Recovery When Grieving by Carolyn Hersh, LCSW

Grief and Eating Disorder Recovery On May 8th, 2017 my mother died due to complications from cancer. It was an unexpected death. I still cannot believe she died. My mom was diagnosed in January and passed away in May. She had gone to the hospital for trouble breathing and never left.

I can clearly remember going back to my childhood home and seeing her sneakers in her room waiting for her to return to them. I cried so hard seeing everything she had touched just days before but left, never to feel her embrace again. I was one of those things she left.

It’s been more than a year now since I lost my mom. It was a year that tested me in so many ways: emotionally, physically, and spiritually. One thing I had to face was how my eating disorder and my longstanding recovery would play out through the worst thing that has ever happened to me.

I have my own history of emotional eating and bulimia nervosa. It started at a young age. Whenever I was sad as a child my mom’s solution to cheer me up was a trip to the bakery for a giant cookie. My emotional eating and my hatred of being the larger kid was just one of many factors that led me to a path of destructive behaviors of binging, purging, and restricting.

I’ve been through enough therapy and treatment that I am able to recognize moments when I find myself starting to eat mindlessly. I check in with what emotions or events are going on. I have, for the most part, overcome being an emotional eater. But, then I was hit with an intensity of emotions that I had never felt before. The seven stages of grief are very real and I definitely went through and felt each of them.

My anger, my sadness, my pleading to bring my mom back, to having brief moments of acceptance washed over me on a daily basis. My sadness felt like someone placed a brick on top of my heart. Trying to breathe became difficult at times. I was angry, intensely angry, at cancer, the doctors, the hospital, at God, at my mother, and at myself. We hear so often how eating disorders fester when we feel a loss of control. Losing my mother was the ultimate reminder “you have absolutely no control over this.”

In the early weeks and even months of living in a world where my mother no longer existed, I wanted comfort and distraction. I wanted food. I wanted alcohol. I wanted anything that would take this pain away. And in those moments of pure sadness, I consumed. I knew full well this wasn’t the way to handle my emotions. I decided I need to reach out to my dietitian because yes, even professionals need tune-ups. I remember sitting in my dietitian’s office crying because I gained weight and was feeling out of control with my body and my feelings. I quickly felt hypocritical as an advocate for all bodies are beautiful and guilty because a weight gain should not be something I should be crying about. I lost my mother. Worse things have occurred other than gaining a few pounds. My dietitian reminded me that I know how to eat and that my body will go back to where it should be when I honor my hunger and satiety cues. But, then she shocked me by saying, “Carolyn, maybe you needed to allow yourself to binge in those moments. So it happened. You binged. It’s done. Now, go back to your real coping skills.”

My dietitian gave me permission to accept my binges. She demonstrated compassion for me when I had no self-compassion. She was right. Sometimes we have to be okay with where we are at. My dietitian did not give me the green light to revert back to maladaptive behaviors. She pushed me back on a path of not beating myself up during a time where the last thing I needed was to hurt myself more.

So, how do you manage recovery in a time of grief?

  • Don’t go back to your eating disorder. Just don’t. You know it won’t help and when you are feeling low why make yourself feel lower? But, if you skip a meal or eat a few extra cookies just know that it is not a relapse. I do not consider my binging moments a relapse. They happened. I engaged and then I stepped away. Be gentle toward yourself and give yourself permission to say “It’s okay it happened. Now, what can I do to get back to my recovery?”
  • Go back to your coping skills. Maybe I could have engaged in binging and purging. Maybe I could have thrown my hands in the air and said: “what’s the point?” But I didn’t. In all honesty, I knew this wasn’t something I wanted. So, I made a list of things for me to do to help me through those really tough moments. I took time off from work and went figure skating with friends. The ice was always a very therapeutic place for me, and just being able to feel that cold air whip across my face me feel happy. I spent time journaling, cuddling with my dog, and reaching out to friends and family when I needed to talk. I began nightly walks with one of my girlfriends where we had heart to hearts. I made self-care a priority. You have to. The small lapses that I fell into never once trumped the real self-care that I was doing for myself. If I had beaten myself up for binges and weight gain then it could have sent me on that spiral back to a full relapse. Self-care may mean forgiving yourself for your lapses. Forgiving myself helped me continue to move forward.
  • Death really sucks. Losing someone you love is painful. It can be a torturous pain. There is no way around that. Losing my mother and thinking about her still to this very moment makes my stomach twist, my heart pound, and my eyes water. There will be bad days. I use a lot of radical acceptance in my grief where I acknowledge this is how it is and I have to figure out now how I continue to live in a world where my mom isn’t calling me. It’s hard to do. Believe me, there are days I do not want to accept this, but if I have to pull from my DBT workbook, acting the opposite is what gets me through the rough days. I don’t want to accept my mother is gone, but that is the reality. I do not, however, have to forget her and how she has impacted my life.
  • It’s okay to cry. It’s okay to feel whatever it is you are feeling and it is okay if those feelings come and go in minutes or if they last for days. There is no wrong way to grieve. During my grief I went to Nashville for a vacation, I would go out on weekends with friends and laugh, and I eventually moved to California. I managed to feel happy on some holidays and cried on others. I did not stop living, but I allowed for my grief to take space in my life.

