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.


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).

Binge Eating Disorder Dieting

Is Weight Suppression Driving Your Binge Eating?


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.


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.

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.

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.

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.

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.

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.


Adults with ARFID


Avoidant Restrictive Food Intake Disorder (ARFID) was only recognized as a disorder affecting those older than age 6 as recently as 2013. Treatment and recognition of this disorder are in their infancy. Thus, many people with ARFID have lived with it for years without any treatment. Many adults with ARFID have simply had to learn to cope with it on their own.

I have been facilitating a free support group for adults with ARFID in California for the past two years.  During this time over 80 people have come through the group. This has given me a window into what life is like for adults with ARFID.

What is ARFID?

ARFID is an eating disorder in which difficulty in eating enough food negatively impacts either the patient’s health or their ability to manage school or career and social life. Unlike anorexia nervosa, bulimia nervosa, or binge eating disorder, insufficient eating in ARFID is not primarily driven by the desire to modify one’s shape and size.

It is important to recognize that ARFID is a heterogeneous disorder. There are three main types.

  • Sensory sensitivity. People who have sensory sensitivity have often been picky eaters since childhood. They may be very sensitive to differences in taste and texture and cling to a narrow range of foods, most often struggling the most with vegetables, fruit, and meats—the foods most likely to have been poisonous to our ancestors.
  • Low interest. Also often developing in early childhood, people with low interest tend to have less interest in eating, experience less hunger and find food less rewarding. It is theorized that these people may be born with relatively low hunger hormone levels
  • Aversive consequences. This type tends to develop later in life in those who have a predisposition to be anxious. In response to a triggering event—such as having the stomach flu or watching someone choke—people may fear potential negative events such as vomiting, choking, or gastrointestinal distress that can occur after eating. As a result, they may start to phobically avoid eating certain foods or eating altogether.

People with ARFID often have more than one type, and they may also have another eating disorder such as anorexia or bulimia, or a history of one.

There is one promising treatment for adults with ARFID and that is CBT-AR. While this can help many, my group illustrates that this treatment is hard to access and may not adequately address all the impacts of living with this disorder for many years. In fact, the creators of CBT-AR acknowledge that successful treatment will not likely make a person “a foodie” and there may be residual features.

Impact of Living with ARFID

While there is a multitude of differences among the people with ARFID, here are some common themes.

Being misunderstood. Many adults with ARFID report a long history of not knowing what was wrong with them, families not understanding how to feed them, and even professionals providing misdiagnoses (e.g., anorexia). Those who did receive treatment almost always report that they were treated as if they had anorexia—treatment providers refused to believe they did not have body image concerns that were driving their restriction. Most reported not fitting into traditional eating disorder spaces and many report never having met another person with ARFID.

Shame. Many adults with ARFID report shame about their limited diet or about their preferred foods. They feel embarrassed when they order off the kids’ menu or modify meals at restaurants or are unable to eat with peers. Some have been teased about their narrow palate. They report feeling very self-conscious when others ask about their eating struggles.

Overwhelmed by having to provide meals for themselves. When I assess people with ARFID, one of the questions most universally endorsed (from the PARDI, an assessment measure) is “I find eating to be a chore.” People with ARFID don’t typically look forward to eating; even so, they have to ensure they eat, usually 5 to 6 times a day to maintain a minimum healthy weight for their bodies. When eating is a chore, unrewarding, perhaps even terrifying, this can be a heavy burden.

Many have trouble preparing their own meals.  These people can benefit from support and structure. A participant who did fine as long as meals were provided by their workplace, started to struggle only during the pandemic when they started to work from home.  Many adults with ARFID have trouble identifying any foods that appeal to them and find choosing foods overwhelming.

Social consequences. The problems with eating have reverberations much beyond eating. It often significantly impacts social interactions because so many social interactions involve meals.  Many adults report their ARFID limits their ability to socialize. They may dread eating with others or socializing at all, feel left out when others are sharing food, and be so repelled by the food eaten by others that it is hard to even sit with them. One group member reported that whenever someone tried to comment on their food choice they would deflect to change the conversation. Others feel guilt for placing limits on where their friends can eat with them.

