Childhood Eating Disorders Blog

While researching a story for the newsletter Eating Disorders Recovery Today (Family Based Treatment: New Directions), I uncovered a number of novel uses of what is known as the Maudsley approach, or Family Based Treatment (FBT). This approach was developed in England roughly 20 years ago and has since gained popularity in the U.S. The core of the FBT philosophy is that the parents of the anorexic child or adolescent are put firmly in charge of refeeding their child rather than medical professionals and therapists. Where often parents feel blamed or somehow responsible for their child’s eating disorder, FBT shifts the blame from parents and teaches that parents and child are allies against a common enemy: the eating disorder. FBT also instills confidence in parents that they can work with their child to conquer the disorder.

FBT was at first used mainly as a treatment for adolescent anorexics, but after seeing how effective it can be among those patients, researchers have continued to widen their use of the approach to include bulimics and other forms of eating problems. They have also begun to combine FBT with other modes of therapy, such as cognitive behavior techniques, nutrition education, psychoeducation (educating families about the biology of eating disorders), and memory and cognitive exercises.

At the Mt. Sinai eating disorders program in New York City, researchers have been looking at the effectiveness of FBT with sub-threshold anorexics, patients who have disordered eating but fall short of a full-blown anorexia diagnosis. Dr. Alicia Hirsch at Mt. Sinai told me that she can foresee the day when FBT will be used with adults as well as adolescents, perhaps with spouses taking on the support role of parents.

In one sense, Sarah K. Ravin, Ph.D., is already doing this kind of work. Dr. Ravin, a private post-doctoral psychology resident in Coral Gables, FL, became interested in FBT while training at Children’s National Medical Center’s Eating Disorders Clinic in Washington, D.C. and working with a multidisciplinary treatment team that followed Maudsley protocol for treatment of adolescent anorexics. Work at college counseling centers at American University in Washington, D.C. and the University of Miami followed. When I talked to her, she was employing a modified FBT treatment plan with a college student.

The parental, or support role in that case was played by the patient’s boyfriend, whom, Dr. Ravin said, had been “very involved and pushed her to get treatment.” She noted, “The couple shares many meals together, including dinner most nights. More than anything, the patient needs meal support, and [the boyfriend] can be very helpful with that.” Dr. Ravin acknowledged the potential complications of this treatment plan since traditional Maudsley calls for the parent to temporarily assume a more authoritarian role while the patient regresses developmentally. But she noted that the boyfriend assumed more of a support role without being too permissive: He needed to be able to say “No, we’re not having rice cakes for dinner.”

Dr. Ravin has also had the experience of being the only member on a treatment team advocating FBT. In order to help family members, psychiatrists and nutritionists understand the value of this approach, Dr. Ravin told me, “I’ve made reading lists for people, emailed and photocopied articles. It’s a tough line to toe, because when you’re young and less experienced as I am, oftentimes people who are 50 or 60 don’t want to be told what to do by a young person.”

If you’ve read our book, you know that Marcia and I are strong advocates of FBT, and urge readers to consider some form of the Maudsley approach. The reality is that many communities in the U.S. don’t have trained Madsley practioners such as Marcia. It is still possible, however, to seek experts who believe that parents or loved ones are not to blame, and encourage them to be key players in the recovery of their child, partner or loved one.

Two sites that offer Maudsley information, tips on how to search for a qualified Maudsley practitioner and a list of family based practitioners around the world are F.E.A.S.T. (Families Empowered and Supporting Treatment of Eating Disorders) and  Maudsley Parents.

Take care,

Nancy

Eating Disorders and the Ralph Lauren Boycott: Join us!

An open letter to Conan O’Brien: Fat jokes hurt. Fat jokes make it okay for
everyone, even children, to discriminate against large people. Last month I
was appalled to hear Conan in his monologue move into fat joke territory. He
started off by saying, “Earlier today in California millions of people took
part in a massive earthquake drill. Either that or Kirstie Alley’s
jazzercising again.”

Having Conan make fat jokes makes large people fair game for everyone.
Fortunately, Conan and other media types have moved beyond obvious gay
bashing and woman hating, but it is still acceptable to bash fat people
because of their size. Let’s not forget that a person’s size is determined
by genetics and is affected by eating disorders.

