Childhood Eating Disorders Blog

I’m just back from a great conference, which I’ll be telling you more about. But first let me tell you about Jane Fonda’s keynote speech. Fonda brought many eating disorder professionals, including me, to tears with the story of her recovery from an eating disorder during her keynote presentation at the Renfrew Center Foundation Conference for Professionals last week in Philadelphia.

At times reading from her candid 2006 memoir My Life So Far, Fonda told us that as a school girl she had learned to binge/purge from a friend in boarding school. The reason she kept on bingeing and purging, she said, was the belief that she had to be perfect and thin to be loved by her father. She pointed out that she didn’t think her father meant to cause her harm but that generations of Fonda men had openly preferred really thin women. Jane’s open, non-apologetic description of how she fell into a life dominated by an eating disorder was heart wrenching.

Fonda ended up suffering for over 30 years with a “half-crippling” eating disorder that became a “real addiction.” She compared her periods of anorexia as being a “dry drunk,” meaning that she wasn’t bingeing or purging but she had all the other aspects of an eating disorder. She finally realized that she was either going to die — maybe not physically because she hadn’t needed to be hospitalized, but spiritually– if she did not stop her eating disordered behaviors cold turkey. She later did counseling, noting that it is much harder for adults to recover from eating disorders than teenagers. She reminded her audience that as hard as recovery is to achieve, it is accompanied by profound growth.

When asked by an audience member about Hollywood’s contribution to eating disorder, Fonda said that she felt that the media’s scrutiny of the bodies of female celebrities contributes to eating disorders among women and young girls.

Marcia Herrin and Nancy Matsumoto, authors of The Parent’s Guide to Eating Disorders, 2007

Dear Readers,

                Since one of us grew up there, we feel we have the right to say that California is a strange place. It’s on the cutting edge when it comes to environmental and energy issues, and is the hotbed of the so-called liberal elite. But it is also the state that elected both Ronald Reagan and Arnold Schwarzenegger, and just passed a ballot proposition reversing the legality of same-sex marriage. The latest salvo in the food and nutrition wars also comes from the kooky left-coast state, in the form of the outlawing of the school bake sale.

                In the recent New York Times article, Bake Sales Fall Victim to Push for Healthier Foods, Patricia Leigh Brown reports that the school bake sale is “fast becoming obsolete” as a result of strict nutrition standards governing public schools that restrict the percentages of sugar, fat and saturated fat in foods sold on campus during the school day. California may have started this trend by passing this strict nutrition law in 2005 and putting it into effect in July 2007, but nationwide, more and more school districts are adopting similar nutrition standards, some even tougher than California’s.

                The movement, of course, is fueled by concern over obesity rates in America. As we have noted in our post, Should College Dining Halls Post Calorie Counts?, the goals of well-intentioned anti-obesity crusaders can sometimes conflict with those of people suffering from eating disorders. This is especially clear in the Times’s account of an Oakland, CA elementary school teacher who taught her students about “good foods” versus “bad foods,” and offered them healthy snacks.

                We’re all for healthy snacks, but telling kids that they shouldn’t eat certain foods makes these foods more enticing to some and makes others kids feel guilty for enjoying these foods. A very good predictor of risk for developing an eating disorder, in fact, is when one begins to categorize foods as “good” and “bad.” We need to teach kids to enjoy balanced meals including dessert and moderately sized snacks. It’s consuming too many calories that causes obesity, not eating so-called “bad” foods.

Demonizing and banning certain foods, we fear, will lead to an increase in both eating disorders and obesity.

                Labeling foods as “good” or “healthy,” may seem pretty benign, but it can be as harmful as demonizing foods containing high percentages of sugar or saturated fat.  We have seen kids who feel that as long as a food is good for them they can eat unlimited quantities, a practice that can result in a variety of physiological problems, including bulimia, binge eating disorder and obesity.

                The bottom line: these schools are making a big mistake by banning bake sales and preaching the gospel of good versus bad foods.  Several recent studies even suggest that schools may not play as big of a role in the way kids eat as most people believe. Check out this recent New York Times story, Are Schools Really to Blame for Poor Eating?  to read more about these studies, which seem to indicate that no matter what the school’s nutrition policies, the biggest unwanted weight gain among students occurs during the summer, when school is not in session. Hear that, parents?

