Spring Blog Round-Up


“Where flowers bloom, so does hope.”
~Lady Bird Johnson
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Our CED Staff has been busy guest blogging for Eating Disorder Hope on a variety of topics from nutrition and meal plans to body image and relapse prevention. We hope you’ll take a look and share with friends, colleagues or clients who might benefit from the following information.

If you have questions about eating disorder treatment or a topic you’d like to see us write more about, please send your suggestions and requests to our Community Outreach Coordinator, Kate Clemmer at  kclemmer@sheppardpratt.org


The Importance of Incorporating Fear & Challenge Foods in Recovery

Written by Caitlyn Royster, R.D. & Rebecca Hart, R.D., Registered Dietitians

While you may technically be following your meal plan, without incorporating fear foods you are still giving the eating disorder a major foothold by preserving fear and anxiety. It might seem like choosing safe foods is better than acting on symptoms. However, over time this restriction can snowball and lead to relapse. READ MORE…


Mother’s Day Makeover: Boosting Body Image for Ourselves and Future Generations

Written by Irene Rovira, Ph.D.
Psychology Coordinator

Most of us appreciate all the mother figures and mom-types in our lives – including aunts, sisters, mentors and best friends – for the love they give or how they make us feel. We do not value them based on their weight or size. Yet we often hold a double standard when it comes to how we view ourselves…READ MORE to find 7 Tips to help boost body image for yourself and future generations



4 Changes You Can Make in Your Home to Support Eating Disorder Recovery & Reduce Relapse

Written by Kate Clemmer, LCSW-C
Community Outreach & Education Coordinator

It’s safe to say no one who has been through recovery from an eating disorder would downplay the difficulty or complexity of it. And while recovery is never simple or easy, there are some simple and straightforward changes you can make to reinforce recovery efforts and help prevent relapse. These specific modifications are not changes in thinking (cognition) or even changes in behavior but rather, changes to your physical living space – your home environment.  READ MORE…


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What is a “Fear Food”?

 


At some point during treatment for foods_fearan eating disorder, most individuals will meet with a Registered Dietitian. One of the many important things you’ll do during those sessions is identify and discuss your personal list of fear foods. This is an important step that allows the dietitian to individualize treatment, help you plan for and overcome obstacles, and work alongside the rest of the treatment team to empower you in your recovery.

What are fear foods?
A fear food, or challenge food, is a term for foods that one finds difficult to incorporate into everyday eating. This term is used for foods that feel scary to eat, often because of negative thoughts or feelings related to the food’s nutrient content. Fear foods can be items or categories of food that one perceives to be “bad” and which, when consumed, might trigger feelings of intense guilt or shame. As a result, people with eating disorders often completely avoid or restrict their fear foods. Sometimes, just being around a particular food or being faced with the possibility of eating it can result in increased anxiety.

For people with anorexia, bulimia or binge eating disorder, these fears and the perception of certain foods as “bad” are often related to anxiety about anticipated weight gain and/or an inability to stop eating the food once they begin. In other words, there tends to be a strong belief that eating a fear food will instantly make you fat or that eating a certain food will make you lose control and overeat.

A person’s list of fear foods might be specific, like ice cream or peanut butter.  For others, their fear foods might encompass a whole category like all desserts or fried foods. Someone else’s fear food list might include an entire nutrient group such as carbohydrates. Common fear foods are also items considered by many to be tasty, but may also be labeled as “junk food” in our current culture.

Where do fear foods come from?
Fear foods develop from personal values, attitudes, feelings and even memories associated with a certain food. Messages from the people close to you – family, friends, coaches, teachers, healthcare providers – all play a significant role in determining your thoughts about food and can ultimately influence your (dis)comfort with particular food items.

Fear foods may also stem from a variety of impersonal sources including trending cultural ideas about food, media messages, advertisements or even nutrition information intended to be educational and beneficial. For example, there are multitudes of articles and news stories that include lists of supposedly good vs. bad foods, or foods that are better/worse for health.

Another frequent source of fear or shame related to food is dieting. Given that most diets limit or cut out certain foods, dieters start to believe that the eliminated food is bad. The more diets a person goes on, the more fear foods they are likely to have.

What are some consequences of avoiding fear foods?

  • Limited variety and lack of enjoyment in meals
  • Social isolation
  • Obsessive thoughts about the feared food
  • Worsening anxiety
  • Increased eating disorder symptoms and heightened risk of relapse
  • Prolonged negative relationship with food

People without eating disorders may have fear foods too but the consequences for those with eating disorders are much steeper since we know that limiting variety and continuing to avoid specific foods during recovery raises one’s chances for relapse. Two of our CED dietitians recently wrote in more detail about this topic for our friends at Eating Disorder Hope in a post entitled, The Importance of Incorporating Fear Foods and Challenge Foods in Recovery.

Remember, no single food has the power to make you thin or fat. And, ironically, the avoidance of a food is typically what leads a person to overeat it.

