Childhood Eating Disorders Blog

Dear Readers,

                I’m just back from viewing two very good new films about eating disorders that I would like to recommend to you. Swept is a short film about a brother visiting his sister while she is in a residential treatment center for an eating disorder.  Beauty Mark is a documentary about former champion tri-athlete Diane Israel, whose obsessive drive for athletic perfection, eating disorder and work as a psychotherapist led her on a journey to understand the drive for physical perfection at any cost that lies at the bottom of so many eating disorders. Both of these films were part of a National Eating Disorders Awareness Week event at Pace University in New York City, sponsored by NEDA (the National Eating Disorders Association).

              Swept depicts a difficult confrontation between an anorexic and her brother. The sister, in typical anorexic fashion pushes away food, connection with others, even an expression of love and concern by her own brother. Hints of parental discord, of family problems being “swept” under the carpet (hence the title) point to possible factors in the disorder, and the sister’s distaste at becoming a ‘project” for her well-meaning brother may seem familiar to some of you.

                Some of Beauty Mark too, will make those of you battling eating-disorders cringe with recognition: the frenzied spinning class, led by a former body builder who tearfully admits she hates her body, the male tri-athlete whose obsessive exercise leads to hospitalization, where he bench-presses his bed.  Israel is a compelling guide, leading the viewer on a tour of these driven athletes, through her own lifelong quest for approval and perfection, and through interviews with various experts. She even visits a seriously burned and disfigured mother and son who have learned the hard way that beauty is more than just skin deep.

                Moderator Sondra Kronberg, a nutritionist and well-known lecturer on eating disorders, offered these insights:

·         Eating disorders are not about food, but involve food.

·         An eating disorder is a creative adaption for survival

·         “I’m not good enough,” is a feeling that is a running theme one encounters among those battling eating disorders

Take care,

Nancy

Dear Readers,  I am proud that my professional organization, the Academy of Eating Disorders , is offering well researched guidelines to help professionals, schools, and families to as sensitively approach and treat overweight children as we do children struggling with eating disorders. Help distribute this timely information. Marcia

February 26, 2009

AED Guidelines for Childhood Obesity Prevention Programs

Sigrún Daníelsdóttir, Cand.Psych., Deb Burgard, Ph.D., & Wendy Oliver-Pyatt, M.D.

Studies from around the world show that body weight in youth has increased over the past decades (Chinn & Rona, 2001; Kautiainen, Rimpelä, Vikat, & Virtanen, 2002; Tremblay & Willms, 2000; Troiano & Flegal, 1998), although the most recent evidence suggests that this increase may be leveling off, at least in the United States (Ogden, Carroll, & Flegal, 2008).  Concern over rising weights has spurred various community and school-based interventions aimed at decreasing childhood “overweight.” These include the mandatory screening of children’s BMI, banning of “junk food” in school cafeterias, limiting vending machines in schools and promotional campaigns emphasizing the dangers of excess weight. Many health professionals have voiced concern about the safety and efficacy of these interventions, fearing that they have little positive effect and may inadvertently contribute to overconcern with weight and shape, unhealthy weight control practices, and weight bias (e.g. Berg, 2001; Cogan, Smith, & Maine, 2008; Ikeda, Crawford, & Woodward-Lopez, 2006; Neumark-Sztainer, Wall, Story & van den Berg, 2008).

A substantial body of evidence from the eating disorder literature demonstrates that a general emphasis on appearance and weight control can promote eating disordered behaviors. For example, when important agents in children’s social environment (e.g. parents and peers) endorse a preference for thinness and place an importance on weight control, this can contribute to body dissatisfaction, dieting, low self-esteem and weight bias among children and adolescents (Davison & Birch, 2001; Davison & Birch, 2004; Dohnt & Tiggemann, 2006; Smolak, Levine, & Schermer, 1999). Additionally, weight-control practices among young people reliably predict greater weight gain, regardless of baseline weight, than that of adolescents who do not engage in such practices (Neumark-Sztainer et al., 2006). Thus, it is important to evaluate the unintended consequences of “obesity prevention” programs, which may lead to unhealthy behaviors and weight displacements in both directions.