Take care,

Marcia and Nancy

The holidays are nearly here again, and for families where over- or undereating is an issue, these food-oriented festivities, which kick off with Thanksgiving, can be fraught. Here, we offer a few tips on how to handle this challenging time of year. They are applicable to families dealing with an eating disorder or for anyone who wants to eat healthily during the holidays

·         Try making your family’s holiday traditions more about relationships and activities than about food.

·         Don’t skip meals or plan to undereat or diet the day following a family holiday.

·         Do what you can to keep the variety of dishes reasonable and minimize food that is left out for grabbing and snacking.

·         Talk to other family members in advance about not pushing food or commenting on diets, calories, or weight loss. Even too much emphasis on trying to make healthy choices at holiday meals can add to the stress.

·         It is particularly important if your child is recovering from a serious eating disorder to have pre-warned family members about the kind of talk and attention that is appropriate. I suggest that parents develop a kind of code or signal that tells family members or other guests, “change the subject, and fast!”

·          Because meal schedules may be altered and more snack foods and desserts are served during the holidays, it’s important that parents of an eating-disordered child be extra-solicitous and vigilant. If circumstances conspire to create a level of stress that interferes with your child’s recovery, you and your child should sit down and prioritize the extras in your lives. Remember that the first item on your list of important things to accomplish – even during the holidays — should be your child’s recovery.

My patient Jane’s treatment was in its early stages when she faced her first family Thanksgiving meal. As much as her parents wanted her to be able to fully participate in the traditional meal, it was clear that Jane was far from ready. Jane, her parents, and I decided that the best approach was to carefully plan in advance what Jane would eat, focusing on taking care of the basic food groups: protein, carbs, calcium, fat, veggies, and what we call “fun foods,” or treats eaten purely for enjoyment. We agreed that Jane could eat some turkey for protein, a slice of bread and butter for carbs and fat, a glass of milk, and green beans. We decided Jane could bring a fun food from home that felt “safe.”

Holiday meals can also be a time for progress. Sarah, a freshman in college and a patient of mine recovering from anorexia, is excited about participating fully in her family’s Thanksgiving for the first time in years. Sarah knows that her grandmother will start the family festivities by serving a traditional Italian meal in the early afternoon. A few hours later, out will come a full Thanksgiving meal with all the trimmings. Sarah knows that she needs to have her usual good breakfast, to think of the Italian meal as lunch and the traditional Thanksgiving meal as dinner. Sarah’s parents are ready to negotiate serving sizes and other choices if she needs help.

We hope that these tips will help you all enjoy the spirit, the meaning, the fun and the foods of the holiday season!

Marcia and Nancy

Dear Readers,

We recently received this comment from a reader, Karen F. Chambre:

“I am very interested in the mental health parity law. A law has already passed in California. A main problem is that some of the insurance companies have is they find loopholes and do not offer parity for parity diagnoses. Is this new law different?”

I’ve written about the mental health parity law a few times on this blog since the law includes eating disorders and has been a major focus of eating-disorder advocates. Here is an answer to Karen’s question and an update on the legislation.  I found this good document on the Web site of the Mental Health Association in California, which explains the impact that the new federal legislation will have in California. The new law won’t take effect until January 1, 2010. 

 A spokesperson for U.S. Rep. Patrick Kennedy’s (D-RI) office offered these further explanations on how the new mental health parity law will close loopholes found in the existing 1996 law:

·         The current law merely prohibits health plans from offering lower annual or lifetime benefits for mental health coverage than for physical health coverage.  Most plans get around this requirement by imposing additional treatment limits or cost-sharing (higher co-pays) for mental health care, both of which are allowed. The legislation just passed closes this massive loophole by no longer allowing most health plans that cover mental health to require patients to pay, say, 50% coinsurance for mental health outpatient services when other outpatient services require only 20% in cost sharing. Nor does the new law allow health plans to cap psychiatric inpatient stays at 30 days if they allow unlimited stays for treatment of other conditions.

