancestors continued to consume milk and dairy products despite displaying symptoms of lactose intolerance for thousands of years, without any ill effects. 

What is Lactose Intolerance?

Lactose intolerance is an inability to digest lactose, the sugar that occurs naturally in milk. Lactase—spelled with an “a”is an enzyme produced in the small intestine which is responsible for breaking down lactose. When a person has insufficient lactase in their small intestine, the normal bacteria in our gastrointestinal tract take over and break down the lactose carbohydrate to create energy for themselves. When this happens, we get the production of gas and also increased motility of the gut. This is often what people refer to as symptoms of “toots and shoots.”

All female mammals produce milk to feed their young. The nursing babies digest the milk with the help of lactase. Usually, when the young mammals are weaned, they stop producing lactase, which makes sense practically. Why should our bodies waste energy making an enzyme that is no longer needed?

Humans, however, are unique among mammals in that we continue consuming milk and dairy products into adulthood. Approximately one-third of the population has a genetic mutation that allows us to produce lactase throughout our lives, making it easier to digest milk.

What are the Symptoms of Lactose Intolerance and How Common is It?

The other two-thirds of humans experience some degree of lactose intolerance. It is estimated that 36% of Americans and 68% of the world population have some degree of lactose intolerance. 

The symptoms of lactose intolerance include:

  • Diarrhea
  • Nausea, and sometimes vomiting
  • Stomach cramps
  • Stomach pain
  • Bloating
  • Gas

These symptoms usually occur within 30 minutes to 2 hours of consuming products with lactose. Lactose intolerance often runs in families and is most common in Asian Americans, African Americans, Mexican Americans, and Native Americans.

The other question that often arises is why some dairy foods cause gas and abdominal pain while other dairy foods do not. There is no clear answer to this question. Some people will say that their symptoms will start only after eating a great deal of dairy-based foods—such as pizza followed by ice cream.  Others will feel it immediately after only small amounts of dairy. It is thought that fermented dairy products like yogurt and hard cheeses are easier to digest.

What Are the Health Risks of Being Lactose-Intolerant?

Research shows that people who cannot make lactase do not suffer any significant health consequences. They do not die at a higher rate, do not have weaker bones, and have just as many children as people with the mutation do. In short, the risk is discomfort.

Most people have a partial deficiency rather than a complete deficiency of lactase enzyme, meaning they make some—if not a totally sufficient—amount of lactase. For people with eating disorders, it is important to understand that temporary partial deficiencies can occur when one decreases the amount of dairy they are eating, thus depressing the production of lactase enzyme. When a person is malnourished, it is likely they will produce less lactase. This may occur when someone has been restricting dairy foods, either because they fear that the foods are not “healthy” or because the dairy foods are causing physical distress.

This can in fact become a self-maintaining cycle: where someone has started to restrict dairy, then starts producing less lactase, then experiences distress when eating dairy, concludes they are intolerant, and restricts further. At many eating disorder treatment centers, it is often presumed that patients who have been restricting their intake will experience at least temporary partial lactose intolerance and so they are treated with the presumption that they will need additional lactase.

How Can Lactose Intolerance be Managed?

Fortunately, the solution need not be to avoid dairy altogether. The pharmaceutical industry has introduced lactase pills that clients can ingest prior to eating dairy products. The pills work like lactase produced in the body to break down the lactose in milk. Lactase pills are often used in clients with some malnutrition from any cause, as the amount of lactase enzyme produced and/or available is insufficient in their gut due to malnourishment even though they are not technically lactose intolerant. This allows them to better digest the dairy products that often add higher fat content to foods. The milk industry has also introduced lactose-free milk with added lactase. This product has nearly the same taste, texture, and nutritional benefits as milk. It does tend to be a little sweeter.

The Importance of Dairy for Eating Disorder Recovery

For a person with an eating disorder, dairy can be a critical food source. Milk has more calories and total macro and micro-nutrients than alternatives and can facilitate the refeeding process for those needing to restore weight. By contrast, milk avoidance undermines recovery by perpetuating fear around commonly-encountered animal-based foods and beverages and creating situations in which one can’t get all of one’s nutritional needs met. Just think about how many situations in which you find yourself in which pizza is the primary nutritive substance. While ethics around consuming dairy are often stated as a reason to avoid it, our highest obligation is to the patient.  In the context of an active eating disorder, it is best to reincorporate all foods and beverages. Later in recovery when rationalization is less of a concern, ethical tradeoffs can be re-evaluated.

If dairy products cause physical distress, we encourage the use of lactose-free milk or lactase pills until dairy is better tolerated. Dairy can also be gradually added back in an exposure-based hierarchical way. This is essential in preventing any fear associated with dairy and allowing the normalization of dairy into everyday diets. This way, “temporary” lactose intolerance can also usually be worked through.

We do not encourage the elimination of dairy from the diet unless a medical doctor trained in eating disorders has deemed it medically necessary. A medical doctor is also the only one who should recommend the removal of dairy due to a milk protein allergy (specifically whey protein or casein protein). However, this type of allergy is considered rare, occurring in less than 2% of the population. Children are more susceptible to milk protein allergies, but most outgrow their allergy by 5 years of age.

In Conclusion

We know that more varied and higher fat diets lead to more lasting recovery.  It is in the best interest of every person with an eating disorder to include as many dairy foods as possible in their recovery meal plan. If you have eliminated dairy from your diet or are supporting someone who has, we strongly encourage working towards the inclusion of dairy products. We recommend adding dairy back gradually and to use lactase pills to manage any physical symptoms. Lactase pills can safely be used long-term.

Dairy-rich foods are a traditional part of many food cultures. We want you to be able to enjoy an ice cream outing with friends, shared late-night pizza ordered in, and social gatherings around a cheese board. Dairy foods are some of the tastiest and most joyful foods and we want you to be able to eat them while strengthening your eating disorder recovery.

Source

Evershed, R.P., Davey Smith, G., Roffet-Salque, M. et al. Dairying, diseases and the evolution of lactase persistence in Europe. Nature 608, 336–345 (2022). https://doi.org/10.1038/s41586-022-05010-7

Categories
Binge Eating Disorder Dieting

Is Weight Suppression Driving Your Binge Eating?

Dall.e

If you have bulimia nervosa, did you know that being at a weight that is too low for your body could be a problem? And that it could be driving your binge eating and other behaviors?

Many people are aware that patients with anorexia nervosa need to gain weight in order to recover, but few people are aware that this may also apply to people with bulimia nervosa. This article will review research on the role of previous and current weight on the development and maintenance of bulimia nervosa.

What is Weight Suppression and Why Is It a Problem?

Weight suppression is the difference between one’s highest adult body weight and one’s current weight. It can also be thought of as the amount of weight one has lost from a previous high weight, most commonly in response to dieting.

Human bodies are meant to come in a variety of shapes and sizes. When a person of any size tries to reduce their size to smaller than that intended by their genetics, binge eating may be the body’s natural defense to avoid death by starvation and return the body to a healthier higher weight.

Weight loss decreases metabolism and the amount of energy the body burns. It also seems to increase appetite. The hormone leptin, which sends satiety signals to the brain, is believed to play a role in this process. Studies indicate that individuals with high weight suppression—that is, who have lost a lot of weight—appear to have lower levels of leptin. For these reasons, there is a strong biological predisposition to regain lost weight.

Early Research on Weight Suppression in Bulimia Nervosa

In 1979, Gerald Russell published the seminal paper that first described bulimia nervosa as a variant of anorexia nervosa. In this paper, he noted that weight suppression seemed to play a role in the development of bulimia nervosa. He described these patients as trying to drive their weight below a healthy body weight and, as a result, starting to binge and purge.

In Russell’s initial study of 30 patients with bulimia nervosa, 17 had previously met full criteria for anorexia nervosa, including the low weight. Another 7 patients had also lost weight, but not enough to qualify for anorexia nervosa. Every patient but one had experienced at least some weight loss prior to the onset of bulimia nervosa

Despite this early account, prior to the last 15 years there was not much research on weight suppression. More recently, several researchers have begun to study the impact of current and past weights on eating disorders. Although still in its early stage, this research is helping us to better understand the dangers of weight suppression.