In the end, going back to my eating disorder would just have caused more chaos in an already chaotic time in my life. I know it won’t give me control, it won’t make me happy, and it certainly will not bring my mother back. I have this blue butterfly pendant necklace my mom bought me before I went into an intensive outpatient program. It gave me strength then and I wear it now to continue to remind myself that my mother was every bit a part of my recovery and is every bit still a part of me. Now, why would I want to throw all that away?

Carolyn Hersh is available to see patients with eating disorders and has Saturday hours. Contact us for more information. 323-743-1122 or lmuhlheim@eatingdisordertherapyla.com 

This Halloween, Serve Candy to Your Teen in Recovery

A Family-Based Treatment (FBT)-approach

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

Halloween presents an ideal opportunity.

A Taste of Recovery

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

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

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

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

Exposure

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

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

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

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

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

Here’s How to Incorporate Candy During Halloween:

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

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

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

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

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

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

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

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

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

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

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

Signs Your Child Received FBT

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

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

Dead giveaways your child did not get FBT

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

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

Summary

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

August 2018 LACPA Eating Disorder SIG Event

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

Presenter: Jaye Azoff, Psy.D.

Title: The Anatomy of a Recovery

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

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

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

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

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

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

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

RSVP to:  drmuhlheim@gmail.com

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

To the Family Member Who Worries I Am Not Helping Your Loved One’s “Weight Problem”

To the family member who worries I am not helping your loved ones "weight problem"
image by Representation Matters

Dear Family Member,

I understand your fears. I get it. You want the best for your loved one. You want him or her to have the best and healthiest and fullest life possible. I do too.

You believe that helping your loved one to lose weight will help achieve these goals. Here, I disagree—I will explain below.

You believe that weight loss will lead to better health. You have heard the scary information about the dangers of obesity and know there is an all-out war on obesity. Or you have seen or heard your loved one ridiculed or judged negatively by peers because they didn’t conform to a certain size.

 

However, did you know that:

I have been working in the field of eating disorders since my training at a bulimia research lab in 1991. When I first learned to treat binge-eating disorder, a course of cognitive behavioral therapy (CBT) for binge eating was expected to be followed by a course of behavioral weight loss. However, since that time we have learned that behavioral weight loss doesn’t work. And while CBT for binge-eating disorder can be successful, it rarely leads to significant weight loss, even among those considered to be in an “overweight” weight category. However, CBT does lead to cessation of binge eating and prevention of further weight gain, which are lofty goals in their own right.

I firmly believe that bodies are meant to come in a variety of shapes and sizes. We are not all meant to be Size 0 or 2 or 4.

Take shoe size: while the average woman today has an 8 shoe size, most do not—some will have size 5 and others will have size 10. Shoe size has a normal distribution within the population.

Just as with shoe size, so it is with body weight. Every body appears to have a set point, a weight at which it functions optimally. This set point is not destined to be at the 50th percentile for every person—some will be heavier and some will lighter. Repeated attempts at dieting seem to increase a body’s setpoint, which is the opposite of what most dieters are trying to achieve.

I no longer support attempts at deliberate weight loss because I have come to believe it is not only fruitless but in fact harmful. Every day in my practice I witness the destruction left by the war on obesity and failed diet attempts. I see the carnage of past dieting, weight regain, shame and self-loathing in the form of disordered eating and intractable eating disorders. Against this backdrop, I believe that above all else, my duty to your family member is to not harm them.