Unfortunately, few studies have examined the effects of “obesity prevention” efforts on risk-factors for eating disorders, such as body dissatisfaction and weight loss dieting. Those that have suggest that focusing on health, not weight, may be key to avoiding harm to body image and eating behaviors. For example, Austin, Field, Wiecha, Peterson & Gortmaker (2005) found lowered rates of disordered eating in a school-based intervenion that focused on promoting healthy diet and activity patterns, rather than on weight per se. These findings emphasize the feasibility of simultaneously promoting body esteem and healthy lifestyle behaviors in youth, as others have suggested (Neumark-Sztainer, 2005). Expanding the vision of “obesity prevention” programs to include the prevention of eating disorders and related issues, may help to ensure that they promote overall health and safety.

Body weight cannot be evaluated in a vacuum. It is not a reliable proxy for eating behaviors and physical activity. Although statistical associations exist between body weight and risk for morbidity and mortality, being heavy or slender is not by definition pathological. Correlation does not imply causation and the middle of the weight spectrum can cloak a panoply of unhealthy practices. Since healthy living is important for children of all sizes, interventions should focus on lifestyle rather than weight.

The Academy for Eating Disorders applauds efforts to make children’s environments as healthy as possible. However, it is important that special care be taken in the construction and implementation of “obesity prevention” programs to minimize any harm that might result. To this end, the following guidelines have been developed for school-and community-based interventions addressing rising weights in youth.

* Interventions should focus on health, not weight, so as to not contribute to the overvaluation of weight and shape and negative attitudes about fatness that are common among children and have harmful effects on their physical, social and psychological well-being.

* The World Health Organization defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Consistent with this definition, interventions aimed at addressing weight concerns should be constructed from a holistic perspective, where equal consideration is given to social, emotional and physical aspects of children’s health.

* Interventions should focus not only on providing opportunities for appropriate levels of physical activity and healthy eating, but also promote self-esteem, body satisfaction, and respect for body size diversity. Prospective studies show that body dissatisfaction and weight-related teasing are associated with binge eating and other eating disordered behaviors, lower levels of physical activity and increased weight gain over time. Thus, constructing a social environment where all children are supported in feeling good about their bodies is essential to promoting health in youth.

* Interventions should focus only on modifiable behaviors (e.g. physical activity, intake of sugar-sweetened beverages, teasing, time spent watching television), where there is evidence that such modification will improve children’s health.

* Weight is not a behavior and therefore not an appropriate target for behavior modification. Children across the weight spectrum benefit from limiting time spent watching television and eating a healthy diet. Interventions should be weight-neutral, i.e. not have specific goals for weight change but aim to increase healthy living at any size.

* It is unrealistic to expect all children to fit into the “normal weight” category. Thus, interventions should not be marketed as “obesity prevention.” Rather, interventions should be referred to as “health promotion,” as the ultimate goal is the health and well-being of all children, and health encompasses many factors besides weight.

* School-based interventions should avoid the language of “overweight” and “obesity” since these terms may promote weight-based stigma. Moreover, several of the most effective interventions have not focused on weight per se.

* Interventions should focus on making children’s environments healthier rather than focusing solely on personal responsibility. In the school setting, these include serving healthy meals, providing opportunities for fun physical activities, implementing a no-teasing policy, and providing students and school staff with educational sessions about body image, media literacy, and weight bias. In the community setting, these include making neighborhoods safer, providing access to nutritious foods, constructing sidewalks and bicycle lanes, building safe outside play areas, and encouraging parents to serve regular family meals, create a non-distracting eating environment, and provide more active alternatives to TV viewing.

* Interventions should be careful not to use language that has implicit or explicit anti-fat messages, such as “fat is bad,” “fat people eat too much”, etc.

* Children of all sizes deserve a healthy environment and will benefit from a healthy lifestyle and positive self-image. School-based interventions should not target heavier children specifically with segregated programs aimed at lowering weights. However, this should not discourage efforts to provide physical activities tailored for larger bodies or to address the experiences that heavier children share as a group.