Way back in 1993, Newsweek magazine published an op-ed by Jennifer Coleman, entitled “Discrimination at Large: Jokes about Overweight People are as Wrong and Damaging as any Racial
or Ethnic Slur.”

I couldn’t have said it better myself.  I am compelled to write about
Conan’s faux pas after a session tonight with a young twenty-something male
patient who is struggling with a serious eating disorder. He told me how he
still is hurt by the teasing about his larger-than-average size that he has
received for as long as he can remember. “Kids were so mean to me because I
was fat,” my patient told me.

Coleman ends her piece by saying “Hating fat people is not inborn; it has to
be nurtured and developed.  It’s taught from the moment most of us are able to walk and
speak. We learn it through Saturday morning cartoons, prime-time TV and
movies. Have you ever seen a fat person in a movie who wasn’t evil,
disgusting, pathetic or lampooned? Santa Claus doesn’t count.”

Let’s let Conan know that he has crossed the line. You can tell NBC and Conan
know how you feel at http://www.nbc.com/contact/general/

Just “select show” and scroll down to Tonight Show/Conan, click and write your message.

Marcia Herrin and Nancy Matsumoto, authors of the Parent’s Guide to Eating Disorders, Gurze Press, 2007.

Many of you are caring for a child or loved one suffering from an eating disorder, or are yourself battling one. You probably feel like you can barely keep your head above water amid the endless daily challenges you face. Keeping your child’s eating on track or sticking to your own food plan can feel like a full-time job. Although this may seem like just another task on an already-full to-do list, it can be very helpful to connect to an organization in your community that does work in the field of eating disorders research and advocacy. It’s a way to learn more about the disease you are battling, as well as to find a sense of community and a source of support.

In the Boston area, a shining example of this type of place is The Harris Center for Education and Advocacy in Eating Disorders at Massachusetts General Hospital. The center, headed by David Herzog, M.D.,  is celebrating its 15^th anniversary this year, and has already made a difference in a number of different eating disorder-related areas.

In 2000, the Harris Center founded the Washington, D.C.-based Eating Disorders Coalition for Research, Policy, & Action (EDC) to advocate for better access to care for eating disorders patients, health insurance parity and funding for research.  In Massachusetts, a mental health parity law—mandating that severe mental illness be treated on a par with physical illness—went into effect in 2000. But it wasn’t until July 2009 that legislation was passed mandating that eating disorders be included among the “biologically based” mental illnesses covered by the parity law. The EDC was a key part of the effort to pass this bill.  

For 20 years now, Massachusetts General Hospital has also been conducting a study on eating disorder patients to look at the long-term course of their disorders. One of the more controversial questions about eating disorders is whether or not full recovery is possible. This study, now being done under the auspices of the Harris Center, will shed light on what the health of you or your loved one struggling with an eating disorder might look like in 15 or 20 years.

For more information on the exciting research the center is conducting or funding, its ongoing advocacy work, and the various symposia it holds, take a look at its website: http://www.harriscentermgh.org/. Then look for a place in your own community you can turn to for education and support!  If finding something locally is difficult the National Eating Disorder Association’s Parent, Family& Friends Network is a good place to start.

Take care,

Nancy

Dear Readers,

You may know Diane Israel from the powerful documentary film about her life, Beauty Mark. Diane was a highly successful triathlete for 15 years, the Colorado mountain running champion and a world-class racer. She was also anorexic from about the age of 12 until well into her twenties. She did not have a period until she was 30, and as a result, her bones weakened, leading to 17 stress fractures.  Diane knew what she was doing to her body. Yet the combination of the teen’s belief that she was invincible and her fear the curves and added weight of womanhood would put an end to her running greatness made it easy to ignore the warning signs of a serious eating disorder.

The truth for her and for many eating-disordered athletes is that, “we don’t know how to handle being and staying a great athlete as our body changes,” says Diane. Coaches, she believes, must be educated so they can help the eating-disordered athlete “make the transition into adulthood while remaining a great athlete.”

I spoke to Diane this week in my job as coordinator for a planned National Eating Disorders Association (NEDA) Coaches Toolkit. The toolkit will have all kinds of helpful advice for athletic coaches and trainers such as how to recognize athletes who are at risk for or are struggling with an eating disorder, how to broach the topic with them, and how to manage the tricky team dynamics that can result when one athlete is struggling with an eating disorder.  We’ll be including Diane’s own story of her struggle with anorexia, and her advice to coaches on how to prevent more cases like hers from occurring.