There is no magic solution. Failing to fit the thin mold can be a burden. I wish I could wave a magic wand and have your loved one’s body transform into one that would not be stigmatized, would be celebrated, and would fit into all spaces. But I can’t change your loved one’s genetic body destiny, just as I can’t change any person’s ethnic background or skin color to conform to the privileged group. And I believe the solution is not to change your loved one’s body to conform—the solution is to fight to end weight stigma and the oppression of larger bodies.

Here’s what I can do:

  • I can help your loved one recover from an eating disorder, using evidence-based treatments backed by scientific research.
  • I can help your loved one work on accepting and appreciating their body and all its capabilities.
  • I can help your loved one unfetter themselves from self-imposed rules and restrictions and live a fuller life.
  • I can help your loved unburden themselves from shame and self-loathing.
  • I can help your loved one to advocate for themselves if he or she needs accommodations from a world that was not built to accommodate his or her body.
  • I can help your loved one learn to stand up to weight stigma and bullying.
  • I can help your loved one request and receive respectful health care.
  • I can help your loved one improve their relationship with food so that eating and social situations are enjoyable.
  • I can help your loved one achieve peace.

If you want these things for your loved one, please let me do what I was hired to do—guide your loved one to healthiest, best, and fullest life possible. Please examine the basis of your own hope that your loved one will conform to the thin standard. While I know this comes from a good place, it’s not pointing to the right destination. There are happier places to land. There is much work to be done. We all have weight stigma.

To learn more, I suggest reading the following articles:

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

Are We Setting Recovery Weights Too Low?

Is Weight Suppression Driving Your Binge Eating?

How Health at Every Size Can Help With Eating Disorder Recovery

Family-Based Treatment Can Help Depression and Self-Esteem Too!

FBT Depression and Self-Esteem

Family-based treatment (FBT) is a relatively new evidence-based treatment for adolescent eating disorders. It represents a paradigm shift from older treatments that focused on helping adolescents become independent from parents in order to recover from their eating disorder. In FBT, parents are central members of the treatment team and they are charged with guiding and changing their adolescent’s eating disorder behaviors. In FBT, the therapist meets weekly with the entire family, spending only about 5 minutes alone with the adolescent at the start of each session. It is designed as a standalone treatment. The adolescent is also followed by a medical doctor, but does not have additional appointments with a therapist or a dietitian.

Symptoms of depression and low self-esteem are common in adolescents with bulimia nervosa. One of the many concerns that I hear from parents considering Family-Based Treatment (FBT) for their child with anorexia or bulimia is that FBT won’t address other symptoms the child may have like depression or anxiety. Furthermore, families who are receiving FBT often feel pressured to add additional treatments such as individual psychotherapy for their adolescents to address these other issues. Even other non-FBT clinicians continue to be incredulous that adolescents can improve without other treatment. Fortunately, Cara Bohon, Ph.D. and colleagues at Stanford University recently published a paper that addresses this concern for adolescents with bulimia nervosa.

In their study, 110 adolescents with bulimia nervosa from two sites were randomly assigned to receive either individual Cognitive Behavioral Therapy (CBT) for adolescents or FBT. Cognitive-Behavioral Therapy (CBT), which is the most successful treatment for adults with eating disorders, focuses on understanding the factors maintaining the bulimia symptoms and developing strategies to challenge problematic thoughts and change behaviors. The therapist meets weekly with the adolescent. The two treatments are of comparable lengths.

Results showed that both FBT and CBT significantly reduced symptoms of depression and improved self-esteem. Previous papers suggest that abstinence from eating disorder symptoms occurs faster in FBT when compared with CBT for adolescents with bulimia nervosa. Thus, FBT may be a better option in many cases.

It is important to dispel parents’ fears that FBT will not adequately address depression and self-esteem. The authors state in the paper, “This concern can subsequently steer families away from an evidence‐supported approach in favor of therapies that may not be as successful in reducing binge eating and purging.”

In fact, the researchers point out that it may be that the cycles of binge eating and purging of bulimia serve to maintain depressive symptoms and poor self-esteem. Thus, one may not need a treatment that directly targets depression.

Dr. Bohon stated, “The reason we conducted this study is because comorbid depression is the norm with bulimia nervosa, and it was important to establish that you don’t automatically need any extra treatment to see improvement in the context of FBT. Obviously, if someone is still struggling after completing FBT, a referral for CBT for depression or another evidence-based treatment would be important, but it is likely not needed for most individuals.”