Recent Research on Weight Suppression’s Role in Bulimia Nervosa

Research indicates that prior to the start of their illness, people with bulimia nervosa often start out at a higher than average body weight. As the eating disorder progresses, people with bulimia nervosa seem to lose a significant amount of weight. By the time they present for treatment, they are generally within what is usually considered a “healthy” weight range–-but crucially, they tend to be well below their highest adult weights. One study measuring the average degree of weight suppression in people with bulimia found the average amount of weight suppressed was approximately 30 pounds.

These findings indicate that individuals may use bulimic behaviors such as restricting and purging to avoid returning to higher body weights. Not surprisingly, greater weight suppression appears to be associated with more bulimic symptoms and a longer length of illness. Greater weight suppression also predicts weight gain in patients with bulimia nervosa both during and after treatment. The role of weight suppression is important because it illustrates that bulimia nervosa is not merely caused by psychological factors—complex biological factors are also at play.

Patients with weight suppression and bulimia nervosa who are preoccupied with achieving a lower weight appear to be stuck in a bio-behavioral bind. Their weight suppression makes them more prone to weight gain–-but the preoccupation with maintaining a lower weight makes this weight gain highly threatening.

Researchers do not yet fully understand whether as little as 5 pounds of weight suppression is problematic, or whether only larger amounts of weight suppression are an issue. They also do not know whether the effects of weight suppression are greater if someone was at a higher weight for a longer period of time or whether their weight has been suppressed for a longer time. These are among the answers that researchers studying weight suppression hope to be able to answer.

What Does this Mean for People With Bulimia Nervosa?

Juarascio and colleagues (2017) suggest that some patients who do not recover with a course of Cognitive Behavioral Therapy (CBT) for bulimia nervosa might improve their recovery by gaining weight. It appears that weight gain could reduce the urge to binge and purge. They recommend that clinicians routinely and thoroughly assess for relevant weight history. They also recommend that patients with significant weight suppression and those who gain weight during the initiation of regular eating should receive additional education about the impact of weight suppression on symptoms of bulimia nervosa. They also recommend that clinicians educate patients about the fact that over time, dieting often backfires and leads to weight gain.

Thus, even if you are eating enough and not restricting intake, continuing to binge may indicate that you need to gain weight. Successful treatment may include accepting that genetics contribute to variations in body size and shape and that your appropriate weight may be one that is higher than you now prefer. You are not destined to inhabit the same body as someone else.

Self-acceptance can be hard psychological work, but this is one place where we can help support you. Keep in mind that the alternative to acceptance may be a continuation of bingeing and purging.

How Do I Know if My Weight is Suppressed?

Some questions to consider:

  • Is your current weight lower than your highest adult weight?
  • Are you preoccupied with thoughts about food?
  • Do you experience episodes of eating in which you eat unusually large amounts of food in a short period of time and feel out of control while doing so?
  • Do you eat impulsively–when you haven’t planned to–or engage in emotional eating?

If more than one of the above is true, consider seeking help and gaining some weight. Getting to a weight that is biologically determined healthy for you, regardless of where that number is on population norms, is usually the healthiest. We do not yet have enough research to know whether you would need to go back to your highest weight, or whether regaining some of the suppressed weight may be sufficient. You may find that weight gain will relieve some preoccupation with food, reduce some symptoms of bulimia nervosa, and generally improve the quality of your life. You may also discover that the negative consequences of weight gain that you fear do not come true.

When weight is not suppressed you can more fully enjoy eating a variety of foods without obsessive worry and live life more fully. You can go out for dinner and enjoy a drink, indulge in a cupcake for a coworker’s birthday, and travel to a different region and experience the local cuisine all without accompanying anxiety.

This is a good blog post where one woman discussed accepting a higher body weight and living more fully.

Sources

L Butryn, Meghan, Michael Lowe, Debra Safer, and W Stewart Agras. 2006. Weight Suppression Is a Robust Predictor of Outcome in the Cognitive-Behavioral Treatment of Bulimia Nervosa. Vol. 115. https://doi.org/10.1037/0021-843X.115.1.62.

Gorrell S, Reilly EE, Schaumberg K, Anderson LM, Donahue JM. Weight suppression and its relation to eating disorder and weight outcomes: a narrative review. Eat Disord. 2019 Jan-Feb;27(1):52-81. doi: 10.1080/10640266.2018.1499297. Epub 2018 Jul 24. PMID: 30040543; PMCID: PMC6377342.

Juarascio, Adrienne, Elin L. Lantz, Alexandra Muratore, and Michael Lowe. 2017. “Addressing Weight Suppression to Improve Treatment Outcome for Bulimia Nervosa.” Cognitive and Behavioral Practice, October. https://doi.org/10.1016/j.cbpra.2017.09.004.

Keel, Pamela K., Lindsay P. Bodell, Alissa A. Haedt-Matt, Diana L. Williams, and Jonathan Appelbaum. 2017. “Weight Suppression and Bulimic Syndrome Maintenance: Preliminary Findings for the Mediating Role of Leptin.” The International Journal of Eating Disorders 50 (12):1432–36. https://doi.org/10.1002/eat.22788.

Keel, Pamela K., and Todd F. Heatherton. 2010. “Weight Suppression Predicts Maintenance and Onset of Bulimic Syndromes at 10-Year Follow-Up.” Journal of Abnormal Psychology 119 (2):268–75. https://doi.org/10.1037/a0019190.

Keel, Pamela K., Lindsay P. Bodell, Alissa A. Haedt-Matt, Diana L. Williams, and Jonathan Appelbaum. 2017. “Weight Suppression and Bulimic Syndrome Maintenance: Preliminary Findings for the Mediating Role of Leptin.” The International Journal of Eating Disorders 50 (12):1432–36. https://doi.org/10.1002/eat.22788.

Keel PK, Bodell LP, Forney KJ, Appelbaum J, Williams D. Examining weight suppression as a transdiagnostic factor influencing illness trajectory in bulimic eating disorders. Physiol Behav. 2019 Sep 1;208:112565. doi: 10.1016/j.physbeh.2019.112565. Epub 2019 May 30. PMID: 31153878; PMCID: PMC6636832.

Russell, G. 1979. “Bulimia Nervosa: An Ominous Variant of Anorexia Nervosa.” Psychological Medicine 9 (3):429–48.

Categories
ARFID

How Diet Culture Can Harm Your Recovery from ARFID

by Carolyn Comas, LCSW, CEDS-S

People diagnosed with Avoidant Restrictive Food Intake Disorder (ARFID) struggle with consuming adequate nutritional intake due to either 1) fear of aversive consequences (i.e choking), 2) low interest in food altogether, or 3) sensory sensitivity to food textures, smells, or appearance. Usually, people with ARFID do not report refraining from eating due to fears of weight gain or efforts to lose weight. In fact, many people with ARFID welcome weight gain and want to expand their food variety.   

The Impact of Diet Culture

The current Diagnostic and Statistical Manual (DSM-5) excludes those whose eating is restrictive due to shape and weight concerns from receiving a diagnosis of ARFID. However, this does not mean that people with ARFID are immune to the societal messages around food and bodies. Sadly, we all live in a world that is very much driven by diet culture. Most of us, with or without eating disorders, can be impacted by diet culture. We are constantly bombarded by many sources, ranging from the media to doctors’ messages about the danger of fatness and categorizing foods as healthy or unhealthy. 

Dieting is one of the leading causes of eating disorders. According to a study by the National Eating Disorder Association, 35 percent of people who diet progress into pathological dieters. Of this 35 percent, up to 25 percent will develop a full-blown eating disorder. People with ARFID could develop another eating disorder, such as bulimia nervosa or anorexia nervosa at some point in their life.

People with ARFID already face the challenge of limited food choices and heightened anxiety around eating. They can be very vulnerable to messages that their preferred foods  “aren’t healthy” or “junk food.”  This can lead to even more anxiety and shame around their food choices. People with ARFID thus have to battle their disorder as well as the concerns that diet culture imposes around food and body size.

Dieting encourages us to ignore our bodies’ needs. Diet culture emphasizes that our worth is based on the size of our bodies. In Christy Harrison’s book, Anti-Diet, she calls it “the life thief.” And that’s what it does- it steals the joy out of fun events or the everyday activity because it convinces us we need to carefully balance everything we put in our body. And if we go off the diet or “cheat” we are made to feel bad and unworthy causing a vicious cycle of yo-yo dieting. 