·         While many states have parity laws on the books, ERISA (non-governmental pension and benefit) plans are not covered under these laws. The new federal legislation brings ERISA plans into the fold, vastly increasing the number of Americans the law applies to.

      ·          State mental health parity laws that are less stringent than the new federal parity law will be overridden      by the new law. 

If you would like to read a good summary of the bill, which was pushed through as part of the federal government’s notorious $700 billion bailout package, check out this page of the Bazelon Center for Mental Health Law’s site.

Take care,

Nancy

One of our readers, Shane, asked a great question about the difference between being an “abstinent” eating disorder sufferer and being fully recovered. Marcia responds, “This question reminds me of a college student I work with who has not had an episode of bingeing and purging for almost six months. She knows she isn’t recovered, though, because she still thinks obsessively of food and counts calories. She’s working with me so that she will be able to enjoy food without worry.”

            Harvard’s Dr. David Herzog has done the most work on defining what it means to be recovered from an eating disorder. He wrote a seminal academic paper in 1999 in which he defined recovery as a substantial enough improvement that the formerly eating-disordered person is able to lead a productive life without medical or psychiatric impairment. So if you at one time needed intensive counseling and/or occasional hospitalization and can now live a normal life with only occasional nutritional, medical or psychological support, you could be considered “recovered.”   

            For the anorexic this means maintaining a healthy weight, normal menstrual function, and much-reduced obsession with weight. For the bulimic, it means refraining from bingeing and purging. To answer Shane’s question directly, we would say that abstinence implies maintaining health and not engaging in eating-disordered behaviors, but holding on to the obsession with weight and other eating-disordered thoughts. In other words, you may still be obsessed with food, weight and have poor body image, but you don’t act on those thoughts and feelings.

            We hope this answers your question, Shane.

Take care,

Marcia and Nancy

Dear Readers, This weekend, Nancy and I read about efforts in Michigan to publicize the oft over looked fact that boys get eating disorders too. One of the organizers of these efforts is the mother of a Michigan boy who died at the age of 22 from an eating disorder. The boy’s eating problems started when he, wanting to look buff, began undereating and overexercising the summer before entering high school.

Because of our worry that early warning signs in boys may go unnoticed because parents, teachers, coaches, even doctors and other adults in the child’s life may believe that eating disorders are a “girl problem,” we devoted an entire chapter to “Boys” in our book, The Parent’s Guide to Eating Disorders, 2007, Gurze Press. It is usually harder for boys to ask for help for an eating disorder because of the embarrassment of admitting that having a girl’s disease.” In this chapter, we discuss some of the reasons for newly recognized increase in male eating disorders, and how boys’ disorders differ from those of girls’. We describe approaches that work best with boys.

It is important for parents to know that it is rarer for boys to diet their way into an eating disorder, as girls usually do. When boys develop an eating disorder, they most often have one of the following risk factors that induce their eating disorder.

•    Being chubby as children and/or experiencing more teasing about body size
•    Having a higher-than-average body weight
•    Body dissatisfaction
•    Participation in high-risk sports that favor thinness or include weight classes, such as wrestling, boxing, crew, bodybuilding, weight-lifting, gymnastics, figure skating, or long-distance running
•    Depression

Take care,

Marcia and Nancy

Dear Readers,

                Eating disorders and calorie counting often go hand in hand. The desire to lose weight or stay thin often creates an intense obsession with monitoring calories. Trips to the supermarket become marathon session devoted to reading the calorie and fat counts of every item put into the shopping cart. Marcia and others who treat eating-disorder patients try to help break them of this habit and learn how to make healthy choices that will maintain a normal weight.

                 The problem is that this goal is at odds with those of anti-obesity crusaders, who would like to see more nutrition and calorie labeling. The hope is that if overweight consumers at a fast food restaurant, for example, see just how many calories and fat grams that cheeseburger they plan on ordering contains, they might choose something healthier. This is all well and good except for the fact that for a certain segment of the population, especially those of college age, this could be too much information and may help trigger or fuel an eating disorder.