If you think you might need assistance reintegrating fear foods or overcoming negative thoughts about food and eating in general, please call The Center for Eating Disorders at (410) 938-5252 for a free phone consultation. 


In individuals with different eating disorder diagnoses, or those with co-occurring disorders, fear foods might manifest differently. For example, in individuals with ARFID, anxiety may be related to a fear of choking or to a perceived health consequence of eating the food item. In individuals with PTSD, fear foods may stem from associations with the traumatic experience.  In both cases, treatment methods may differ, and the treatment team should take into account the origin and underpinnings of each fear food when providing education and support.


Blog Contributors:
Hannah Huguenin, MS, RD, LDN
Samantha Lewandowski, MS, RD, LDN
Kate Clemmer, LCSW-C

Mindful Eating on Campus ~ Part 1

college student at laptopFew things are more stressful for a student who is in recovery from their eating disorder than trying to negotiate eating on campus. College living is full of obstacles to eating consistently and mindfully: buffets in the dining halls; eating between classes and on the go; staying up until 4 AM; social events involving food; and limited access to the grocery store or a working kitchen. While many students in treatment are given guidelines as to how to eat in a healthy manner, it is often difficult to implement those strategies in a campus setting but it is possible.  A great resource for this task is the book, Mindful Eating 101: A Guide to Healthy Eating in College and Beyondby Dr. Susan Albers which we will reference throughout this post.

Mindfulness is an old concept that has, more recently become somewhat of a cultural catch phrase. Standing at a coffee shop bulletin board, you may notice advertisements for mindful meditation classes or yoga classes that promise skill development in the art of mindfulness or even magazine covers that stress the importance of mindful living. So, what is mindfulness?  Mindfulness refers to the ability to bring one’s awareness completely to the present moment.  In contrast, mindlessness, refers to behaving or doing things without much attention.

Consider that you are eating dinner in your dorm in front of the TV during your favorite night of Mindful Eating 101television. As you laugh along with the show and get intrigued by products during the commercials, you occasionally pick up your phone and make plans for the evening and attempt to skim a chapter in your text book for tomorrow’s quiz.  All the while, you also continue to go through the motions of eating your dinner…mindlessly. In this situation, your attention is likely focused on the characters and themes in the TV show and not on your food or your body’s response to the food.  When this happens, it is common for people to eat more than they normally would because they aren’t really enjoying their food, and they aren’t in touch with the mechanisms in the body that tell us when we want to stop eating. In contrast, when you choose a meal from the dining hall and sit at a table to enjoy it with a friend but without other distractions, you may find that you eat more slowly, you savor the tastes of the food, and you have an increased awareness of your hunger/satiety cues, which allow you to stop when you feel full. This style of eating would be considered mindful eating.

Individuals who’ve struggled with an eating disorder or have chronically dieted often lose touch with their body’s natural ability to regulate food and eating processes.  Sometimes they may need help establishing normal eating patterns again and re-connecting to their bodies.  In eating disorder treatment, mindfulness is a concept that is used frequently in helping people to develop awareness of their thoughts, emotions, patterns, triggers, and hunger/fullness cues.

Eating mindfully is an important skill because it allows you to eat exactly what your body wants in just the right amounts. Restricting your food intake or dieting is not mindful because it denies your body of the food that it needs for fuel and nourishment.  Bingeing is also not mindful eating because it exceeds the amount of food that your body wants or needs and may cause you to feel uncomfortably full or even pained.  Mindfulness involves trusting your body to maintain a balance.  Learning to eat mindfully can take time, so be gentle with yourself as you practice the steps that will allow you to eat intuitively in response to your own body’s needs.

Dr. Albers outlines the seven habits of mindful eaters in her book.  These habits are the key components of learning to eat mindfully.

  1. Awareness: Use your senses to gather information about the world. By using sight, sound, hearing, touch and taste, you can become attuned to what is going on around you at any moment. Turning this inward, you can better recognize your hunger, fullness and thirst cues to help guide your eating choices.
  2. Observation: Simply notice your thoughts and feelings as an impartial observer. The key is to do this without judgment. For example, if you have the thought “I am fat,” simply notice that it is there, label it as a negative thought, and move on.
  3. Shifting out of autopilot: Some of our routines become so mundane that it is difficult to pay close attention to the details. These routines sometimes enable mindless eating or skipping meals completely, and so you may want to change the routine or bring awareness to it in order to be more mindful. Try waking up a few minutes earlier to fit in breakfast or consider meeting a classmate someplace for lunch that you’ve never been before.
  4. Finding the gray area: Black and White thinking refers to thinking in extremes. Food is good or bad. Someone is fat or skinny. Clearly, life is not that simple. To be mindful, one must be flexible and avoid operating in extremes. An example of this is someone who is on a diet that forbids bread; even if a person wants bread they will deprive themselves of it because of the diet. Sometimes, this deprivation can lead to the person bingeing on bread. In contrast, a mindful eater would recognize the particular craving and allow herself to have an appropriate serving of bread at the time when she wants it.
  5. Be in the moment:  As a college student, you may find yourself frequently eating in class, while cramming for a test, or even while walking or driving across campus. Multi-tasking like this is not considered mindful because you cannot use your senses to enjoy the food or to stay aware of your hunger and fullness cues. Ideally, a mindful eater would sit with their meal on a plate at a table and devote their full attention to eating. However, this is not always a realistic goal for a college student.  Try making small changes that help you stay present during meals, such as always sitting down to eat and turning off your phone to remind yourself to stop texting and posting on Facebook until you finish your lunch.
  6. Non judgmental: Notice judgmental thoughts and proceed with compassion instead of criticism. Often at the campus dining halls, various stations offer different types and categories of food. If you notice yourself judging a particular food station ( “I can’t order from that section, everything is full of fat.”) notice the criticism attached to the food and label it (“there I go thinking of foods in good and bad categories again.”) Practice compassion and focus on truthful statements (“this food may have fat in it, but I need some fat to help me protect my organs”).  Try to incorporate different foods from each of the various food stations at the dining hall throughout the course of the week.
  7. Acceptance: Accept things for how they are as opposed to how you think they should be. Dr. Albers gives a great example in her book of accepting your shoe size, even if you wish it were different, because there really is nothing that you can do about it. As much as you may wish to have smaller or larger feet, eventually you must let go and accept that your feet are the size that they are.