People with ARFID with whom we have worked report confusion around some of these messages, which clearly come from diet culture, and affected their ability to eat their preferred foods:

  • “Water is the only hydrating beverage and I should only be consuming water.”
  • “I was only offered wheat bread which I didn’t like so I didn’t eat bread.”
  • “I must eat vegetables in order to be healthy.”
  • “Fried foods are bad so I should limit my chicken nuggets and french fries.”

Standing up to Diet Culture

If you have a loved one struggling with ARFID it is recommended to check your own relationship with food and body image. Explore your own internalized fat phobia. Great books include The Body is Not an Apology by Sonja Renee Taylor and What We Don’t Talk About When We Talk About Fat by Aubrey Gordon. If you are worried about the types of food you or your child is eating because it is “unhealthy” check in on what you are really worried about. Is it truly about the nutritional value of the food or is there a belief that these particular foods can lead to being in a larger body? If the fear is being in a larger body then you have work to do. Learn about Health at Every Size® and recognize that the size of our bodies does not correlate to how healthy or unhealthy we are.

Remember, it is better to be fed than to be dead. If all you or your child can eat is chicken nuggets or french fries or potato chips or white bread (or all 4), then that’s what needs to show up at each meal and snack. You or they should have permission to eat preferred foods at every meal and snack without shame. With therapy, the goal is to incorporate more food groups and decrease fear and anxiety around novel foods. Realistically people who struggle with ARFID might never have the most expansive palette and that’s okay. If protein has to come from a package or be fried then that’s where the protein has to come from. Insisting that one food is better than another can make a person with ARFID feel ashamed, embarrassed, or more anxious about their food choices and further limit their eating. We never want to limit the food choices of people with ARFID beyond those limitations that the disorder causes. Choosing to feed yourself foods our culture considers “less healthy” rather than not eating is the best and dare I say–-healthiest choice there is.

When it comes to expanding variety and trying new foods we always have to start with what feels safe for the person with ARFID. While the goal might be to eat blueberries the first step might be eating blueberry muffins or chocolate-covered blueberries. The goals of treatment are to make meals less intimidating and have the patient feel like they can master trying new things. We don’t want to increase shame by disparaging their food choices.

We need to create peace, joy, and relaxation around meals. Labeling food “good” or “bad” or “healthy” or “unhealthy” can increase anxiety and discomfort.  Patients may second guess their food choices or end up becoming even more limited in what they eat. A fat-phobic mindset can be intimidating. Taking a Health at Every Size ® approach will be as important as it is in the treatment of anorexia and bulimia. It is the safest approach to navigating the world of diet culture. 

Let’s push back on diet culture and spread the message that all bodies are good bodies regardless of their size. We need to make the world safe for people in fat bodies and for those in thin bodies who are fearful of becoming fat. Ultimately, diet culture is not only harmful to people with other eating disorders but is also harmful to those with ARFID.

Groups at EDTLA

We have groups for adults with ARFID as well as parents of teens with ARFID. For more information, check our Groups page.

Categories
Health at Every Size

How a Health at Every Size(R) (HAES) Approach Can Help With Eating Disorder Recovery

Body Liberation Photography
Eating disorders are not only about body image. Nor have they only recently arisen in response to societal pressures to be thin. In fact, eating disorders date back to at least the 13th and 14th centuries, when it was documented that women were fasting to demonstrate religious devotion. However, today eating disorders do occur in the context of a society obsessed with thinness, afraid of fatness, and permeated with diet culture. This makes recovery more difficult.

How Diet Culture Impacts Eating Disorders

There are probably no other mental disorders whose behaviors the culture admires and values as greatly as the eating disorders. People frequently praise people with restrictive eating disorders for their self-control and success at dieting or commitment to exercise. Imagine being praised for the symptoms of other disorders, such as excessive worry or the inability to get out of bed due to depression. When it becomes “normal” for everyday discussions to revolve around diet suggestions or the shame of eating tasty food, recovery becomes even harder.

Research on Weight Stigma

The focus on eradicating “obesity” leads to discrimination and stigmatization of people living in larger bodies. In turn, this stigma encourages numerous negative psychological and health consequences. Studies have shown that weight stigma increases unhealthy eating behaviors— including binge eating—and decreases participation in physical activity. Weight stigma also has been shown to lead to depression, stress, low self-esteem, and negative body image. In fact, many of the negative health consequences commonly attributed to greater weight are now believed to be exacerbated by weight stigma itself.

Research on Weight Loss

Most individuals are unable to maintain weight loss long-term. Only 3% of dieters maintained weight loss at 5 years according to one study (Anderson et al, 2001). Mann and colleagues (2007) found that one-third to two-thirds of dieters regained more weight than they initially lost on their diets and concluded there was “little support for the notion that diets lead to lasting weight loss or health benefits.”
Diet failure can also lead to weight cycling: alternating periods of weight loss and weight gain. Weight cycling has been shown to lead to psychological and health problems. In addition, it can lead to reduced metabolic energy expenditure, which makes regain more likely.

What is Health at Every Size®?

Health at Every Size® (HAES) is an approach to health that shifts the focus from weight to health. It is a philosophy that has emerged primarily since the late 1990s. It is promoted by the Association for Size Diversity and Health (ASDAH), which owns the phrase as a registered trademark.

The primary goal of HAES® is to promote healthy behaviors for people of all sizes. HAES® is grounded in five principles:

  • Weight Inclusivity: acceptance that bodies naturally come in a variety of shapes and sizes, and no size of body is inherently better than any other size of body.
  • Health Enhancement: the focus on health rather than weight and attendance to additional disparities that contribute to health including economic, social, spiritual, emotional, and physical factors.
  • Respectful Care: acknowledgment of weight bias and weight-based discrimination, and the commitment to work towards its end. This involves the adoption of an intersectional lens to understand different identities such as race, body size, gender, sexual identity, etc.
  • Eating for Well-Being: flexible, individualized eating based on hunger, satiety, nutritional needs, and pleasure—not external eating guidelines focused on weight control.
  • Life-Enhancing Movement: encouragement of enjoyable physical activities for people in a range of bodies with a range of abilities, to the extent that they wish to participate.

What Research is there in support of HAES®?

Several studies support the use of HAES® interventions. Individuals who received HAES®-based interventions had improvements in physiological, behavioral, and psychological measures. Subjects exhibited statistically and clinically-relevant improvements in blood pressure and blood cholesterol levels. They displayed increased physical activity and decreased eating disorder symptoms. Subjects also had increased self-esteem and body image and decreased anxiety and depression. They exhibited increased fruit and vegetable intake. No studies found any negative consequences associated with the HAES® interventions. Subjects who receive HAES® interventions seem to stay in their programs longer. This is promising, considering that patients in weight loss programs often drop out.

How Can a HAES® Approach Help With Eating Disorder Recovery?

Weight recovery is a prerequisite for recovery from anorexia nervosa. Aside from the necessity of restoring suppressed weight for individuals with eating disorders who are weight suppressed, the treatment of eating disorders should not aim to address weight issues. Weight loss has not proven effective for patients with binge eating disorder. There is growing evidence that individuals who try to lose weight and maintain a suppressed weight—that is, a weight lower than a previous higher weight—are at increased risk for binge eating disorder and bulimia nervosa. Individuals with bulimia nervosa who maintain a suppressed weight are less likely to fully recover. A persistent focus on limiting weight gain or losing weight can drive and maintain eating disorder behaviors. Research shows that continued focus on weight loss as a goal can lead to food and body preoccupation, eating disorders, weight stigma, and reduced self-esteem.
Conventional thinking suggests that feeling bad about one’s body would motivate behavioral changes that promote weight loss; in fact, the opposite is true. Feeling bad about one’s body drives more destructive behaviors. By contrast, body acceptance can help promote healthier behaviors.

Renouncing the dieting mindset and returning forbidden foods back into their diet can be a formidable challenge for patients surrounded by friends and family who talk about losing weight or avoiding certain foods. Adopting a HAES mindset can challenge the veneration of thinner bodies and promote body acceptance.