* Determining normal or abnormal growth in children should be dependent on the consistency of their growth over time and not just the percentile at which they are growing. Childhood overweight should be defined as an upward weight divergence that is abnormal for an individual child, which can be determined only by comparing the child to him- or herself over time. This can be accomplished by consulting an individual growth chart, rather than an arbitrary BMI cutoff.

* Interventions should aim for the maintenance of individually appropriate weights—that is, that children will continue to grow at their natural rate and follow their own growth curve—underscoring that a healthy weight is not a fixed number but varies for each individual.

* A sudden shift away from the growth curve in either direction may indicate a problem, but further information about lifestyle habits, physical markers and psychological functioning is needed before a diagnosis can be made. Changes in weight are not always a sign of abnormal development. An increase in weight often precedes a growth spurt in children and some girls begin to gain body fat as part of normal adolescence at a very young age.

* Weighing students should only be performed when there is a clear and compelling need for the information. The height and weight of a child should be measured in a sensitive, straightforward and friendly manner, in a private setting. Height and weight should be recorded without remark. Further, BMI assessment should be considered just one part of an overall health evaluation and not as the single marker for a student’s health status.

* Weight must be handled as carefully as any other individually identifiable health information

* The ideal intervention is an integrated approach that addresses risk factors for the spectrum of weight-related problems, including screening for unhealthy weight control behaviors; and promotes protective behaviors, such as decreasing dieting, increasing balanced nutrition, encouraging mindful eating, increasing activity, promoting positive body image and decreasing weight-related teasing and harassment.

* Interventions should honor the role of parents in promoting children’s health and help them support and model healthy behaviors at home without overemphasizing weight.

* Interventions should provide diversity training for parents, teachers and school-staff for the purpose of recognizing and addressing weight-related stigma and harassment and constructing a size-friendly environment in and out of school.

* Interventions should be created and led by qualified health care providers who acknowledge the importance of a health focus over a weight focus when targeting lifestyle and weight concerns in youth.

* Representatives of the community to be studied should be included in the planning process to ensure that interventions are sensitive to diverse norms, cultural traditions, and practices.  In this spirit, it is important that interventions be pilot tested before implementation in order to collect quantitative and qualitative feedback from the participants themselves.

* It is important that interventions be evaluated by qualified health care providers and/or researchers, who are familiar with the research on risk factors for eating disorders, as the interventions are being implemented in schools or communities. Ideally, the assessment should not only evaluate changes in eating and activity levels but also self-esteem, social functioning, weight bias and eating disorder risk factors, such as body dissatisfaction, dieting and thin-ideal internalization.

References

Austin, S.B., Field, A.E., Wiecha, J, Peterson, K.E. & Gortmaker, S.L. (2005). The impact of a school-based prevention trial on disordered weight control behaviors in early adolescent girls. Archives of Pediatrics and Adolescent Medicine, 159, 225-230.

Berg, F. M. (2001). Children and Teens Afraid to Eat: Helping Youth in Today’s Weight Obsessed World (3rd Ed). Hettinger, ND: Healthy Weight Network.

Chinn, S., & Rona, R. J. (2001). Prevalence and trends in overweight and obesity in three cross sectional studies of British children 1974-94. British Medical Journal, 322, 24-26.

Cogan, J. C., Smith, J. P., & Maine, M. D. (2008). The risks of a quick fix: A case against mandatory body mass index reporting laws. Eating Disorders, 16, 2-13.

Davison, K. K., & Birch, L. L. (2001). Weight status, parent reaction, and self-concept in five-year-old girls. Pediatrics, 107, 46-53.

Davison, K. K., & Birch, L. L. (2004). Predictors of fat stereotypes among 9-year old girls and their parents. Obesity Research, 12, 86-94.

Dohnt, H., & Tiggemann, M. (2006). The contribution of peer and media influences to the development of body dissatisfaction and self-esteem in young girls: A prospective study. Developmental Psychology, 42, 929-936.

Ikeda, J. P., Crawford, P. B., & Woodward-Lopez, G. (2006). BMI screening in schools: Helpful or harmful? Health Education Research, 21, 761-769.

Kautiainen, S., Rimpelä, A.,Vikat, A., & Virtanen, S. M. (2002). Secular trends in overweight and obesity among Finnish adolescents in 1977-1999. International Journal of Obesity and Related Metabolic Disorders, 26, 544-552.