If you’ve struggled with disordered eating, it may be easier to practice mindfulness at first with something that is not related to food. Try this simple exercise to practice the aforementioned skills. Close your eyes and simply count how many sounds you can hear in the room. When you think you have counted the sounds in the room, push yourself to try to hear beyond the room. Can you hear sounds from outside? In the hallway? What about the sounds closest to you…can you hear your own breathing? The sounds that you hear are happening in the here and now; congratulations…you have been successful at being mindful of the present moment! Now you might want to try doing a similar exercise with your food, using your senses to guide your eating.

For more information and tips on healthy eating during college, read Mindful Eating on Campus: Part 2 HERE…

 

Written by Jennifer Moran, PsyD, Therapist and College Liaison at The Center for Eating Disorders at Sheppard Pratt; Originally published on 10/11/11

 Photo Credit:
1. Vichaya Kiatying-Angsulee and freedigitalphotos.net
2. Susan Albers / mindfuleatingcafe.com

For more information about Dr. Albers and her Mindful Eating series, visit her website at www.mindfuleatingcafe.com.

FOOD LOGS: How they can help with eating disorder recovery (& why you might still be avoiding them)

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coffee-writing-stuart-milesFood logs are one of a variety of therapeutic tools used during treatment for an eating disorderFood logs – also referred to as food records or food journals – can take many forms.  Some people prefer to jot things down free form in a personal notebook while others do best filling out the prepared charts provided by their dietitian.  Many others have gone tech-friendly and use an app on their phone to track info and share it with providers. Regardless of the form it takes, a food log does much more than track your food.  A helpful format for food logs will include the time of day, a description of the meal or snack, actual food and beverage intake, location/setting of the meal and, most importantly, an individual’s thoughts and feelings before, during and after eating. Completing food logs and subsequently reviewing them with a registered dietitian can be a pretty powerful part of the recovery process. Not surprisingly, and perhaps because they can be so powerful, many individuals also experience some resistance to using them.  If you’ve ever been encouraged to complete food logs as part of your treatment for an eating disorder but had trouble starting or committing to the process, we thought it might help to know why a dietitian would recommend doing them and the specific ways in which they can aid in the recovery process.

Completing food logs throughout the week maximizes time spent in session with your providers. Weekly nutrition counseling sessions are often 30 minutes long.  It could potentially take up the most of that half hour to do a 24 or 48-hour verbal recall of your meals during the session. It’s easier to get down to business if the logs are already done. Plain and simple.

Food logs are like x-rays. If you hurt your arm and asked your doctor to put a cast on it, she would require you to get an x-ray first to see if, how and where it was broken. If you refused, she broken-armwould only be able to give you broad advice, like “take a Tylenol and get some rest.”  (If you’ve broken a bone before you probably know that wouldn’t help a whole lot). On the other hand, if your doctor could look at the x-ray of your arm she could fit you for the exact type of splint or cast needed, assign the proper amount of physical therapy, and provide individualized prescriptions for your pain.  In much the same way, food logs allow the dietitian to give you tailored advice and individualized strategies, rather than simply relying on a general, one-size-fits-all nutrition goal.