                So it was with interest that Marcia and I read that Harvard just last week reversed its 10-year-old policy of prominently posting nutrition info in its dining halls. (For a nicely done commentary on this change, take a look at Elizabeth Wade’s piece on the American Council on Science and Health’s website. Our colleague David Herzog, director of the Harris Center for Education and Advocacy in Eating Disorders at Massachusetts General Hospital, advocated for this change. Marcia dealt with this very issue 10 years ago at Dartmouth College, where she headed the eating disorders prevention program. “We decided not to post calories because students struggling with eating disorders said very plainly that this information would cause them harm,” says Marcia, who is glad that Harvard is now following suit.          

                “Students recovering from eating disorders found that not having the calories listed helped them overcome their obsession and fear of calories,” explains Marcia. “Some students I’ve worked with are so dependent on nutrition labels and calorie counting that they buy all their food at the local supermarket instead of eating at the dining hall. The sad thing is that instead of being able to eat the fresh food made to order at the college dining hall, these students would end up eating less nutritious packaged foods. In working with students, I often have them practice eating in Dartmouth’s dining hall so they can handle joining friends for a nice dinner at an off-campus restaurant, or getting ready for the family Thanksgiving dinner,” Marcia explains. “Most restaurants (especially nice ones) don’t publish calorie counts, and of course neither do families.”

                For the obsessive calorie counter who is not in college and going to a dining hall, Marcia suggests buying fewer packaged foods so you have less contact with labels. I have found that when eating is based on my Food Plan, with its focus on food groups rather than calories, before long counting calories seem irrelevant. I often have patients thrilled to find that they forgot to count calories because with the food plan calories had become irrelevant. 

                Both California and New York have passed laws that require chain restaurants to post calorie counts. We’re happy to see that small, locally run restaurants in both states remain free of this requirement. At college dining halls posting this information is optional. We hope that other schools take heed of college students’ high risk for eating disorders and refrain from posting calorie and fat counts in dining halls.

Take care,

Marcia and Nancy

As anyone who hasn’t been living in a cave knows, these are precarious financial times. With Wall Street in disarray, the cost of food and gas skyrocketing and property and 401(k) values plummeting, families are looking for ways to spend less. Studies have shown that in tight financial times, people are more willing to sacrifice mental health expenditures than other forms of medical care.

These thoughts were in Marcia’s mind recently after hearing a young patient tell her about the massive binge she had engaged in over the weekend.   “I found myself calculating the food costs of the gorge - nearly $50!” says Marcia. Of course we know that there are bigger economic issues at stake here than the grocery bills of a binge eater or the sometimes highly specialized food demands of the anorexic.

For many parents of Marcia’s patients, the question is, “Can we afford the weekly visits to  Marcia, the therapist,  and our doctor, each of whom play an important role in keeping our child healthy?” And these are families with health insurance. Families who are uninsured are in much worse shape. “Even the cost of gas is an issue in my rural state of New Hampshire, where families may have to drive several hours several times aweek for treatment,” says Marcia.

A recent Wall Street Journal article, “Angst is Rising, but Many Must Forego Therapy,” tells the story of a family in New Jersey that took out a second mortgage on its home to foot the estimated $80,000 in treatment expenses over the past two years for their eating disordered daughter. “I have been thinking about sacrificing care, how it’s going to have to happen if things keep going the way they are, because we can’t keep paying $400 a week,” the 21-year-old daughter is quoted as saying. The question is, how can we make economic concerns a positive motivating force for the eating-disordered child, rather than another source of fear and anxiety?

This strategy is probably best used with the bulimic or binge eater living at home.  “I hope parents will consider sitting down with their child and discussing the economic reasons they won’t be overstocking the house with foods that support the child’s eating disorder,” Marcia advises. “Parents need to do this in a kind way with real care not to make the child feel guilty about having an eating problem.”

In the case of anorexia, where undereating  not overeating is the problem, parents may have to actually convince their child that spending a little more money for a food that he or she will be able to eat is well worth the money. After all, they can explain, if spending a few dollars extra a week to get the right kind of ice cream is going to keep their child safe and out of the hospital, then that special ice cream is probably worth its weight in gold.