The HAES® approach shifts the focus from the resolution of weight issues to the resolution of body discontent. It encourages you to accept your body’s “set point”: the weight to which your body tends to return when you don’t fixate on weight loss and instead respond to your body’s natural cues for hunger and fullness; the weight you to which you return between diets; and the weight you maintain without a lot of effort. This is the weight your body “wants to be.”

While a HAES® approach acknowledges a correlation between higher weights and certain medical conditions, it questions whether this relationship is purely causal. The data suggest that behavior change may play a greater role in health improvement than weight loss itself. We know that weight loss rarely works, and when it does, people lose only a modest amount of weight and maintain even less of it. Is weight loss just an occasional and incidental result of the health improvements driven by these behaviors, rather than an important end in itself?

Each body is different. Humans naturally come in all varieties of shapes and sizes. It can be hard to remember this in a world where the dolls with which our children play are all white and svelte and the protagonists in television and movies are also in conventionally attractive bodies. The shape and size of our bodies are largely determined by genetics, just as is the color of our eyes and skin. A HAES® approach allows you to trust your body to maintain the body size and shape that is right for YOU.

The HAES® approach advocates for intuitive eating—listening to and acting on internal hunger and satiety cues and preferences. Those in recovery who have previously allowed proscriptive external diet rules to drive their food decisions may be especially helped by the HAES approach. HAES also recommends pleasurable movement—exercising for the goal of pleasure rather than weight loss. Decoupling exercise from weight loss is challenging for many patients with eating disorders.

We can work with people in person in Los Angeles and virtually throughout the state of California seeking HAES-informed treatment.

How Can I Learn About HAES?

There are many ways to learn more about HAES. Check out the following resources.

Websites

Video:

  • The Problem With Poodle Science by The Association for Size Diversity and Health is an animated video exposing the limitations of current research on weight and health

Books:

  • Health at Every Size: The Surprising Truth About Your Weight, by Linda Bacon, PhD addresses weight myths and gives the science behind HAES.
  • Body Respect: What Conventional Health Books Leave Out, Get Wrong, or Just Plain Fail to Understand about Weight, by Linda Bacon, PhD, and Lucy Aphramor, PhD, RD includes the latest science on diets and health and why diets fail. It teaches how to adopt a HAES approach.

There are also many blogs and social media groups and accounts focused on Health at Every Size. Try searching for #HAES.

Sources

Anderson, J. W., Konz, E. C., Frederich, R. C., & Wood, C. L. (2001). Long-term weight-loss maintenance: a meta-analysis of US studies. Am J Clin Nutr, 74(5), 579-584.

Bacon, Linda, and Lucy Aphramor. 2011. “Weight Science: Evaluating the Evidence for a Paradigm Shift.” Nutrition Journal 10 (January): 9.

Mann, T., Tomiyama, A. J., Westling, E., Lew, A.-M., Samuels, B., & Chatman, J. (2007). Medicare’s search for effective obesity treatments: diets are not the answer. Am Psychol, 62(3), 220-233.

Penney, Tarra L., and Sara F. L. Kirk. 2015. “The Health at Every Size Paradigm and Obesity: Missing Empirical Evidence May Help Push the Reframing Obesity Debate Forward.” American Journal of Public Health 105 (5): e38-42.

Puhl, Rebecca M., and Chelsea A. Heuer. 2010. “Obesity Stigma: Important Considerations for Public Health.” American Journal of Public Health 100 (6): 1019–28.

Tylka, Tracy L., Rachel A. Annunziato, Deb Burgard, Sigrún Daníelsdóttir, Ellen Shuman, Chad Davis, and Rachel M. Calogero. 2014. “The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss.” Research article. 2014.

Categories
Dieting Eating Disorders Family based treatment teen eating disorder

What Parents of Teens with Eating Disorders Need to Understand About Diet Culture

Body Liberation Photography

 

Many parents experience guilt when their teen is diagnosed with an eating disorder. Nearly every parent can point to a time they themselves dieted, opted not to have a dessert they really wanted, expressed a preference toward thinness, or discouraged their child from keeping eating. You may have done things to try to keep your teen’s weight down and you likely did it with love and good intention—to protect your child from weight stigma and perceived subsequent health and social consequences.

It is common to wonder whether such actions contributed to the development of your teen’s eating disorder. Guilt is common for parents to experience when their child has any illness. In the case of eating disorders, many of the behaviors that are part of the disorder are reinforced by our culture’s preference for thinness and so blame is even more compelling.

What is Diet Culture?

Diet culture is a system of beliefs that values thinness and promotes it as a way to increase one’s worth. It creates rules about what type of eating is “healthy” and oppresses people who don’t meet the thin ideal.

Diet culture messages are everywhere, so it’s not your fault that you’ve absorbed them and subscribed to these beliefs without ever thinking twice about them. Diet culture is the soup in which we all swim. It’s the dominant paradigm. You likely have heard fear-mongering messages from other health professionals. You see it in the news.

Why is this system of beliefs so dominant? It’s promoted by a $70 billion diet industry. It’s entrenched in our fatphobic healthcare system. It’s reinforced by the media.

Parents often become the unwitting messengers of the dominant cultural message they hear from other health professionals. But this is an important turning point. Now that you are helping your teen with an eating disorder, it’s time to question what you think you know about health and weight and eating. You were not born hating your body. You developed these beliefs and you can unlearn them. It is never too late to start unlearning and unsubscribing to diet culture. We want you to join us in helping to break down the institutions that reinforce fatphobia and contribute to the development and maintenance of eating disorders and make your teen’s recovery harder. Your teen needs you fighting for their liberation.

We believe that parents are important allies for their teens with eating disorders. Even if you have disparaged your own body, dieted, cheered when your teen started eating healthier, or encouraged them to exercise in the early development of their eating disorder, we want you to know that you are not to blame for your teen’s eating disorder. Please show yourself compassion. Your teen needs you.

This also applies if your teen has Avoidant Restrictive Food Intake Disorder (ARFID), an eating disorder not typically driven by weight and shape concerns. Diet culture equally impacts people with ARFID.

How to Do This

  • Learn about how health is much broader than weight. Read the resources on our website about Health at Every Size ® to expose yourself to messages that challenge the weight-normative paradigm.
  • Stop talking critically about any body, including your own body and especially fat bodies. Model body appreciation and respect for all bodies and for body diversity.
  • Accept that your teen likely needs to gain weight and examine your fears about what that means for them and for you. Read our article on recovery weights.
  • Encourage your teen to see fat not as something to be feared. We don’t want to reinforce what the eating disorder is afraid of. We need to make it safe for people to be fat.
  • Curate your social media feed. The mainstream media images we see are not diverse, and the images we do see of larger bodies are often portrayed in a particularly negative and stigmatizing way, adding fuel to the fire. One way to build your own acceptance of body diversity is to acclimate to seeing a broader range of bodies portrayed in a desirable way.
  • Refrain from categorizing foods as healthy or unhealthy, good or bad. Model eating a variety of foods including foods you may have previously demonized, including desserts. Model eating with enjoyment and the social connection that comes from sharing meals.
  • If you previously promoted leaner, restrictive or “healthy” eating and are worried about creating confusion or appearing hypocritical with a new message around more flexible eating and more calorically dense foods, you can unapologetically explain to your teen that, in light of their eating disorder and what you are now learning, that you are also working towards a broader understanding of health and nutrition and becoming a more flexible eater. Some of the more powerful situations I’ve encountered include when a parent shares their own process in rethinking their relationship with food and their body while simultaneously doing their own work alongside their teen in recovery.
  • Teach your teen to think more critically about health and media messages they observe.
  • Take the Weight Implicit Association Test. Be gentle with yourself and remember we all have weight bias.

It’s never too late to change your thinking about weight and food. Many parents of teens who’ve had eating disorders have become great advocates for size diversity. Please join us in the anti-diet movement.

Categories
body image Weight bias

Weight Bias and Figure Skating

The author at the 2004 Intercollegiate National Championships where she won a silver medal

By Carolyn Comas, LCSW

For a long time I was embarrassed to tell people that I was a figure skater. I was afraid that someone would look at me and laugh at the idea that someone like me skated. I felt this way because I am in a larger body and have always been. Even though I loved to ice skate, I somehow knew that I was not in the ideal body for this sport. It never occurred to me back then that these thoughts and beliefs were biases that I had been taught both implicitly and explicitly. 