Food logs provide insight into your bigger picture. Sure, your food logs communicate specific details from each meal, but they also show trends and patterns over the course of the week related to meal times, location, hunger/satiety  cues, situational triggers and thoughts. Dietitians can often see connections on the food logs that patients don’t always see themselves. Seeing “the forest for the trees”  allows the dietitian to offer the most useful and beneficial feedback to the patient. Let’s say you arrived home from work late and ate an entire large pizza. Looking back on the food log we may see that you had an 8-hour gap without a meal that caused you to feel extremely hungry. Perhaps a goal would be set to have an afternoon snack available for those situations to help you get to dinner hungry, but not ravenous. On the other hand, maybe you had a stable breakfast, lunch, and afternoon snack, but your dietitian notices you hadn’t allowed yourself pizza in six months despite the fact that it’s one of your favorite foods. A more appropriate goal in that situation would be to practice food habituation with pizza (exposure to a food over time makes the food less compelling) and having a support person around when you’re eating it for a while. The bottom line: It’s harder to learn from the incident when we only see it from one angle. Food logs help us both have more perspective on why things happen, to know whether the set-up was physical or emotional and how to address the physical and emotional needs going forward.

Food logs provide a way to monitor progress. Nutrition therapy is about making changes that improve your relationship with food and your health. We tend to set small weekly goals that create momentum towards overarching goals and bigger changes over time. How will either of us know if the goals are met if we don’t keep track of them? Keeping a food log provides an objective look at progress from week to week and month to month.  It also takes the pressure off of you and your dietitian to recall from memory all of the details of your food and symptom use from the past month.  Rest assured, as you heal from your eating disorder you will have many more important things to use your brain for!

Returning to a normal and healthy relationship with food means appropriately responding to hunger and fullness signals. It’s impossible to do that if your signals are broken from chaotic or disordered eating. The best thing to get your digestive system and metabolism back on track is structured eating – meaning adequate amounts of food with adequate frequency.  Food logs aid in structured eating accountability, and structured eating over time sharpens your signals. Food logs and structured eating can provide the training wheels to help you get to a place of intuitive eating.

Food logs help connect your mind with your body.  Putting your pen to paper before, during or after a meal increases mindfulness with eating which can decrease mindless eating. Logging intake with your thoughts improves your ability to tell the difference between emotional hunger and physical hunger.  This practice also increases awareness to how certain foods make your body feel – energy, mood, mental clarity, digestive happiness, etc. Being aware of how foods make your body feel is important in working towards more sustainable and fulfilling eating practices.

Keeping up with food logs can help prevent relapse during transitions.  If you’ve ever received care for an eating disorder in an inpatient or partial hospital setting, you know the transition into outpatient or even intensive outpatient treatment can be difficult as you are once again responsible for completing more meals on your own. One way to help maintain the stability or progress you made in the higher level of care is to continue to self-monitor your intake and associated emotions during that transition and promptly discuss any specific challenges you encounter with your outpatient providers.  If you’re completing food logs, it’s easier to catch a slip-up before it becomes a full-blown relapse.

As mentioned earlier it’s not uncommon for individuals to question the benefit of food logs or to experience some resistance to the idea of completing them. A common reaction from patients is that, “writing down everything I eat makes things worse“ or “I don’t like doing food logs because it reminds hands with pen.africa and freedigitalphotosme of acting on my eating disorder.” As providers, we completely understand that rigidly tracking food and exercise can often be a symptom of the eating disorder.  That being said, there is a big difference between keeping a detailed, private food diary and collaborating with a dietitian to complete food logs during treatment. For one, the end goals are very different. If you tracked your food before it was probably to monitor strict adherence to dangerous eating disorder behaviors or dieting techniques. Those logs probably involved weighing, measuring, and counting calories and were done to benefit the distorted rules of the ED, not to honor or nourish your body. Conversely, the goal for food logs in treatment is to monitor weekly goals, help normalize eating behavior and to improve your relationship with food. When doing food logs with a dietitian, there is no good vs. bad, no shaming, no judgement. The role of the dietitian is not to be the food police waiting to condemn you. Rather, their role is that of a supportive detective. To examine the data, to see if there is something that is setting you up for problematic eating behaviors and then provide you with education and ideas to help make improvements going forward.

Still not sure? Here are a few additional tips for those of you who may have lingering fears about food logs…

For those that are embarrassed to show anyone… Does it make you nervous or uncomfortable to think about showing someone else a record of your daily eating behaviors? If you are worried that your dietitian will be shocked, grossed out, alarmed, or otherwise disturbed by your food log it can be helpful to think of the dietitian like any other specialist.  Take a dermatologist for example. You might feel nervous or uncomfortable during an annual skin check but to the dermatologist, that’s what they do everyday – they look at freckles and moles all day long.  Food logs and weights can be things that feel vulnerable to share, but remember, those are just pieces of data that the dietitian analyzes and they’ve seen and heard it all before. It’s their job to look at meal patterns and associated thoughts/behaviors. Vulnerability takes courage, but being courageous can lead to positive change. If you’re feeling shameful about sharing your food logs, remember this quote from AA – “secrets thrive in the dark and die in the light.” Being honest with your dietitian and allowing him or her to see your food logs is one of the first steps in moving away from the pain of the eating disorder.