Source

Valenzuela, Fabiola, James Lock, Daniel Le Grange, and Cara Bohon. 2018. “Comorbid Depressive Symptoms and Self-Esteem Improve after Either Cognitive-Behavioural Therapy or Family-Based Treatment for Adolescent Bulimia Nervosa.” European Eating Disorders Review: The Journal of the Eating Disorders Association26 (3): 253–58. https://doi.org/10.1002/erv.2582.

Are We Setting Recovery Weights Too Low?

 

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

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

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

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

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

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

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

How Are Recovery Weights Established?

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

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

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

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

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

Lebow and colleagues concluded that:

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

Why Might Providers Set Recovery Weights Too Low?

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

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

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

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

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

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

The parent responded:

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

What Do Parents Say About Recovery Weights?

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

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

Summary of Recovery BMI

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

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

BMI 21-22      4

BMI 22            3

BMI 22-23      4

BMI 23            1

BMI 23-34      5

BMI 24            4

BMI 24-25      4

BMI 25            4

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

Stay Tuned for A Survey For Parents

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

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

Sources

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

On Empowering Parents—Not Pathologizing Them

Empowering Parents I often write about the importance of including parents in the treatment of adolescents and young adults. My work is informed by my training in Family-based Treatment (FBT), which as a central part of treatment seeks to empower parents to help their ailing children with eating disorders to return to health. When asked why families should be the center of treatment, I usually cite the AED guidelines on the role of the family, The Nine Truths About Eating Disorders, and the vast evidence base underlying FBT. I often discuss how providers who see families with children with eating disorders get a distorted view of the family: they do not have the benefit of having seen how it functioned prior to the eating disorder. Parents’ behaviors are often pathologized when they are actually the normal response of healthy parents to a child in distress.

This post is different—here I will share a more personal perspective.

Recently, one of my children (anonymized here because the story is theirs to tell) stumbled. My child was fighting a mental health issue that was not an eating disorder. The experience of watching my child struggle, and struggling to help my child, has further informed my thinking on this issue.

Sadly, it remains common for parents of children, adolescents, and young adults with mental health problems to be judged, labeled, blamed, and excised from the child’s treatment. This has happened to families with whom I have worked. Parents have sometimes been labeled as “enmeshed” or “overprotective.” This is not productive.

I’m writing this blog to share how beneficial it was personally to be included in my young adult child’s treatment. First, let me give you some background.

For Most of My Parenting Years, I Was Balanced

I care for my children deeply and have chosen a career that has allowed me the flexibility to be present in their lives and to be their primary caretaker. At the same time, I have been anything but a coddler. All three of my children were sleep-trained at less than six months, left at a young age with non-family babysitters, and dropped at preschool on the first day. I shed some tears, but I was not a parent who stayed and watched outside of the classroom for months; I went to work.

I also developed a certain toughness to set limits. During my kids’ early years, I worked at Los Angeles County Jail, where I encountered numerous inmates demanding sleeping medications or “more desirable” housing assignments and then threatening suicide when they didn’t get their way. I became a pro at placing inmates on suicide watch and walking away despite their sometimes yelling at the top of their lungs that they would tell the entire jail, “It’s because of you, Dr. Muhlheim, that I will kill myself.”

I am not a perfect mother, but I am a highly dedicated, devoted one. I have sought to balance my joy in raising my children with time to pursue my own interests and career.

When My Child Started to Struggle I Became Highly Involved

When I work with parents of teens and young adults with eating disorders, I encourage parents to trust their instincts. “Parents know their kids best,” I tell them. During the transition to college, when my child was supposed to be individuating, I knew something was amiss, so I hovered more than usual.

Fortunately, when my child wobbled, I was prepared. I trusted my instincts. I was fully present: watching, standing close, getting my child help. I helped save my child’s life. There are powerful cultural expectations that parents should back off and allow their child to individuate. There is less support for parents who choose to step in at this moment. Observing my behavior at that time, I may have been labeled as overprotective.

Even my child, who recognized the need for parental help, was fighting against it. This was confusing to their therapist, who later wrote in a report, “There is a weird dichotomy between the child and the parents. The child refuses to sign a release of information for the therapist to speak to the parents, but the child appears to reach out to the mother for support.”

Rather than pathologizing hovering parents, we need to recognize that they are doing it for a reason.