Sensory overwhelm. Many have sensory “superpowers” which can be more of a curse than a blessing. Many in the group report such a sensitivity to smells that they cannot be around others eating certain smelly foods, a disinterest in eating if something has been prepared in the kitchen or microwave before them. Several adults report problems with doing the dishes after meals because of disgust around the smells and residue on the dishes. People with ARFID report having to use various strategies to manage dirty dishes.

Difficulty with flexibility. Similarly, many adults with ARFID report strong allegiance to particular brands or restaurants and have great difficulty if any aspect of a preferred food is varied. Many can report that others have often tried to pass off a different product as “the same” and they can always detect a difference. This makes eating in different locations and especially travel, particularly hard.

Anxiety. Anxiety is a common experience for adults living with ARFID, especially in those with a fear of aversive consequences presentation. Research indicates that people with ARFID often have other anxiety disorders, including OCD. Many individuals with ARFID experience anxiety in areas besides eating.

Gastrointestinal distress. Overlap with disorders of gut-brain interaction (DGBI) are common. Many with a history of gastrointestinal (GI) symptoms may restrict eating in order to avoid further symptoms. An individual with ARFID may be more sensitive to sensations in their body and digestive tract.  They may also have a predisposition to anxiety which can contribute to GI symptoms. Nausea is a common sensation and several group members report assistance from medications that help with nausea.

Neurodiversity. Many group attendees self-identify as neurodivergent. Although research is limited, many researchers and providers have noted the overlap between ARFID and autism or attention deficit hyperactivity disorder (ADHD). Individuals with autism often have greater sensory sensitivity and rigidity, features that overlap with symptoms of ARFID. People with ARFID and neurodivergence may also struggle with issues of attention, information processing, and social interactions.


We need more resources for adults with ARFID as demonstrated by the participants in my group and their desire to learn more about their condition and to educate others. We are collaborating with other professionals to share and develop more resources for people with ARFID.

ARFID Groups

We have a FREE weekly Adult ARFID support group for adults in California with ARFID.

We also have a monthly support group for parents of people 10 to 20 with ARFID, open to people in any location.


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.

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.



  • 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


  • 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.


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.


ARFID Parent Support Group

We welcome parents of youth 10 to 20 with Avoidant Restrictive Food Intake Disorder (ARFID) to our virtual support group.

Parenting a young person with ARFID is challenging. Feeding a young person with ARFID is extremely challenging. Meals may feel like a constant struggle. You have likely been given conflicting advice about whether to cater to their food preferences or not. You may feel like you’re running ragged searching for their preferred brand of yogurt or chicken nuggets or having to bring home the exact right fast food every night. You may have run out of ideas for what to serve them. They may be eating the same eight foods over and over again and the list of foods they are willing to eat only seems to get smaller over time. You feel worried about their health and you know they are not getting enough nutrition.

We have been supporting parents in supporting their teens with ARFID. Our work is rooted in Family-Based Treatment for adolescent eating disorders and Cognitive-Behavioral Therapy for ARFID. In our work with families of teens with ARFID, we see how hard it is to parent and feed and support recovery. This is why we have created a monthly support group for parents of teens with ARFID.

This monthly group is alternately led by Lauren Muhlheim, Psy.D., CEDS-S and Carolyn Comas, LCSW, CEDS-S over zoom. We will provide psychoeducation about ARFID, the different types of ARFID, how it may develop, maintaining factors, and recovery strategies. Parents will be able to share struggles and successes.

To Register

For more information about the group, please contact or you may register for the monthly group (priced at $30) on our group page. (Please be sure you are registering for our monthly ARFID Parent group and NOT our free weekly Adult ARFID group.


Below are some strategies for supporting your teen with ARFID:


Dieting Eating Disorders Family based treatment teen eating disorder

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

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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.