For those who struggle with perfectionism… Food logs aid in improving nutrition behaviors just like practicing an instrument aids in learning the skill of playing an instrument. Writing down logs is intended to keep you in the mindset of practicing your nutrition goals for the week. The more often you practice a particular skill, the more it becomes a habit over time. That progression will not be perfect, and that’s a good thing. Even when you have a rough week and the goals aren’t met, food logs are still very helpful!  As providers, we actually learn more from the rough days than we do from the stable days. The logs allow us to see and discuss what some of the barriers might have been to meeting the goal, so we know what to try or be mindful of the following week. Portraying a “perfect” day of eating when it’s not what actually happened is not helpful.  Recording struggles or slip-ups in a food log allows us to work together to correct the focus and try again. Just like it takes practicing a song on the piano before you can play it without looking at the music – food logs keep you intentional in your practice of positive nutrition behaviors before you can naturally engage in the behaviors without the logs.

For those who don’t want to be stuck doing food logs for the rest of their lives (a.k.a. everyone)… Food logs are used to benefit an individual’s relationship with food and establish normal eating.  To that end, the goal is never for someone to be reliant on tracking their intake or completing food logs for the rest of time.  Rather, this is a temporary tool to help bridge the gap between eating disordered and eating intuitively. It might seem counter intuitive to spend your time tracking food in an effort to heal from a disorder that caused you to obsessively focus on food.  But if your goal is to one day be free from disordered eating, it can help to remember this: learning a new behavior often requires focusing on it more before you can focus on it less.

If a dietitian has recommended that you try doing food logs and you were never quite ready to give it a try but you continue to struggle with your ED, it might be worth taking some time for self-reflection. Would it be worth trying something new?  Consider what you would do if your car was stuck in the mud and the first two tow trucks to the scene couldn’t pull you out because they didn’t have the right tools. What would you say to a third one that came along with a different towing device?  Trying something new can sometimes help you to get unstuck. Even if you have tried food logs before and just couldn’t commit to the process, perhaps approaching an old tool with a new perspective or deeper understanding of how it works, could make all the difference.

CED-2014-19334-Mandala-FINALNot wanting to try food logs or other therapeutic tools suggested by your team, can be a form of avoidance. Consider whether you might be avoiding an awareness of particular behaviors or feelings.  Are you trying to avoid being accountable to make changes?  Are you avoiding acknowledgement of your body’s basic needs?  If any of these resonate with you, try being honest with your dietitian or therapist about why you may have been resistant to doing food logs in the past.  Ask for some strategies to make them more manageable or less anxiety-producing. Food logs do take time and you may not always like doing them, but there’s no denying that they can play an important role in facilitating positive change with the support of your treatment team. At the end of the day, doing food logs is temporary. A healthy relationship with food and your body lasts a lifetime.

Written by Hannah Huguenin, R.D. and Kate Clemmer, LCSW-C

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Are you struggling with an eating disorder but you’re not sure where to go for help? Contact The Center for Eating Disorders at Sheppard Pratt at (410) 938-5252 to do an initial phone assessment or visit eatingdisorder.org to learn more.  You may also want to check out our upcoming free events and workshops.

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Hannah Huguenin MS, RD, LDN

Registered Dietitian

Hannah Huguenin received her Bachelor of Science degree in Dietetics with a minor in Chemistry from Olivet Nazarene University in Illinois. She received her Masters degree from the University of Kansas Medical Center in Kansas City where she also completed her Dietetic Internship. During this internship, Hannah completed a rotation on an acute care eating disorder unit at the Research Medical Center in Kansas City. She has been with The Center for Eating Disorders since 2008, and provides individual nutritional counseling for the outpatient population. In her role at the Center, she provides ongoing support to help patients decrease eating disorder behaviors, meet their nutritional goals and improve their relationship with food through nutrition education.
 
 
Kate Clemmer, LCSW-C
Community Outreach Coordinator

Kate Clemmer earned her Master of Social Work degree from the University of Maryland, Baltimore in 2005 with a focus on Management & Community Organization and a specialization in Child, Adolescent & Family Health. Before joining the Center for Eating Disorders in 2008, Kate provided school-based therapy to adolescents and families in Baltimore City and coordinated a multi-school health education and prevention program. As the CED’s Outreach Coordinator, Kate currently facilitates trainings and workshops in the community, provides outreach to individuals interested in the Center’s services and coordinates the Center’s annual community events. These events include an annual Symposium for health professionals, the Love Your Tree Body Image Campaign, and National Eating Disorders Awareness Week. Kate also facilitates the Center’s community support group for individuals with eating disorders and their friends/family, held on Wednesday evenings.

 

Photo credit: freedigitalphoto.net and (in order) Stuart Miles, Boaz Yiftach, Africa

Exciting Developments at The Center for Eating Disorders’ Intensive Outpatient Program

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An Intensive Outpatient Program (IOP) for eating disorders can be important for individuals who are transitioning out of an inpatient or partial hospital setting but would still benefit from more support and structure than is typically offered through weekly outpatient therapy.  The Center for Eating Disorders’  IOP provides 16 hours per week of intensive treatment in the evenings to allow individuals to fully engage in school, work and family during the day while continuing to focus on their recovery.