Professionals Supporting, Not Blaming Parents

The hardest moments of this whole journey were those times that, on top of his worry for our child and whether they could or would actually recover, my husband blamed himself for causing the problems our child was facing. This tendency of parents—to blame themselves for any problem that befalls a child—is typical, whether or not the problem could be attributed to parenting. I noticed that when my husband started to blame himself, we both became hopeless and lost focus on helping our child. These were dark times—it was hard to have our own faith and be present for our child.

Fortunately, we had the means to seek out high-quality treatment. Our child was treated in a center that specializes in treatment often used for a problem for which parents have historically been blamed. In this program, we as parents were given much-needed support and services as well. Importantly, the clinicians never indicated they believed that we had caused our child’s problems. Instead, we were validated, supported, and given a framework for understanding our child’s problems that did not point the finger at us.

Made/Makes All the Difference

Further, our responses to our struggling child were validated as a reasonable response to experiencing our child’s struggles. We were supported in our child’s recovery, empowered to play a role, included in the treatment, and seen as parents doing our best. This was profound. I think it made all the difference.

Our child worked hard and so did we. With the proper help and our support, our child is now healthy and firmly back on track. My hope for other parents of floundering adolescents and young adults is that they are treated with the same respect that we were.

How To Choose A Supplemental Nutrition Shake

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

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

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

Caloric Density

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

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

Macronutrient Comparison

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

Macronutrients are often measured in terms of “exchanges”:

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

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

Ingredients

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

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

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

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

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

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

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

 

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

 

Ensure Product Family

Ensure brand nutritional supplementsEnsure Original

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

Calories: 220 calories per 8-ounce serving

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

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

EDTLA TASTE RATING: Not tasted

Ensure Plus

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

Calories: 350 calories per 8-ounce serving

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

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

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

 

Ensure Enlive

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

Calories: 350 calories per 8-ounce serving

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

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

EDTLA TASTE RATING: Strawberry flavor 8

 

Ensure Clear

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

Calories: 200 calories per 6.8-ounce serving

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

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

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

 

Boost brand nutritional supplementsBoost Product Family

Boost

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

Calories: 240 calories per 8-ounce serving

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

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

EDTLA TASTE RATING: Not tasted

 

Boost Plus

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

Calories: 360 calories per 8-ounce serving

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

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

EDTLA TASTE RATING: Chocolate flavored 6; Vanilla flavored 5

 

Boost Breeze

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

Calories: 250 calories per 8-ounce serving

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

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

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

 

Store brand nutritional supplementsStore Brands

Rite Aid Original Nutrition Shake

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

Calories: 220 calories per 8-ounce serving

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

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

EDTLA TASTE RATING: Chocolate flavored 6

 

CVS Nutritional Shake

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

Calories: 220 calories per 8-ounce serving

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

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

EDTLA TASTE RATING: Milk chocolate flavor (not tasted)

 

Kroger Nutrition Shake Fortify Plus

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

Calories: 350 calories per 8-ounce serving

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

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

EDTLA TASTE RATING: Chocolate flavored 6

 

Orgain brand nutritional supplementsOrgain Organic Nutrition Product Family

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

Complete Protein Shake-Sweet Vanilla Bean

Designated as Grass Fed Dairy

Calories: 250 calories per 11-ounce serving

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

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

EDTLA TASTE RATING: 4

 

Plant Based Protein Shake-Smooth Chocolate

Designated as Vegan & Dairy Free

Calories: 220 calories per 11-ounce serving

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

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

EDTLA TASTE RATING: 4

 

Kate Farms Product Family

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

 

Komplete

Calories: 290 calories per 11-ounce serving

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

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

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

 

Core Essentials Standard Formula 1.0 cal/mL:

Calories: 325 calories per 11-ounce serving

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

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

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

 

Core Essentials Peptide Plus 1.5 cal/mL:

Calories: 500 calories per 11-ounce serving

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

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

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

 

Other Brands/Products

Benecalorie brand nutritional supplementsBenecalorie

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

Calories: 330 calories per 1.5-ounce serving

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

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

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

 

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

April 2018 LACPA Eating Disorder SIG

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

Date: Tuesday, April 24th at 7:00 pm 

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

Title: Understanding Brain Development in the Treatment of Eating Disorders

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

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

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

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

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

RSVP to:  drmuhlheim@gmail.com

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