Eating Disorders Family based treatment

Externalizing an Eating Disorder: When, Why, and How Do You Do That and Who is “Ed” Anyway?


Externalizing an eating disorder is a therapeutic strategy that became more widely known through Jenni Schaefer’s book Life Without Ed, cowritten with her therapist Thom Rutledge. The book summarizes Jenni’s recovery from an eating disorder.

Jenni describes how in her treatment she learned to personify the eating disorder as “Ed,” an abusive boyfriend. As explained in the blurb on her website, “By thinking of her eating disorder as a unique personality separate from her own, [she] was able to break up with Ed once and for all.” The book details the various exercises she used in her recovery, including creating a formal “divorce decree” with the eating disorder and pushing back on him at every turn. In an Academy for Eating Disorders tweetchat (2014) on the topic, Jenni Schaefer tweeted, “Ed could say whatever he wanted. To be in recovery, I had to make the decision to disagree with and disobey him.”

This “externalization” strategy is borrowed from narrative therapy. A key principle of narrative therapy is that the person is not the problem – instead, the problem is the problem. The problem is viewed as something with which the person is in a relationship, not as something that is part of the person. It follows then that the person can separate themselves from the problem and reduce its effects on them.

Family-based treatment (FBT), the leading evidence-based treatment for adolescent eating disorders, adopts narrative therapy’s externalization strategy in dealing with the eating disorder. The perspective taken by FBT clinicians is that the teen must be extricated from the eating disorder’s clutches.

When working with families, the FBT therapist encourages them to treat the eating disorder as an external force that has invaded the teen and hijacked their brain. Some families will even name the illness after a favorite villain such as “Voldemort” or refer to it as “the monster.” The therapist then rallies parents and other family members to unite against this common enemy to help their teen fend it off.

Many patients and family members can relate to this externalization strategy because the teen does appear to transform into a “different person” under the spell of the eating disorder, especially around mealtimes. This externalization allows families to reframe the situation: the teen does not want to restrict their eating—instead, that the eating disorder is an alien force that makes them restrict their eating.

While both Life Without Ed and FBT have given externalization popular traction, research has not definitively answered whether it is a helpful technique. While we do have research showing FBT to be highly effective, FBT includes so many elements it’s possible that it might work without the externalization component. In order to know for sure, we would need special research in the form of dismantling studies that test each individual element of a full treatment—to determine the role of externalization on the overall treatment outcome. There is one recent qualitative paper that studied the process of externalizing the eating disorder.

What are some advantages of externalizing the eating disorder?

  • It offers a convenient and relatable metaphor: “The eating disorder is possessing you.”
  • It can make it easier to call out certain behaviors as problematic even if they do not feel troubling to the patient themselves.
  • Experiencing the eating disorder as an unwelcome invader may help marshal the patient to fight back against it.
  • Redirecting the anger of families and caregivers towards the eating disorder allows them to retain compassion for the patient.
  • It puts everyone on the same team battling a common enemy: the eating disorder.
  • It can help the patient become accountable for their own recovery by learning to rebel against and defy Ed.

Reasons you might not want to externalize the eating disorder

Some professionals worry that giving the eating disorder its own persona gives it too much power and might encourage patients to blame the eating disorder while absolving them of any responsibility for recovery. Some people find externalization too trendy and are put off by it.

According to the qualitative paper by Voswinkel and colleagues (2021), there were mixed perceptions about externalizing by patients interviewed. Some people with eating disorders feel like the eating disorder is a part of them and felt they were not taken seriously or criticized by externalization. Many of the characteristics of patients with eating disorders—such as perfectionism—are actually personality traits that by themselves are not problematic. So by associating these characteristics with an external agent, there is a risk of inadvertently criticizing the patient. People with eating disorders may find the externalization technique dismissive or invalidating of their experience and may become angry when their family members externalize the eating disorder.

So, should you do It?