Biases are preconceived ideas about something or someone. They can be negative or positive but often we associate biases as negative. For me, I grew up with the bias that “real figure skaters” were in small slender bodies. I only saw petite tiny women (and girls) glide across the ice when I would watch the Olympics or National Championships. I never saw an ice skater that looked like me.

 In my personal experience as an ice skater  I can remember a dance and ice skating store shop owner looking down at me as she said, “we don’t carry your size.” I had coaches that reminded me that I’d skate faster if I was smaller and applauded me when I lost weight. I was highly aware that some coaches weighed their students and told them what they could and could not eat. It is really no surprise that in the sport of figure skating there are increased rates of eating disorders and overexercise, and many skaters experience poor relationships to food and body.

I was surrounded by weight stigma as I was teased by kids at school for being fat. It definitely reinforced the belief that my body was wrong. Fortunately I had friends and family who didn’t judge me and supported my passion for skating. Regardless of my size I was a real figure skater. I wore the sparkly dresses. I could do difficult jumps and all types of spins. I competed in competitions and even took home a few medals and trophies. I learned to ice dance with a partner. I performed in ice shows and represented my college at the Intercollegiate Nationals three times. I even took home a silver medal for my event. Eventually I would go on to teach others to skate. I was in love with this sport and I guess in some ways I pushed some invisible boundaries by not succumbing to the negative messages about whether I belonged on the ice or not.

Biases can be so harmful because they create this belief that the size of your body cannot do a certain sport, wear a certain piece of clothing, or just feel like you don’t belong. It was not until I was into my coaching career that I truly saw how our biases could stand in the way of doing something that could be fun. I had two students who changed the way I saw what someone can or cannot do.

The first was a 60 year old man who wanted to learn how to ice skate so he could skate with his grandson who was a hockey player.  He shared that he was diagnosed with Parkinson’s disease and wanted to ice skate with his grandson before the disease progressed enough that he wouldn’t be able to do difficult physical activity like ice skating. He told me his left leg was already significantly weaker than his right leg, but he wanted to try so that he could surprise his grandson.

The second student was an eight year old  boy who was on the autistic spectrum. His parents wanted him to learn to ice skate because his father was a hockey player and wanted to be able to ice skate with his son. Unfortunately, this student’s autism was severe enough that he would never be able to play on an ice hockey team or join in an ice skating class with others his age. Our one on one lessons focused on just teaching him to stand on the ice, feeling the cold ice with his bare hands, and marching his feet.

If we listen to what society says about only one type of body being right we might miss out on something pretty incredible. Too often in my work as a therapist I hear clients say they can’t do something because their body doesn’t fit the expectations of what has been deemed normal by society. My two ice skating students were people who many might presume were unable to ice skate because of their bodies. They did not struggle with weight stigma, but  stigma around disabilities. Many coaches did not want to teach them because they felt it would be too hard to work with them. For me, it was a blessing.

I wish there was more representation of different types of bodies in figure skating and in all sports for that matter. I hope that we can tear down these negative fat biases and that more people in bigger bodies get the opportunity to do the things they wish. Maybe some things need to be modified and maybe you won’t be an Olympic champion, but body size should not be a limiting factor of what one is allowed to do. Think about how your own biases prevent you from doing something.

I am no longer ashamed to tell people I was a figure skater. I am proud to share about my ice skating experiences and the jumps and spins I was able to do. I do not care if there is judgement because figure skating is hard. I bet most people couldn’t do a flying camel spin into a sit spin combination. But, I could, and I deserve to show that off.

Categories
Family based treatment Health at Every Size Uncategorized

How We Set Recovery Weights

Photo by Samuel Ramos on Unsplash
If you have an eating disorder, or your child has one, there is a good chance that weight gain will be an essential part of the recovery process. This is true not just for people in objectively small bodies, but also for people in larger bodies who are diagnosed with Atypical Anorexia, a weight-biased diagnostic category included in the DSM-5. It is even true for people recovering from bulimia nervosa and binge eating disorder.

The eating disorders field lacks consensus on how to set recovery weights. I know a respected professional who argues adolescents should be routinely restored only up to the 25th percentile weight for age. They argue that this reduces their potential for experiencing weight stigma and reduces their anxiety. However, I see a problem with this, as do many of my colleagues and many families and recovered people.

This article discusses why weight recovery is a priority; what the research on weight suppression says; how we use growth curves in setting recovery weights; what evidence suggests that many providers set recovery weights too low; and how this applies to people in larger bodies.

Why Prioritize Weight Recovery

We know that while weight recovery in anorexia is not sufficient for recovery in and of itself, it appears to be a prerequisite for full psychological recovery. Eating disorder cognitions as well as most of the physical symptoms appear to recede only with full weight restoration (Swenne et al., 2017). Food is medicine not just for the body, but for the brain as well. That is why we often say, “Food is medicine.”

The research on timelines for eating disorder recovery show that remission of eating disorder behaviors such as binge eating and purging takes an average of eight or nine months, and weight recovery takes on average 12 months. But it takes even longer to end eating disorder thoughts, including the preoccupation with shape and weight and urges to restrict, purge, or exercise. These thoughts can persist for nearly a year after a person has reached a normal weight, has stopped engaging in behaviors, or both.

Weight Suppression and Negative Energy Balance

We also know that weight suppression—defined in adults as the difference between a person’s current weight and their previous higher adult weight—predicts continuation of eating disorder symptoms including binge eating. In children and adolescents, weight suppression would be defined as a negative deviation from one’s expected weight curve (more on growth curves below). Therefore, at EDTLA we prioritize full weight restoration for all patients in all body sizes and with all eating disorders. Failing to fully restore a person to their recovery weight for body and brain could prevent them from a full recovery.

A negative energy balance—taking in less energy than one’s body needs—may be a primary contributor to the development of an eating disorder in someone who has the innate susceptibility. Cindy Bulik, Ph.D. describes how a negative energy balance lowers anxiety for a person with this vulnerability, creating a trap. Restriction becomes seductive under these conditions. Couple this with the evidence that the weight loss leading to the development of anorexia nervosa could be unintentional—such as a side effect of an illness or an overexpenditure of energy for sports combined with undereating.  Together these suggest the best defense against relapse is maintaining an adequate energy balance and a healthy weight where the brain is functioning well enough to not act on residual thoughts.

Using Growth Curves to Estimate Recovery Weights

In this section, I will discuss why using individual growth records is so important. We have received guidance from our colleagues specializing in adolescent medicine and eating disorders. Like many eating disorder dietitians, one of the things we do is look at childhood growth records when they are available. This method is more tailored than using population averages such as BMI to set recovery goals.

In the US, most pediatricians and family medicine doctors document children’s growth on the CDC growth chart, which plots height, weight, and body mass index (BMI) against age-based averages.  In healthy children and teens, height and weight each increase along a consistent growth curve. Some children and teens grow steadily along the 95th percentile, some along the 75th percentile, some along the 50th percentile, and still others along the 25thh percentile.

But not every body is the same, and it’s normal for individuals’ height and weight to follow different growth curves. For some children and teens, a weight along the 75th percentile and height on the 25th percentile is normal. This defines the growth curves for that individual. Just as not every woman of average height wears a size 8 shoe, not everyone of average height is meant to be at the 50th percentile for weight. There is always a normal distribution in a population. These growth percentages appear to be largely genetically determined.

A deviation on an individual’s growth curve for weight, height, or BMI—even in the absence of actual weight loss—may indicate there is a problem such as an eating disorder. A child should be growing and gaining weight during this time, so the failure of a child or teen to gain the appropriate weight can be equivalent to weight loss. This means that when there is actual weight loss, the amount of suppression—the difference between current weight and where one should be on a growth trajectory—is usually even greater than the actual pounds lost.

Thus, a parent may come to us and say, “My child has only lost 10 pounds.” However, when that weight is plotted and we notice that the child also failed to gain any weight in the months before they lost weight, we might now look at their curve and see that in fact, the child should gain 20 pounds (or more!) to catch up to where they should be on their own unique growth curve. Some kids may not have lost any weight at all—but have fallen short of their appropriate gain for so long that they now should gain at least 10 pounds.