Just this week Marcia met with her patient Melissa and her parents.  Melissa is a sweet 15-year-old newly diagnosed with anorexia nervosa.  Marcia had encouraged Melissa to have some frozen yogurt topped with chocolate and nuts in the evening. Melissa thought that it was best if she just had this treat once a week because her parents wouldn’t want to spend money on her favorite local organic frozen yogurt. Doug and Rebecca, Melissa’s mom and dad, made it very clear to Melissa that her health and progress with her food plan was well worth the cost of the yogurt. “You’re more than worth it to us,” both parents said in unison.

These two examples show you how family budget concerns can cut very different ways, depending on the type of eating disorder your child is battling and her personality. If you are unsure about whether or how to bring in financial issues to your child’s treatment plan, please consult your nutritionist or doctor.

Take care,

Marcia and Nancy

Dear Readers,

We heard some good news this week. Some of you may have read about the Mental Health Parity Bill that was passed in both the House and the Senate on September 23. This is big news for the eating disorders community because the bill requires health insurers to cover mental illnesses (which include anorexia, bulimia and binge-eating disorder) exactly as they do physical illnesses.

As many of you probably know from first-hand experience, under current law, it’s common for insurers to charge higher co-pays for mental health benefits. Often, in the case of eating disorders, insurers will simply deny coverage, claiming treatment is not medically necessary. (See our LA Times op-ed piece piece on the tragic consequences of this practice for one young anorexic woman in California).

I spoke to Mike Harney, policy advisor to Rep. Patrick Kennedy (D-RI), chief sponsor of the House bill, who explains that while the content of the House and Senate bills is identical, the House bill  

Is a stand-alone bill that provides for a $3.9 billion 10-year budget offset that would pay for the costs of the legislation, while the Senate version is part of a much larger tax bill. They will have to hammer out an agreement on which form of the bill they will send to White House for the president’s signature. “We’re confident we’ll get a bill this year,” says Harney.  

An earlier, more liberal version of the House bill would have required that all health insurance plans cover all illnesses included in the DSM-IV, or Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. Despite losing this stipulation in the bill, Harney says, “We would still expect that most plans will cover [eating disorders] and now they’ll have to cover them on the same basis as physical disorders.”

An earlier version of the Senate’s mental health parity bill, meanwhile, would have pre-empted any state legislation on mental health parity (meaning that even if a state had in place a more inclusive mental health parity bill, only the weaker federal bill would have been enforceable). The revised Senate bill passed on Tuesday allows states that have tougher mental health parity legislation in place to enforce that law. The new bill “establishes a floor, not a ceiling,” explains Harney.

As of 2007, 43 states had mental parity laws, and 17 of those, or 40%, defined mental illness broadly enough to include eating disorders. So you can see how this federal bill, which President Bush is said to support, will help so many more eating-disordered patients and their families get the treatment they need.

Take care,

Nancy

I’m always amazed to hear about people throughout history who had eating disorders before they even  had a name. Today, anorexia, bulimia and even binge-eating disorder are so widely recognized that there’s even an anthology of essays on various author’s struggles with food, weight and self-image. Titled Going Hungry: Writers on Desire, Self-Denial, and Overcoming Anorexia, this book, along with another book on a woman’s struggle with food and weight, Thin is the New Happy: A Memoir, by Valerie Frankel, were both reviewed in the article, Yearning for the Lean Years,  published  the New York Times a few days ago.

The first book is a serious look at the varieties of torture and self-doubt that men and women of varying ages and ethnicities have experienced in pursuit of the holy grail of thinness. Frankel’s book sounds like a tonic to anyone who has grown up with a mother who snatched Twinkies from their hand and groomed them (often unsuccessfuly) not be fat.

I’m glad to see these kinds of stories being told publicly, in both seriousness and humor. We need more public discussion, to hear more stories like these in order to fight the stigma of eating disorders. For every writer willing to dish up details about epic binges or fanatical starvation tactics, there are hundreds, thousands more, who are suffering in secret. I hope you realize you don’t have to do that any more. Good treatment for eating disorders is increasingly available, even in small towns; it’s mustering up the courage to ask for help that’s the hard part.  

Take care,

Nancy