Clinicians and family members considering externalization should assess the potential risks and benefits of this technique. If you are a person with an eating disorder and this metaphor makes sense to you, you can learn more about the strategy by reading Life Without Ed. If you are a family member of a person with an eating disorder and/or a parent doing FBT, it can also be helpful to consider this as a strategy for talking about the eating disorder with your loved one. Life Without Ed is also good reading for parents and even some teens in recovery.

It is always a good idea to check with the person with the eating disorder about how they perceive externalizing. If you are supporting a person in recovery and they dislike your ascribing the eating disorder its own persona, then you can refrain from talking about it in front of your loved one but still use it as a way to frame your own understanding of the situation.

Eating disorder expert Carolyn Costin, MA, MED, MFT suggests a similar but alternative strategy to externalization: think of the patient as having two aspects of their own self, a “healthy self” and an “eating disorder self.” Eating disorder researcher Kelly Vitousek, Ph.D. offers another option: abandon the metaphor altogether and explain these behaviors to the patient as symptoms of starvation. These alternatives to externalization might be preferable to some people with eating disorders.

Finally, it is important to emphasize that, regardless of the way an eating disorder is framed, behavioral change is critical for recovery. Many of the symptoms and dangers of an eating disorder can be related to nutritional deficits and these symptoms are often improved with proper nutrition and normalization of eating behaviors.


Easing Grief Through Connection (Coping Strategy for the Holidays)

By Carolyn Comas, LCSW

Grief can be complicated and a painful process. This holiday season many of us are experiencing the loss of the past year we were supposed to have. For those who have lost someone special this can compound the difficulty of this years’ holiday season. 2020 has not been easy for many of us and finding joy during the holiday season may feel challenging.

Many years ago when I was first starting out as a therapist I was seeing a client for grief counseling. This client shared with me something I had never heard about. They discussed that when you find a dime it is a sign the person you’ve lost is reaching out to you. It is a sign they are with you. This client told me how they had been finding dimes all over the place. That evening, after having met with that client as I was packing up to go home, I looked down by my chair and noticed a dime.

This concept was not lost on me years later after my own mother died. I would find dimes all the time and kept each one that I found. In a grief support group that I was in many of the group members shared about the signs they received from their loved ones. Some talked about coins they found, some said it was a certain type of bird they’d see, and for others a certain song that came on the radio. What I learned was that it did not really matter what the thing was but how that thing  we found kept us connected to the person we love. It brought comfort. It brought peace. It brought healing.

It is okay if you are not spiritual or religious. A sign doesn’t have to signify anything more than a memory or a feeling of connection to that person. Right before Thanksgiving this year my brother sent me a picture of a sweater he saw at a yard sale. It was adorned with carousel horses. My mother was obsessed with and collected all types of carousel horses. In that instant I had goosebumps. “She’s with you,” I said. And he agreed. “I feel it,” he said. “It is nice to think she is here with me.”

Coincidentally, my mom also collected dimes that she found as she believed they were messages from relatives and friends she had lost in her life. I didn’t know this until my dad told me after I shared with him about my new coin collection. Knowing this was something my mom also did made finding a shiny dime even more special. It  really makes me feel like she is with me.

Losing someone you love can be difficult. Finding ways to stay connected through a sign is one way to ease the pain and bring comfort to your aching heart. During this holiday season, if you are struggling with the loss of a loved one think about something that connects you to them. Is there a holiday tradition you use to do together or a song you both sang? Maybe there was a food that was enjoyed together that you could make now. Whatever it may be, know that this could potentially help with healing from the loss you feel during this holiday time or during any time of the year.

Eating Disorders Evidence-based treatment

Structuring Your Eating Disorder Recovery Environment


Recovery is challenging! I am repeatedly moved and impressed by the courage of my patients as they work through recovery from an eating disorder. One strategy that can help support recovery is a careful ​structuring of one’s recovery environment. This applies to adults working individually in treatment as well as to families helping adolescents to recover.