Neumark-Stzainer, D. (2005). Can we simultaneously work toward the prevention of obesity and eating disorders in children and adolescents? International Journal of Eating Disorders, 38, 220-227.

Neumark-Sztainer, D., Wall, M., Guo, J., Story, M., Haines, J., & Eisenberg, M. (2006). Obesity, disordered eating, and eating disorders in a longitudinal study of adolescents: How do dieters fare five years later? Journal of the American Dietetic Association, 106, 559-568

Neumark-Sztainer, D., Wall, M., Story, M., & van den Berg, P. (2008). Accurate parental classification of overweight adolescents’ weight status: does it matter? Pediatrics, 121, e1495-e1502.

Ogden, C. L., Carroll, M. D., & Flegal, K.M. (2008). High body mass index for age among U.S. children and adolescents, 2003-2006. Journal of the American Medical Association, 299, 2401-2405.

Smolak, L., Levine, M. P., & Schermer, F. (1999). Parental input and weight concerns among elementary school children. International Journal of Eating Disorders, 25, 263-271.

Tremblay, M. S., & Willms, J. D. (2000). Secular trends in the body mass index of Canadian children. Canadian Medical Association Journal, 28, 1429-1433.

Troiano, R. P,. & Flegal, K. M. (1998). Overweight children and adolescents: description, epidemiology, and demographics. Pediatrics, 101, 497-504.

Dear Readers,

                In the past two days, two interesting diet/nutrition stories have appeared in the media that confirm what Marcia and I have been saying for years now. The first was the release yesterday of the results of a study published in The New England Journal of Medicine. Researchers found that when it comes to dieting, it’s not so much what kind of diet you choose, it’s the total number of calories consumed that determines whether or not you lose weight. Researcher put 811 people living in Boston and Baton Rouge on four different diets emphasizing various proportions of fat, protein and carbs. Each diet cut about 750 calories from participant’s normal daily intake. At the end of two years, all of them lost (and regained) similar amounts of weight.

                These finding are consistent our Food Plan, which does not emphasize lowering fat, carbs or protein, but includes a serving size of each in lunch and dinner, and makes carbs a must for breakfast (you need the energy to get going in the morning!) and protein and fat optional.

                The gist of the second story, What’s Eating Our Kids? Fears About ‘Bad’ Foods, which appeared in today’s New York Times, is that more and more kids are developing phobias about eating certain kinds of foods.  Usually these fears stem from parents who give them the message that certain foods are unhealthy, bad, or dangerous to their health. Examples include kids who will only eat organic foods, or won’t eat sugar or are afraid of salt. As we tell readers in The Parent’s Guide to Eating Disorders,  there are no “good” foods and no “bad” foods, and acting as though there are can set up genetically predisposed kids for an eating disorder. In fact, Marcia often gives patients the assignment of learning to eat one of their “fear foods.” If a bulimic child is petrified that eating one brownie will lead to bingeing, then he or she must learn to eat that one brownie for snack or dessert. It’s a scary process, but can be done, and will result in a much happier child. I see people, both young and old, who are battling the effects of the good-food-bad-food thinking that is so pervasive these days.

                This story reminded me of the time my son came home telling me that according to a film he had seen at school, a cheeseburger and french fries were “whoa” foods (as opposed to “go” foods), and so maybe he had better stop eating them. You may not want to encourage your child to make these foods a daily staple, but on the other hand, do you really want your kid to go through life feeling like a criminal if he bites into a burger or drinks a milkshake? So, bottom line: don’t demonize any food. There’s a place at the table for all of them, in proportions that you can help your child determine.

Take care,

Nancy

Dear Readers,

                It’s wonderful to see my inbox flooded with events across the country planned in conjunction with National Eating Disorders Awareness Week. This is the week that eating disorders advocates pull out all the stops, mount their biggest outreach campaigns of the year, and for a brief week, manage to grab a slice of the public’s fragmented attention.