In the past six months, the IOP has seen some exciting changes and updates in programming. The program has returned to (a newly renovated!) space on the ground floor of the Sheppard Pratt B building, just downstairs from the inpatient and partial hospital units. Our multidisciplinary treatment team now includes members from psychiatry, psychology, art therapy, nutrition, occupational therapy, and social work.

Some of the recent exciting additions to IOP include:

  • Medical DirectorHeather Goff, MD has stepped into the role of Medical Director for the IOP, leading the multidisciplinary treatment team in providing care for patients. She also provides psychiatric treatment to all patients, including weekly assessments and medication management.
  • Clinical CoordinatorMorgan Krumeich, PsyD joined the IOP team in 2014 as our new clinical coordinator. She also leads group therapy and works with patients on an individual basis.
  • Collaborative Care Group – IOP now offers a weekly collaborative care group for parents, caregivers, and supports. Run by IOP social worker Annie Hanley, this group is similar to those offered at other levels of care, but is tailored specifically to the needs and issues that may arise during IOP treatment and associated transitions. All support persons are highly encouraged to attend this free weekly group, held on Tuesdays from 6:30PM-7:30PM.
  • Occupational Therapy – Occupational therapist Rachel Dehart has joined the IOP team and runs weekly OT groups for adults. Adolescents also have the opportunity to meet with an occupational therapist as needed. OT groups in IOP focus on the unique needs of individuals with eating disorders, including time management, grocery shopping, clothes shopping, involvement in the community, work or volunteering, and school.
  • Individualized Nutrition Consultations – With two dietitians now on the IOP team, Caitlin Royster and Kelly Daugherty, we continue to offer weekly nutrition groups for all patients. Additionally, dietitians are working to provide individual assessments and nutrition consultation for patients on a weekly basis.

The Intensive Outpatient Program is designed to work closely with individuals, their families, and outpatient providers in order to offer the most comprehensive care possible. And of course, we always work to incorporate patient feedback in order to ensure the IOP is continuously developing and meeting the needs of individuals, families and the community.

If you have questions about the Intensive Outpatient Program, please call (410) 938-5252 or email EatingDisorderInfo@sheppardpratt.org.

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Meet the IOP Staff

Heather Goff, M.D.
Child & Adolescent Psychiatrist
Medical Director, Intensive Outpatient Program
Dr. Goff joined the Center for Eating Disorders in 2011. A child and adolescent psychiatrist, she is board-certified in both Adult Psychiatry and Child & Adolescent Psychiatry, providing her a developmental perspective that enhances her work with patients of all ages. Her initial medical training was at New York Medical College, followed by a residency in Adult Psychiatry at Yale University, where she was a chief resident in 2005-2006. She then went on to complete a fellowship in Child and Adolescent Psychiatry at the Yale Child Study Center, where she was again chosen to be a chief resident in 2007-2008. Upon completion of her post-graduate training, Dr. Goff joined the Yale faculty, with joint appointments in the Department of Psychiatry and the Child Study Center. As a clinician-educator, she was the teaching attending for one of the adolescent inpatient units. She also served as Director of the Child Study Center at Madison, where she provided direct outpatient care to children, adolescents and their families. While at Yale, Dr. Goff was also a fellow at the Edward Zigler Center in Child Development and Public Policy, leading to her interest in the intersection of the media and social policy in the development and treatment of eating disorders. In her role at CED, Dr. Goff spent one year treating individuals in the inpatient and the partial hospital programs. In 2012, she transitioned to a new role as Medical Director of the Center’s Intensive Outpatient Program and is also completing assessments and evaluations for children and adolescents in our outpatient department.

Erin Birely, LGPC
Mental Health Counselor
Erin Birely graduated from Loyola University in Maryland in 2012 with a Master of Science degree in Counseling Psychology. She completed a year of internship at the Center for Eating Disorders from 2011-2012, and subsequently began working full time in 2012. She is currently working towards her LCPC certification. Erin provides individual check ins and goal setting with patients. Additionally she facilitates DBT groups focusing on symptom management and emotion regulation, and IPT groups focusing on processing interpersonal difficulties, as well as leading the Multi-Family and Supports Group on Wednesdays.

Kelly Daugherty, RD, LDN
Clinical Dietitian
Kelly Daugherty received her Bachelor of Science degree in Dietetics from Saint Catherine University in Minnesota. She completed her dietetic internship with an emphasis in clinical nutrition at Johns Hopkins Bayview Medical Center in Baltimore, MD. During this internship, Kelly completed rotations on an acute care eating disorder unit at Johns Hopkins Hospital in Baltimore and at the Center for Eating Disorders. Kelly joined the CED team in November 2014. She completes nutrition assessments, teaches nutrition groups and assists patients with menu planning in the inpatient, partial hospital, and intensive outpatient programs.