This is why we also often say that weight is a moving target. To remain in recovery, a year from now an individual’s goal weight must be higher than the weight that would be healthy at their age today. And this is true even for children who are no longer getting taller, as it is normal for weight to continue to be gained through about age 20.

This is why we will ask to see your child’s (or your) growth records. We will estimate what their weight should be for their current age based on their growth history. Returning to their own growth curve is usually a minimum estimate because we cannot know for certain where some one’s body will end up. We will consult with your child’s pediatrician. You may also want to consult with a specialist in eating disorders and adolescent medicine.

Please be aware that some non-ED specialist pediatricians/health professionals may not be well-informed about this individualized process of setting goal weights. I once had a pediatrician who told a teen’s parents she would be happy if my patient got to a certain weight because that was the weight that the pediatrician—who was herself quite petite—had weighed at the patient’s age.

What? A pediatrician setting a goal weight for a patient based on her own unique growth history!?? When you take your clothes in for alterations, does the tailor cut the clothes to fit the tailor?  Do you see the problem here?

Speaking of growth curves, the use of growth curves to spot early eating disorders is an underutilized practice. In a recent study on pediatric patients hospitalized with an eating disorder, 48% of patients experienced a deviation in the growth curve a median of almost 10 months prior to the first eating disorder symptoms being reported by parents.

We will also show you how your teen’s weight should be tracking on the weight curve. Teens generally gain 30 to 40 pounds in the course of puberty. While many children gain weight and grow naturally during this period, we find that children who have had an eating disorder may need continuing guidance to help their weight keep pace with their age and height. We encourage parents to keep an eye on their teen’s weight to make sure weight continues to track along the expected curve. We respect parents and educate them on this.

The Field Tends to Set Recovery Weights Too Low

Looking at historical growth curves is especially important because parents have shared that in their experience, health professionals often set their teens’ recovery weights too low. This is not surprising; even providers are susceptible to weight stigma. It is challenging for providers to take on a whole cultural system that reinforces the false virtue of thinness.

At EDTLA, we do our best to challenge our own weight biases and that of our patients and their families. We believe that facing the anxiety of a patient or a child restoring to a slightly higher weight has benefits that outweigh the costs. We help the family challenge the belief that being fat is worse than remaining ill. I never want to be the provider who set a goal weight so low that it contributed to prolonging a mental illness from which it may take a patient 9 to 22 years to recover.

Challenging weight bias and setting higher weights goals does not always make us popular. Teens with eating disorders are by definition, terrified of gaining weight. In her blog, eating disorder specialist pediatrician Julie O’Toole discusses the setting of goal weights and how parents fear that too much weight gain will make their teen more depressed and anxious. Dr. O’Toole emphasizes the importance of basing treatment goals on data rather than placating the eating disorder.

Remember that an irrational fear of weight gain is often a symptom of the disorder. The anxiety over one’s body size often improves significantly with recovery, which requires more regular eating patterns and—ironically—weight gain. Please note this is rarely immediate. It may take up to a year of being at one’s healthy weight and learning to tolerate a changed body before the eating disorder thoughts fully subside. On the other hand, appeasing the fear of gaining more weight can maintain the fear and potentially the disorder.

How Does This Apply to People in Bigger Bodies?

We are often asked why a person who has historically been at a higher-than-average body weight must be returned to a weight that is higher than average. We recognize that bodies naturally come in a variety of shapes and sizes.  Some people are meant to be larger. We often encounter patients and families who say “but they looked better when they were a few pounds less” and want to use the eating disorder as an opportunity to keep a person’s weight suppressed. We believe that using an eating disorder as an opportunity to avoid returning to a previous higher weight could hinder the individual from reaching full recovery. And the research on weight suppression supports this. In the words of Julie O’Toole, “Rarely can a child who is genetically programmed to be larger than average be safely held at a ‘thin’ body weight. Size acceptance may be a part of the family’s treatment challenge.” For further guidance on parenting kids in larger bodies we recommend this guide to parenting fat kids.

Of Course, Recovery is About More Than Weight

Remember, though, that an estimated recovery weight is just that—the best estimate of where recovery will occur. I think it is important for parents to have a roadmap and to know generally whether they might be needing to add (at least) 10 pounds or 20 pounds or 40 pounds because it gives you a realistic expectation of how long the weight recovery phase may take. Again, this may change over time and our estimates are usually a minimum weight and bodies may go higher.

Ultimately, recovery is about state, not weight. And recovery means more than just weight recovery. We are looking for recovery of physical health—normalization of heart rate, blood pressure, and body temperature and resumption of menses when appropriate—as well as psychological recovery which includes improved mood, decreased eating disorder thoughts, return of normal hunger cues, and more regular eating, a less fraught relationship with food, improved social functioning, and a return of interest in other age-appropriate activities.

In one informal survey of 29 parents whose teens were given a recovery goal of 19 BMI, most reported recovery actually occurred at a BMI of 23 or greater and none achieved recovery at a BMI lower than 21. Parents will report that often, with an additional ten extra pounds, their teens were more likely to attain state recovery. If someone is not doing well at what we initially estimated to be a recovery weight, we will review that and may suggest after a few months that we raise the goal weight a little.

This post has described our thinking, which is informed by research, parent feedback, and expert opinions by leaders in the intersection of adolescent eating disorders, FBT, and Health at Every Size ®. We hope it helps you understand our recommendations.

But you don’t have to take our word for it. We invite you to do your own research. Below we’ve compiled some resources from leaders and colleagues in the field. And we strongly suggest you watch this video by Eva Musby.

Sources and Further Reading

Boring, Emily When in Doubt Aim Higher: What I Wish I Had Known About Target Weights in Recovery 

Bulik, Cynthia, UNC Exchanges Blog: Negative Energy Balance: A Biological Trap for People Prone to Anorexia Nervosa

Butryn, M. L., Juarascio, A., & Lowe, M. R. (2011). The relation of weight suppression and BMI to bulimic symptoms. The International journal of eating disorders44(7), 612–617.

Eddy KT, Tabri N, Thomas JJ, et al. Recovery From Anorexia Nervosa and Bulimia Nervosa at 22-Year Follow-Up. J Clin Psychiatry. 2017;78(2):184-189. doi:10.4088/JCP.15m10393

ED Matters Podcast Episode 232: Emily Boring: Target Weights and Full Recovery

EDTLA Blog: Are We Setting Recovery Weights Too Low

EDTLA Blog: Unintentional Onset of Anorexia Nervosa

FEAST of Knowledge 2020 – 08 Health At Every Size (HAES) by Rebecka Peebles, MD

Full Bloom Podcast: Why do my child’s caregivers need to present a united front around body positivity? with Lauren Muhlheim, Psy.D., FAED, CEDS

Gaudiani, Jennifer, Weight Goals in Anorexia Nervosa Treatment

Kartini Clinic Blog, April 12, 2013 Determining Ideal Body Weight 

Kartini Clinic Blog Sept 1, 2016 Setting Goal Weights

Lebow, Jocelyn, Leslie A. Sim & Erin C. Accurso (2017): Is there clinical consensus in defining weight restoration for adolescents with anorexia nervosa?, Eating Disorders 2018 May-Jun;26(3):270-277. 

Marion, M., Lacroix, S., Caquard, M. et al. Earlier diagnosis in anorexia nervosa: better watch growth charts!. J Eat Disord 8, 42 (2020).

Musby, Eva Weight-Restoration: Why and How Much Weight Gain?

Musby, Eva: Growth Charts and Weight Gain Made Simple

New Plates Podcast Episode 21: State Not Weight with Dr. Rebecka Peebles

Swenne, I., Parling, T. & Salonen Ros, H. Family-based intervention in adolescent restrictive eating disorders: early treatment response and low weight suppression is associated with favourable one-year outcome. BMC Psychiatry 17, 333 (2017). https://doi.org/10.1186/s12888-017-1486-9

Plot Your Child’s Weight

Watch this video.

Plot your child’s growth and weight here.