At the root of all eating disorders, Diane believes, is a “lack of a sense of self,” what she calls the “self-esteem piece.” She didn’t feel okay about who she was; finding something she could control—how much she ate—numbed her feelings of self-hate and made her feel safer. It helped her make order out of what felt like a chaotic life.

For athletes, their coach is often a god-like figure who must be obeyed at all costs. “There’s a power over the athlete that goes into a parental role, [being a] father figure, or a sibling figure,” Diane explains. In order for coaches not to do the kind of harm that was done to her, says Diane, they must be educated, shown how to train top athletes without fostering eating problems. “Coaches have this obsession, this belief that if you’re thinner you’ll be better, in gymnastics, swimming, running,” Diane says. “We have to teach coaches that thin doesn’t mean better.” Learning to view the athlete as a complete person, not just a tool to help win the next championship is one way to make a better athlete. The coach needs to care about the athlete’s family life, her emotional state, her service to the planet, in other words, “to honor the whole human being,” not just the athletic being, according to Diane.

The coach also has to be able to voice concern over worrying symptoms. “If somebody had come up to me in the locker room and said, “I’m really worried about you,” says Israel, “I probably would have denied [being anorexic] but I would have known that at least someone cared about me. Nobody ever did that for me.” She urges coaches, and any loved ones to “speak from your own immediate pain. Don’t focus on their problem. Don’t say, ‘You look so sick or skinny.’ Say, ‘I’m worried about you. Fear comes up for me when I think of you.’”

Another pointer:  “A huge thing when you are sick is that you feel crazy,” says Diane. The athlete needs to hear—from a coach, family member or friend, “There is support, and you are not crazy.”

Diane has also thought about the inescapable power of media messages telling us that thin is beautiful. Instead of whining about this, she’s developed a no-nonsense way to use popular culture as a tool. “We can blame the media, or we can notice how hooked we are,” she explains. “We can blame, blame blame, but the media is not going away.” Instead, she encourages people to use their reaction to media images of thinness as a barometer of how strong their self-image is at the moment. “When I’m at the health club and I get caught up in reality television or celebrity magazines, I know that my level of self-esteem or self-worth is really shaky. It means I’m focusing on the lacks,” Diane explains. Using media messages as a tool “can be a real gift, a way to show that we are not buying into the culture.”

The NEDA Coaches Toolkit is due out in late spring or summer. Currently available are NEDA Toolkits for Parents and for Educators.

Take care,

Nancy

Dear Readers,

Those of you who have lived with an eating disorder for any length of time, either your child’s, your own, or both, know how all-consuming it can be. The disorder can take over your life to the point that you can barely think of anything else; your entire life becomes about serving your disorder.    Author Michelle M. Lelwica, ThD, calls this “The Religion of Thinness,” which is also the title of her latest book, subtitled “Satisfying the Spiritual Hungers behind Women’s Obsession with Food and Weight.”

Lelwica is uniquely qualified to write about the spiritual dimension of eating disorders since she is a professor of religion at Concordia College in Minnesota as well as a former anorexic and bulimic. She believes that “our obsessions with eating and weight mask the deeper needs of our spirits” and are “a way to maintain peace, order, and security in a world that seems out of control.” The religion of thinness has its own icons and symbols (unrealistically thin models and actresses) and its own rituals (counting calories, daily workouts and weigh-ins). It promises moral superiority and its end goal is the “salvation” of being thin.

The Religion of Thinness teaches readers to see through the myth of thinness by becoming aware of the ways that the media and our culture, including esoteric offshoots such as “Pro-Ana” Web sites, are indoctrinating us into the religion of thinness. Her answer to this problem is a program of “cultural critique and spiritual growth” including lessons in media literacy and spiritual exercises promoting mindfulness and self-acceptance.

The religion of thinness is one that favors the wealthy, ruling class, Lelwica notes. The common association of thinness with wealth actually reflects social reality: studies show that the higher a woman’s household income, the lower her weight. Rich people, in other words, can afford the “thin lifestyle” by buying the services of personal trainers, live in chefs, spa visits, cosmetic surgery and fresh, nutritious foods (more expensive than calorie-dense but nutritionally lacking processed foods).