                The tireless support and advocacy organization NEDA (National Eating Disorders Association), for example, has capitalized on its week in the spotlight by announcing what it calls the STAR Program, (States forTreatment Access and Research), a nationwide effort to promote patient rights and treatment access. NEDA has taken the war against eating disorders to state capitols, introducing into state legislatures a worldwide charter developed by the Academy for Eating Disorders, which advocates for eating disorder patient rights.  With the charter as a guide, the goal of the STAR program is to get local legislators on board the fight to give eating disorder patients and their families equal access to medical care and overturning unfair insurance company practices through legislative lobbying.

                So far, NEDA has signed up volunteers from 31 states. State leaders are given step-by-step training in how to wage a successful charter launch campaign. This is grass-roots activism at its best. I’ve signed on as an individual supporter of the charter, and you can too, by clicking here.

Take care,

Nancy

Dear Readers,

         Those of you who have spent any time reading self-help books or treatment guides have probably come across mention of different psychological approaches used to treat eating disorders such as CBT, DBT, or ACT. We’d like to take some time to decipher this alphabet soup of options. Before we do, however, it’s important to remember that more important than techniques or methods is that you (or your loved one) develop a rapport and a working relationship with an experienced, competent psychotherapist. What matters most is that all involved feel confident the professional can be of help.

         Cognitive Behavioral Therapy (CBT) has been the most studied of the three forms of treatment we’ll discuss here. Many CBT techniques have become part of the standard repertoire of both psychotherapists and nutritionists treating eating disorders. CBT is based on the idea that you can change negative behaviors by changing your way of thinking. By examining your negative thought processes and correcting them, or changing the cognitive errors that give rise to those thoughts, you can alter or eliminate negative behaviors. A bulimic, for example, would learn how to recognize problematic thoughts such as “I am fat,” or “I feel fat.” She would work on changing her thoughts to more reasonable ones, such as “I can’t be fat since others see me as thin.” Seems so simple, but it works.

          Using food records or diaries to record what you eat and how you feel about it is classic CBT. If you never eat breakfast, a therapist using CBT might encourage you to have breakfast every morning while paying attention to how this affects your eating, energy, or mood later in the day. The book Overcoming Your Eating Disorder: A Cognitive-Behavioral Therapy Approach for Bulimia Nervosa and Binge-Eating Disorder by W. Stuart Agras and Robin Apple is one example of a workbook that is based on CBT techniques.

         Dialectical behavioral therapy (DBT) teaches healthier ways to handle painful emotions by recognizing and accepting feelings without judging them as “good” or “bad.” A therapist would teach you mindfulness skills to help you recognize when you are hungry or when you feel full. Your therapist might teach you to use breathing or relaxation exercises, to take an emotional timeout, or find a healthy distraction to keep you from engaging in eating-disordered behaviors. One DBT exercise is the “raisin mediation.” While slowly eating one raisin, the patient is asked to pay attention to the experience of eating the raisin, to any feelings of hunger or fullness, and to thoughts or emotions about eating. These guided food meditations move on to include foods like chocolate cake, cheese, crackers, then whole meals. The DBT workbooks on the market aren’t just focused on eating-disordered behaviors but can be helpful nevertheless. One example is Dialectical Behavior Therapy Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, & Distress Tolerance by Matthew McKay, Jeffrey C. Wood, and Jeffrey Brantley.

         Acceptance and Commitment Therapy (ACT) is a newer approach to treating eating disorders but lacks the solid underpinning of research that anchors CBT and DBT. In ACT, a therapist might work with you on developing a deeper sense of “what really matters in life” for you, beyond just weight control. You would be challenged to take action so that you live in a way that is consistent with your core values. For example, if you value being a good student, then eating well and maintaining a healthy weight are both necessary for you to have the energy to study hard and retain information.

          One example of an ACT-focused book is The Anorexia Workbook: How to Accept Yourself, Heal Your Suffering, and Reclaim Your Life by Michelle Heffner, Georg H. Eifert, and Steven C. Hayes.

         You will notice that these approaches have much in common. They all require open and honest collaboration between you and your clinician.  Many therapists Marcia works with draw from all of these approaches, though you may notice that therapists who work at medical institutions are more likely to use one single approach.

            If nothing else, we hope this little primer has made the alphabet soup of treatment types a little less daunting.

Take care,

Marcia and Nancy