Categories
Dieting Weight bias

When Eating Disorder Providers Are Steeped in Diet Culture

Photo by Sarah Gualtieri on Unsplash

“People are concerned about the fact that I’m a therapist and have an eating disorder, and I’m like, ‘You’re concerned about me? I’m concerned about our entire fucking field.’”

— Shira Rose, FoodPsych with Christy Harrison

This quote has generated a lot of reaction. In this podcast, Shira—who lives in a larger body when she is not using eating disorder behaviors—details how she has suffered from fatphobia in the world and in treatment centers. She shares that she has been significantly harmed by both well-meaning treatment providers and highly-regarded treatment centers.

This blog addresses two questions:

  • How is fatphobia affecting therapy and patients?
  • When is someone well enough to treat?

Shira is my friend and colleague. I regard her above quote to be a challenge to all treatment providers who have not faced their own fatphobia, including those who seemed afraid of Shira’s weight gain, tried to reassure her she was not gaining weight or would not gain weight, tried to help her keep her weight down, and limited her portions. These actions have harmed her by making her afraid to eat enough to sustain her healthy body weight and making her unable to fully recover after a 19-year history of an eating disorder.

Weight Stigma in Treatment

One incident Shira experienced in treatment was relayed to her friend, Sam Dylan Finch who described it in a blog post:

“The dietitian said, ‘You three get two scoops of ice cream.’ She then looked at me and said, ‘You’ll get a kiddie scoop.’”

Some of you won’t understand the gravity of that comment. To be clear, a dietitian told a patient with anorexia nervosa to eat less food than her peers, because she is a patient in a larger body.

The message here being, of course, that Shira needed to eat a child-sized portion of ice cream, because she wasn’t thin enough to “safely” consume more than that.

This plays directly into the eating disorder’s conviction that she needed to tightly control her food intake and her body. Her peers could eat a “normal” amount of ice cream. But she couldn’t and was singled out, because something was “wrong” with her body.

“This was the message I received my entire damn life,” Shira told me. “That I couldn’t eat like everyone else.”

— Sam Dylan Finch

The mixed messages of “eat ice cream” but “only a tiny serving” have further strengthened Shira’s eating disorder. The message treatment providers delivered over and over again was that her body needed to be controlled in order to avoid fatness. She yearned to be able to eat freely.

Shira also acknowledges that there were times in the past when she thought she was fully recovered. She only discovered years later after a relapse that what she thought was fully recovered was only partially recovered. How is this possible? Because we live in a culture where it is considered desirable and virtuous to maintain a low weight, deny ourselves tasty foods, limit the amount we eat, and exercise intensely. No other mental illness is so unfortunately reinforced by our cultural ideals.

And in terms of who is well enough to treat people with eating disorders, is recovery from one’s own eating disorder the only criterion that matters? How would we ever be able to vet that? How do we define recovery anyway?

I agree with Shira that there are many providers in the field who have not faced their own fatphobia. Focusing exclusively on providers who have had an eating disorder and whether or not they are recovered ignores a large portion of the provider community who do not have diagnosable eating disorders but may still be casualties of diet culture, wrestling with internalized weight stigma. These providers may be doing much more harm, but their impact has unfortunately received limited attention.

Providers With History of an Eating Disorder

Research indicates that a significant number of eating disorder treatment professionals have personally experienced an eating disorder. A study by De Vos and colleagues (2015) found that 24 to 47 percent of eating disorder clinicians reported a personal eating disorder history. An unpublished 2013 Academy for Eating Disorders online survey indicated that out of 482 respondents from professional eating disorder organizations, 262 (55%) reported a personal history of an eating disorder and half of those reported working directly with eating disorder patients. If we added subclinical eating disorders and disordered eating I have no doubt the rates would be higher.

Some have suggested over the years that providers with histories of eating disorders should never work in the field. This would be a mistake. Many professionals with their own personal histories (disclosed or not) have made major contributions to the field and to our understanding of eating disorders. Carolyn Costin, MEd, LMFT, CEDS and Mark Warren, MD, MPH, FAED are two public examples of prominent recovered professionals. In the broader field of psychology, one need only look at Marsha Linehan, Ph.D., who developed the leading evidence-based treatment for borderline personality disorder and other conditions based on her own experience of recovery from a severe mental illness to see that blanket restriction like this make no sense. In various surveys, patients have consistently reported it is helpful to work with providers who have had an eating disorder.

Defining Recovery

But even more complicated is the fact that we do not have a solid definition of recovery. In eating disorder research studies, recovery is often defined by three components:

  • Physical—BMI higher than 18.5 or another universal marker like expected goal weight;
  • Behavioral—absence of binge eating, vomiting, laxative use, or fasting; and
  • Cognitive—EDE-Q subscales about shape and weight concerns within 1 standard deviation of age-matched peers.

With dieting widespread (a 2018 study reported 36 percent of Americans were dieting), how many providers with disordered eating and their own extreme weight control behaviors go under the radar? How many providers may be engaging in their own intermittent fasting, keto diets, counting calories, or excessive exercise? I would agree with Shira that we should be equally if not more afraid of these providers.

Who is Fit to Treat Eating Disorder Patients?

If the field can’t decide who is recovered, who is to decide who is fit to treat eating disorder patients? Are therapists who acknowledge they have clinical eating disorders worse than fatphobic dieter providers who deny their own food issues and go on to shame patients, recommend any kind of dietary restriction, and limit the weight gain necessary for full recovery? How do we decide when someone is well enough to treat others?

The following quote from Carolyn Costin M.A., M.E.d., LMFT, FAED, CEDS and Alli Spotts-De Lazzer M.A., LMFT, LPCC, CEDS in their article for Gurze (2016), “To Tell or Not to Tell: Therapists With a Personal History of an Eating Disorder,” highlights an important point:

“Even if the field reaches its consensus on a definition of recovered—and then holds it up as the criteria for being able to be work with eating disorder patients—how would we verify a recovered status? Could standardized measuring and monitoring happen? When substance abuse facilities hire individuals who identify as recovering alcoholics or drug addicts, drug testing can verify if the person is considered clean and sober or ‘using.’ There is no similar test to determine if a person is ‘using’ his or her eating disorder symptoms. Some have suggested that therapists with personal eating disorder histories be subjected to clinical eating disorder assessments and ultrasound checks for ovarian size to determine if they are at a healthy weight (Wright & O’Toole, 2005). Without even discussing the actual merit of these as determining factors, would these tests be administered to all therapists who wish to work with eating disorders or just those who say they once had an eating disorder? And couldn’t those with an eating disorder history be able to avoid such testing by not disclosing they ever had an eating disorder?”

Costin and Spotts-De Lazzer go on to state, “It seems interesting and confusing that there could be so much proposed attention on therapists who have recovered from an eating disorder but not for therapists who have histories of depression, anxiety, post-traumatic stress disorder, or another diagnosis in their past.”

Perhaps we should be focusing on assessing providers for awareness of weight bias instead.

Further, if we shame Shira for being a provider with an eating disorder, how do we make it safe for other providers to acknowledge their own struggles and receive help if they have a lapse or relapse? Shira has reported that a significant number of providers have shared with her that they have struggled or are currently struggling. This says a lot.

So back to the question—how do we decide when someone is well enough to treat others?

I don’t have the answer to this question. The field has been unable to even define recovery.

Am I more afraid of fatphobic dieting therapists who may not be aware of their potential for harm than therapists who believe in and espouse Health At Every Size ® while acknowledging their own mental illnesses? Ultimately, yes, I am.

I think we need to look inward and address the rampant weight bias in the field. With dieting so widespread we have a lot of work to do. I believe everyone deserves treatment to full recovery and safety in their bodies. We need to address structural issues that limit access to care and safety. We need to make it safe for providers to receive help for eating disorders. I think it behooves every professional working with eating disorder patients to look at their own weight bias and work to practice from a weigh-inclusive approach. Only this way can we reduce the harm done to people like Shira.

Sources

Costin, C. & Spotts-De Lazzer (2016). To Tell or Not to Tell: Therapists With a Personal History of an Eating Disorder. Gurze Salucore, Eating Disorders Resource Catalogue.

Stych, A (2018). Percentage of Dieters More Than Doubles. Bizwomen: The Business Journals.