Of the various spiritual exercises that Lelwica offers, I liked one she calls “Touching Your Suffering: An Exercise in Mindfulness.” First the reader is given some exercises to bring her mind and senses fully into the present. Then she is encouraged to revisit a past food- or body-related experience that caused pain: a hurtful comment or a damaged relationship, for example. The idea is to recall the experience, to “sit” with it and accept it, practicing compassion toward oneself. The path to a new, healthier form of spirituality, Lelwica advises, lies in “befriending your demons,” treating yourself with compassion, and then extending that compassion to others who suffer.”   

Take care,

Nancy    

 I’d like to share an email from one of my adult patients that made my day. It came from Alice, a forty-something professional woman who has struggled with bulimia and her weight since college, and read:

 ”Marcia, I want to say thank you for your Food Plan. As I stood in the workplace kitchen today to heat up my leftovers, I was surrounded by women eating horrible-looking Lean Cuisine lunches and slices of shiny, orange fat-free cheese. I thought, “Oh my God, I don’t eat food that I don’t like anymore!” It was an epiphany. I used to pack a “healthy” lunch every day… a Lean Cuisine selection, a fat-free, sugar-free yogurt (if you can even call that yogurt), celery sticks, and a packet of Crystal Light (artificial sweetener). I learned that this was not healthy, and on top of that, I never felt happy or satisfied. Now, I pack leftovers or half a peanut butter and jelly sandwich and a piece of fruit. I also buy a candy bar every day, and I’m perfectly satisfied. You have truly changed my life, so thank you, thank you, thank you!”

Those of you who are not familiar with our “there-are-no-bad-foods” philosophy might be surprised at the reference to buying a candy bar every day. Alice follows my Food Plan, which includes the prescription of two servings of “fun food” per day. Foods in this category usually contain sugar and fat. When they are eaten at the end of a meal, they provide a supreme sense of satisfaction that prevents overeating or bingeing.

It is letters and feedback like this from my patients that keep me going. When they realize that they can buy and eat everyday foods that normal eaters partake of every day, and still stick to their Food Plan, it truly is a revelation. I hope that all of you who are struggling on a regimen of packaged “diet” foods and fat-free everything will try my Food Plan and see for yourself: it IS possible to eat regular, normal-size meals and snacks and not succumb to the negative eating patterns that you are trying so hard to end. Typical diet foods lack the satisfaction of fun foods and over time set you up for overeating. In the 1950s and 1960s when dieting and diet foods were not big business, Americans were thinner and most ate a dessert with lunch and dinner. Alice fondly remembers her grandmother saying, “save room for dessert.” Now, after giving up “diet” foods and normalizing her eating, she sees the wisdom of her grandmother’s words.

Peace,

Marcia

Often Marcia works with young anorexic patients who are struggling to reach the healthy goal weight that the family, the doctor, and Marcia have agreed upon. Typically little gains are followed by losses, often caused by a stressful goings on in the adolescent or young adult’s life, power struggles between the patient and her (or his) parents, or ambivalence about recovery.

Marcia’s patient Zoe came to her last appointment down 1.3 pounds, to 118.6 pounds. It was only 1.4 pounds away from her goal weight of 120 pounds, and yet that 1.4 pounds represents a huge psychic leap for Zoe, one that is incredibly difficult for her to make.

“We talked about possible explanations for Zoe’s weight loss,” says Marcia. “There are a number of factors involved: Zoe’s anxiety about weight gain; mom’s anxiety that maybe Zoe is gaining too fast and a backlash is occurring (Zoe picks up on this hesitation on mom’s part, and may use it to justify not eating); Zoe’s tendency to wake up too late for a good breakfast, and unproductive arguing between Zoe and her mom about whether she’s eating enough. Sometimes the arguing with mom prompts Zoe to want to ‘win’ by getting away with eating less than she knows she should,” explains Marcia.

One way around these obstacles is the reward for positive change. The idea is to reward Zoe with something desirable if she maintains her goal weight of 120 pounds for two weeks in a row. If her weight dips below the goal weight, the reward is taken away. Zoe suggested a pair of boots she likes at a local boutique. Zoe will get the boots if she meets her goal. If her weight dips below her goal weight, however, her parents can take the boots away until the goal is attained and maintained again.