Most evidence-based treatments including cognitive-behavioral therapy (CBT) suggest that patients consider the timing of the start of treatment and potentially postpone it if they anticipate major distractions that will impede recovery. Similarly, it can be helpful when possible to try to minimize challenges.

Recovery looks different for everyone. Some patients are ambivalent about treatment and the changes it will require. Others are eager to be recovered from their eating disorder and just want to get on with life. And many may feel the urge to rush recovery. But I encourage you to “take it slow.”

Recovery 101

As a behaviorist, I like to think of recovery as a set of skills that are learned, developed, and practiced in increasingly challenging environments. Whether you are transitioning to an outpatient level of care or beginning treatment as an outpatient or supporting a teen in recovery at home, those first few months should be treated like “Recovery 101.” This is a training phase in which you are first learning and trying out recovery skills. Your abilities will become more fine-tuned as you practice increasingly difficult skills.

In this phase, it is best to be in a highly structured environment without too many complexities. Most people do best with structure. This is why settings housing large numbers of people tend to be highly structured. (I know – I worked in LA County Jail for 10 years.) This is also why higher levels of care with the sickest patients are highly structured. Structure makes things predictable and reduces anxiety.

In a structured setting, it is easier to follow a routine, such as eating at a regular time, having a familiar meal, and facing fewer distractions. Chaotic and unstructured environments are unpredictable, are more challenging for recovery, and require more advanced and flexible recovery skills.

The Challenge of Environment

In Recovery 101, it is often easiest to start by keeping things simple and predictable. Each element that adds complexity or uncertainty to the environment presents an additional challenge to someone with an eating disorder. Novel situations, different foods, different food venues, and different companions can all bring anxiety to those in early recovery. Any deviation from a routine requires additional skills, so handling each of these should be viewed as a new skill to master.

We can think about this as a ladder with each rung adding new difficulty. At the bottom is generally eating meals at home with support from immediate family. The next rungs might include:

  • Having friends or relatives over for dinner
  • Eating at a close friend’s house
  • Eating at a restaurant where individual entrees are served
  • Eating at a family-style restaurant
  • Eating at a buffet.

Each higher rung on the ladder requires more decisions and thus more skill. Each skill must be practiced.

Take it Slow

Many patients are tempted to climb the ladder quickly, rushing towards the more complicated and challenging situations. This is not advisable when someone is in Recovery 101. Some challenges are better left until recovery skills are stronger, if at all possible. It is easiest to learn skills first in one place and then to practice them in different settings. It is in this way that skills will generalize.

More advanced challenges that may best wait until the basic skills are mastered will vary from individual to individual, but these can include situations such as:

  • Weekend schedules when you have slept late (do you count brunch as breakfast or lunch and how do you handle the rest of the meals when your first meal is 3 hours late?)
  • Cooking for oneself
  • Going to unfamiliar restaurants
  • Eating at a small-plates, buffet, or family-style restaurant
  • Foreign travel to countries where the foods may be entirely unfamiliar

Instead of taking on advanced challenges all at once, consider potential ways to structure the environment during early eating disorder recovery:

  • Having meals planned out for the entire week
  • Eating meals at regular times
  • Regular grocery shopping
  • Having a backup plan (in case you run late or a plan changes)
  • Always carrying snacks (and backup snacks)
  • Planning alternative activities for high-risk times (for many patients that is evenings spent at home. For one patient, that meant going out on evenings her husband would not be home for dinner.)
  • Limiting meals at unfamiliar restaurants
  • Only bringing into the home small quantities of foods on which you have binged
  • Having a support person you can call
  • Structured schedules for every day of the week, including weekends
  • Careful planning ahead (with your team if you have one) for any situation you have not yet practiced

Keep in mind that you may experience setbacks. Sometimes you have to go back down the ladder before going back up again. This is a normal part of recovery.

When recovery is further along, you will be better able to handle more complex and challenging situations. Flexibility will come, but for now, keep it simple.


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