Categories
Eating Disorders Social Media

Instagram to make Diet Ads viewable for ages 18 and over—Why They should Remove Them Altogether

by Carolyn Hersh, LCSW

Photo by NeONBRAND on Unsplash
On September 18th, 2019 Instagram instituted an official policy that all ads promoting diet and weight loss products would only be able to be viewed by users 18 and over. Any ads that have false claims can be reported and subject to removal. This is a huge victory in the world of challenging diet culture. For years, celebrities and social media influencers have been advertising diet and weight loss products that, for the most part, are bogus, promise false results and can be just downright dangerous to someone’s physical and mental health.

Most celebrities who promote these products are doing so for a paycheck and not because they are actually finding these products useful. Unfortunately, advertisements like these can impact impressionable viewers, especially those struggling with poor body image, disordered eating and eating disorders. And while the celebrities may say, “Take this and look like me,” the reality is that these products have no true evidence that they can change anyone.

Emma Collins, Instagram’s public policy manager, made a statement after this policy went into effect, “We want Instagram to be a positive place for everyone that uses it and this policy is part of our ongoing work to reduce the pressure that people can sometimes feel as a result of social media.” While this is a great step forward, it does feel like the next step should be eliminating diet and weight loss products altogether.

There are some major problems with advertising weight loss products. As a Health at Every Size® activist and promoter of body positivity, I can tell you that these products merely reinforce the idea that your body isn’t good enough. They teach that there is only one ideal body, and usually, it is the body of the celebrity promoting the product. It can be really dangerous to tell people that tea will flatten their stomachs or a lollipop will give them curves in the “right” places.

These advertisements put people at risk for developing eating disorders. They promote the very behaviors that are symptoms of eating disorders. These products try to normalize appetite suppression or compensating for what one has eaten via a laxative pill or tea. The messages are not health-promoting. They reinforce diet culture beliefs of certain foods being bad and needing to atone for eating.

A major issue is that there is absolutely no evidence that the products being advertised actually help with weight loss, detoxing your body of toxins, or changing the shape of your body. Most of these products are not even approved by the United States Food and Drug Administration (FDA). The FDA is charged with regulating medications and while there are a few that have been approved, most that are advertised on social media are not. Most of these products carry false claims and use ingredients that can be more harmful than helpful. And that is a huge problem.

We do not often see celebrities sharing disclaimers of potential side effects from using these products. Diet pills may increase heart rate, heart palpitations, the likelihood of a stroke, and even death. The detox teas carry the risk of dehydration, electrolyte imbalance and stripping our guts of the nutrients we need. Side effects can also include an increase in stomach cramping, bloating, and diarrhea. Our bodies were designed to naturally flush out toxins. It is why we have a liver. And for those users of the products looking for a way to lose weight, well the weight “lost” from these teas are usually just water or stool mass. These products place a huge toll on the body and put vital organs at risk.

For these reasons, we should not only be protecting social media users who are under 18. We should be protecting everyone from viewing these ads. Adults are probably more likely to purchase these products and adults are just as susceptible to false promises as adolescents. It is great that places like Instagram are giving us a choice if we want to view these ads. It is definitely a step in the right direction. But, there is nothing safe about these products. From taking a physical toll on our bodies to mentally placing shame on our bodies there is no room for diet pills, detox teas, or any other weight loss product.

If you are currently struggling with how you feel about your body, help is available through support groups, therapy, and even body-positive accounts and groups on social media. The wonderful thing about social media is that there is a community for promoting Health at Every Size® and working on self-love and acceptance. Most of these groups do not cost anything and can have to have positive effects on your mind and body.

Categories
Eating Disorders teen eating disorder

Parents, Don’t Let Your Kids Download Kurbo!

A disclaimer: I have no vested interest in Weight Watchers’ new Kurbo app. This app will in fact create more work for me. But let me be clear: I do not want this kind of work!

I know that you mean well and are merely concerned about your child’s health, but I can assure you that Weight Watchers does not share your concern. They are a commercial enterprise interested in making money and their business model is based on preying upon insecurities.

You would only need to spend a short time in my waiting room to hear from other parents who were once like you—moderately concerned (or maybe unconcerned) about their child’s weight and happy when their child committed to “eating healthier.” The story is nearly always the same. This child has been in what I would call a larger body—you might have called them “overweight”, pediatricians might have labeled them “obese”. It starts with them giving up sweets and then progresses. They start to restrict meat and starches and exercise more. It looks healthy. Over time, some switch gets tripped, and with very little warning the kid has anorexia, a lethal mental illness.

While most cases of anorexia are triggered by dieting, unintentional weight loss can be a trigger as well. It appears that people predisposed to anorexia respond to a negative energy balance in a way that flips this switch and they cross a dieting point of no return. Many of the teens I work with have been hospitalized for life-threatening low heart rates and electrolyte imbalances.

I cannot adequately express the guilt that parents feel from having allowed their teens to start these diets. I don’t blame them. I understand the pressure they are under.

Two of my three children grew out before they grew up. They had gained the weight their bodies needed to fuel puberty and impending growth spurts. I too received the warning from my well-intentioned pediatrician about their weights and weight gain. I knew enough to ignore the implied suggestion of helping them trim down. I cringe to think what might have happened if I had followed it. My children grew just fine and became more proportional according to their genetic predisposition.

My other child was lauded by the same pediatrician for growing up before growing out. It was only years later when I plotted her growth that I realized she had totally fallen off her expected weight curve at the time the pediatrician praised her weight. Yet, I did notice that she didn’t seem to be eating enough. (For more information on the intervention I did with her, read this post.)

The Kurbo app should come with the following warning:

“This app may trigger an eating disorder
from which your child could take 22 years to recover.”

Yes, 22 years! The most rigorous longitudinal study we have of anorexia has shown that at 9 years, only 31% of individuals with anorexia nervosa had recovered. Almost 63% had recovered at 22 years. If this is the path you follow, you may be facing many long years in and out of costly treatments to help your child recover.

Incidentally, Kurbo has made my job tougher. It classifies foods as “green”, “yellow”, or “red”. “Red” foods, such as ice cream, fried chicken, and pizza are “bad” — Kurbo advises kids to avoid them.

I work with children who suffer from anorexia, may be hypermetabolic, and may require ingesting upwards of 6000 kcal per day for several years to recover. I can’t express the difficulty of convincing an anorexic child to eat highly caloric foods to recover, when they immediately parrot back all the health messages they’ve received about these foods being dangerous. It’s terribly confusing to be told that the foods they’ve learned are bad for them are in fact the medicine that will cure them. This is but one reason why we cannot take a one size fits all approach to foods.

Back in my waiting room, maybe you would hear from some of the adults with eating disorders. They might tell you that years of dieting have contributed to weight gain, weight cycling, binge eating, and misery. They will typically remember that this pattern started in childhood with a diet. Dieting disconnects people from their own internal regulatory system (as does tracking calories and exercise).

What Can Parents Do Instead?  The following advice is for parents of kids of all sizes.

I suggest teaching kids that bodies naturally come in all shapes and sizes and that body size is largely genetically determined. I recommend viewing the Poodle Science video from ASDAH. This video does a great job illustrating body diversity and the risks of subjecting everyone to a single body standard. I suggest teaching kids that fat bodies are great too. We have to make it safe for people to be fat in order to prevent and treat eating disorders. Eating disorders are a more lethal problem. Parents can avoid judging or criticizing their own or other peoples’ bodies.

I suggest giving kids access to a range of foods — prohibiting “fun” foods leads kids to overvalue and overeat them. We don’t need to label foods as good or bad. Parents can serve nutritious food as well as fun food and model that they are of equal moral value. They can also model that food is supposed to be pleasurable and offers the opportunity for social and cultural connections.

Parents can also help children to move in ways that are fun, rather than teaching that exercise is penance for eating.

For more specific advice on helping kids develop as strong intuitive eaters with healthy body images, I suggest the work of dietitian Ellyn Satter and my psychotherapist colleagues, Zoe Bisbing and Leslie Bloch, The Full Bloom Project.

To Learn More

I recommend reading the statement from the National Eating Disorders Association: NEDA Statement on Kurbo by WW App.

And also The New York Times Op-Ed by dietitian, Christy Harrison: Our Kids Do Not Need A Weight Watchers App.

 

Exit mobile version
Skip to content