There is good discussion of the use of rewards in our book.  We can summarize by telling you that research shows that rewarding weight gain in anorexia works.  If you decide try this at home with your children, it is essential that you carry through and never waiver in delivering promised rewards when weight is gained. Parents need to be just as firm about withdrawing rewards if your child loses the weight again. Caveat: Never, ever reward weight loss in bulimic or binge-eating children. Parents who do this risk sending the message that love and acceptance is dependent on weight.

Take care,

Marcia and Nancy

I don’t usually address the latest fad diet, but the so-called Cookie Diet pushes my buttons.  In today’s New York Times, an article entitled “A Few Cookies a Day to Keep the Pounds Away?” by Abby Ellin details the kooky regimen of a certain Dr. Sanford Siegel, whose Dr. Siegel ‘s Cookie Diet apparently has fans ranging from legal secretaries to celebrities singing its praises. The diet calls for eating six of Dr. Siegel’s cookies a day, and one “real” meal, for a total of about 1,000 calories.

            I have in jest called my Food Plan “the dessert diet” because I recommend that my patients eat dessert with lunch and dinner whether they are anorexic, bulimic, or binge eaters. Desserts, or fun food, as I like to call them, are foods eaten just for pleasure at the end of a meal to truly end the meal, not leave the door open for snacking or bingeing later on in the evening. The desserts I refer to need to taste good and sate the appetite, which generally means they have to contain fat and sugar in some satisfying combination.

            What I recommend to my patients is a far cry from the Cookie Diet. Dr. Siegel’s diet is dangerously low in total calories, which means that eventually the dieter is going to snap and fall off the wagon. His diet also creates a dependence on his “cookies.” A week’s worth of these snacks costs $56, and enough people are doing the diet for Dr. Siegel’s company to project earnings of $18 million this year.

            The cookies hardly sound tasty: their main ingredient is microcrystalline cellulose - a plant fiber that acts as a bulking agent, emulsifier and thickener.

            The bottom line: the “Cookie Diet” is just the latest fad diet. Don’t fall for it.

Take care,

Marcia and Nancy

 A story in today’s New York Times, Calorie Postings Don’t Change Habits, Study Finds , detailed evidence that posting calorie counts prominently at four fast food chains, McDonald’s, Wendy’s, Burger King and Kentucky Fried Chicken, did not reduce the number of calories customers consumed.

                The study, which was conducted by researchers at New York University and Yale, tracked about 1,100 receipts of customers in poor black and Hispanic areas in New York City and Newark, N.J. It seems that in these neighborhoods, cost is a bigger factor than nutrition, and posting calories didn’t make a difference. The draw of a cheeseburger and fries at these restaurants is that they are cheap, fast and addictive; waving calorie counts in front of people’s faces doesn’t make much of a dent in those factors. In fact, the calorie-informed customers ordered slightly more calories worth of fast food per person than before the postings went into effect.

                About a year ago, Marcia and I blogged about Harvard University deciding to drop calorie counts in its dining halls, and applauded the school for its sensitivity to diners with eating disorders, eating issues or those genetically susceptible to such problems. As we noted, such postings can be a nightmare for those trying to overcome an obsession with calorie counting, exactly what they don’t need in order to recover.

                Since the New York City law governing restaurant chains went into effect in July 2008, I’ve lost track of how many conversations I’ve had with people who hate the postings. They were not people especially aware of eating disorders, but just people who felt the labeling was too much information, numbers that robbed pleasure from the experience of dining out. I’ve felt that way too, on my rare trips to Starbucks, staring at an array of choices and feeling bullied into choosing the healthier, though less delicious option. Or say I choose the delicious option. Instead of the happy anticipation I deserve to feel upon making my choice, I feel like a weak-willed body poisoner.

                New York City’s health and mental hygiene department will be releasing its own analysis of 12,000 restaurant receipts in a few months, the Times reports. It will be interesting to see if that study examines a broader socioeconomic swath of the city, and what the results are. I hope for all of our sakes that the results will be the same, and the popularity of public calorie counting will begin to wane.

Take care,

Nancy