Caitlin Royster, RD, LDN
Clinical Dietitian
Caitlin Royster received her Bachelors of Science in Nutritional Sciences with a concentration in Dietetics from Cornell University. She completed her dietetic internship with a focus on clinical nutrition and nutrition research at the National Institutes of Health in Bethesda, MD. Caitlin joined the Center for Eating Disorders in July 2014. Here she conducts nutrition assessments, teaches nutrition groups, and assists patients with meal planning in the inpatient, partial hospitalization, and intensive outpatient programs. Prior to joining the Center for Eating Disorders, Caitlin worked in an acute care setting providing medical nutrition therapy and nutrition education to patients. Caitlin is passionate about neutralizing food for her patients and takes a non-diet approach to nutrition education.

Rachel Dehart MS, OTR/L
Occupational Therapist II
Rachel Dehart graduated with a Bachelor of Science Degree in Public & Community Health from the University of Maryland, College Park in 2007. She received her Master of Science Degree in Occupational Therapy from Towson University in 2010. Rachel is currently an occupational therapist on the Children’s Short-Term Inpatient Unit where she adapts and grades activities to meet various physical, emotional, and cognitive levels of children aged 3-12. Rachel facilitates Life Skills and Time Management occupational therapy groups in the CED Intensive Outpatient Program to assist patients with re-engagement in meaningful occupations at home and within the community.

Annie Hanley, LGSW
Family Therapist
Annie Hanley graduated from University of South Carolina with a Masters of Social Work in 2014. She is currently certified as a Licensed Graduate Social Worker and is working towards her LCSW-C licensure. Prior to joining the Center for Eating Disorders, Annie provided individual and family therapy at an eating disorder treatment center at both the inpatient and outpatient levels of care. She also has experience using the Trauma-Focused CBT model to work with children who have experienced trauma. In her current role, Annie works as a family therapist in the inpatient, partial hospitalization and intensive outpatient levels of care. She also facilitates groups in the intensive outpatient program (IOP), including the Tuesday IOP Collaborative Care group for family members and support people. Her past research includes examining the role of peer influence on eating disorder development.

Brianna Garrold, ATR
Clinical Art Therapist
Brianna Garrold received her BA in Fine Arts from Notre Dame of Maryland University in 2010 (formerly College of Notre Dame of Maryland) and her MA from The George Washington University in Art Therapy in 2012, with additional coursework in counseling and Trauma-Informed Care. Currently, Brianna works with inpatient, partial hospitalization, and Intensive Outpatient Program patients using the art process to help patients identify and express their emotions, manage anxiety, and treat body image distortions. Brianna received her ATR in September 2014, and is currently working towards completing the LCPC, and the LCPAT, Licensed Clinical Professional Art Therapist.

Morgan Krumeich, Psy.D.
Clinical Coordinator, Intensive Outpatient Program
Dr. Morgan Krumeich graduated from The George Washington University in 2014 with her Doctorate in Clinical Psychology. Prior to obtaining her doctoral degree, Dr. Krumeich obtained a Masters in Clinical Psychology from The George Washington University as well as a Masters in Education (specializing in Applied Child Studies) from Vanderbilt University. She previously spent two years at Sheppard Pratt as a psychology extern at The Lodge School, where she conducted individual therapy, in addition to co-leading group and family therapy. Dr. Krumeich completed a year of internship as a school psychologist in the Newark Public School System before returning to Sheppard Pratt in 2014 to become Clinical Coordinator at the Center for Eating Disorders Intensive Outpatient Program. Dr. Krumeich has specialized training in working with children and adolescents, but she has experience (and enjoys!) working with individuals of all ages.

 

It’s Diet Season: Are You Prepared?

girl with unbrella

Diet season is officially upon us.
Weight loss companies are well aware that millions of Americans are actively making New Year’s resolutions. Armed with teams of marketers and millions of dollars, they’ve spent the last twelve months crafting their year-end advertising.  And year after year they are wildly successful, at least in terms of revenue. According to this report, global weight loss markets were expected to be worth $586.3 billion in 2014. The U.S. is the largest contributor to that figure and was projected to reach $310 billion last year.

Yes, the weight loss industry has been preparing for an entire year. But, you can be prepared too. The first step is anticipating the messages that you will be bombarded with so you’re not caught off guard. Here are just a few of the diet industry’s strategies you are sure to encounter in the new year:

  • They will make a lot of promises for a “better” you, a “more successful” you, a “happier” you, but most emphatically, a “thinner” you. They will use those terms interchangeably to try to convince you that you cannot be better, happier or more successful without weight loss. You can.
  • They will pay celebrities enormous amounts of money to endorse what they are selling. Average salaries for celebrity weight-loss endorsers range from $500,000 to $3 million via ABC News.
  • They will tell you this time will be different.
  • They will make faulty connections between weight and health.
  • They will use scare tactics and personal stories to appeal to your emotions.
  • They will use before and after pictures that may or may not be the same person, are often retouched and photoshopped, or might just be stock images of someone who never used their product.
  • They will try to convince you that your body cannot be trusted to do one of it’s most basic jobs.  They will insist you need to pay them money to rely on external rules or charts for when and how much to eat.
  • They will ignore the natural and healthy diversity of bodies by telling you everyone can be thin if they work hard enough. This also happens to be one of the four toxic myths that promote most body image and weight concerns. This cycle works very well for diet companies because the more concerned people are with their bodies, the more likely they are to engage in weight control behaviors. In other words, it is in their best interest to keep you dissatisfied with your body so that you keep buying their product and it keeps being ineffective.
  • They will share short-term statistics from studies funded by their own investors to show how well their diet plan works for the first 3-6 months. They will not respond to requests for independent, long-term outcome studies.
  • They may tell you their product is “not a diet but a lifestyle”.
  • They will tell you your health is at risk. They will not tell you about studies like this which found the risk of mortality was higher among people in the underweight category than it was for those in the overweight category OR like this one which showed increased health behaviors led to improved health markers even in the absence of weight loss.
  • They may even include the phrase “results not typical” in fine print at the very bottom of their full page ad or in speedy verbal disclaimers at the end of a commercial.
  • It is only January yet still, they will tell you that summer is just around the corner and then attempt to make the case that your body is not “ready” for the beach. Spoiler Alert: If you have a body and you have the chance to go to a beach, then you are ready.
  • Are we missing anything? Can you think of other trends or predictable marketing slogans used by the diet industry to try to sell their products? You can add to the list on our Facebook page.

Why is it important to be prepared?
The National Eating Disorder Association reports that 35% of “normal dieters” progress to pathological dieting, and 20-25% of those individuals will develop eating disorders. This is not because eating disorders are simply “diets gone too far” but because diets trigger biological, emotional and mental shifts in the way you process food and information about that food. It is well established that diets can…

  • Dysregulate and weaken your body’s natural cues for hunger and fullness.
  • Trigger obsessive thoughts about food and weight
  • Cause intense cravings for off-limit foods
  • Create anxiety about certain types of food and in response to specific situations involving food such as eating with other people or in public places when the diet-safe food is unavailable.
  • Establish a pattern of failure, low self-esteem and distrust of one’s body
  • Assign moral judgment to foods
  • Develop a system in which exercise is used as a form of punishment instead of a fun or social activity

Clinging to the diet mentality or getting caught up in weight cycling is futile, not to mention potentially harmful to your health and your wallet. For individuals at risk for eating disorders, or for those in recovery, these dieting side effects can be even more dangerous and may create risk for relapse. This year, don’t let the diet season bring you down. Be prepared to stand up against diet pressures by knowing exactly what to expect.  If you find yourself getting overwhelmed or tempted by the ads this season, print out the list above and try checking off all of the marketing tactics you notice.  Then choose to move towards nourishment, self-care and non-judgment by inviting a body-positive friend to lunch, scheduling a massage, setting the table for a mindful eating experience or reaching out for extra support from a treatment provider.

Other Helpful Resources:

  1. Mindful Eating on Campus: Parts 1 & 2
  2. The Resolution Solution
  3. A Message for People Considering Their Next Diet (pdf) from Linda Bacon, PhD
  4. Ringing in the New Year in a New Way
  5. What is Intuitive Eating?
  6. www.eatingdisorder.org

Join CED on Facebook for body image inspiration and recovery support.

*Above image courtesy of freedigitalphotos.net and a454

Body Respect Q&A with Linda Bacon, Ph.D. ~ Part I


Linda Bacon, Ph.D. is an internationally recognized authority on weight and health.  She will stop by Baltimore this fall for two events aimed at dispelling long held myths about weight and health within the medical community and in our society at large. A nutrition professor and researcher, Dr. Bacon holds graduate degrees in physiology, psychology, and exercise metabolism, with a specialty in nutrition. She has conducted federally funded studies on diet and health, and  published in top scientific journals. Dr. Bacon’s advocacy for Health at Every Size (HAES) has generated a large following on social media platforms and the international lecture circuit. Her book, Health at Every Size: The Surprising Truth About Your Weight, called the “Bible” of the alternative health movement by Prevention Magazine, ranks consistently high in Amazon’s health titles. Her latest book, Body Respect: What Conventional Health Books Get Wrong, Leave Out, or Just Fail to Understand, co-authored by Lucy Aphramor, is a crash course in all you need to know about bodies and health.

We recently had the pleasure of corresponding with Dr. Bacon to get answers to some of your most popular questions about HAES, the work she does dispelling diet myths and her newest book, Body Respect.  You can find Part I of her responses below, and Part II is available here.

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Q & A with LINDA BACON, Ph.D.

Q: What led you to pursue writing about and researching health and weight science?

LB: My journey began from own personal pain: in my adolescence and early twenties, I believed that I was fat, that there was something wrong with being fat, and if only I lost weight, everything in my life would be better: my parents would be more proud of me, I’d be more popular… Those thoughts sent me on the painful journey of fighting my weight, and included an academic search for a solution. What I found along that academic journey surprised me: the research contradicted many of the commonly accepted beliefs I held about weight. I developed a critical lens through my work first as a psychotherapist, next as an exercise physiologist and later a nutritionist. And that critical lens has been so valuable in re-learning how to look at myself, and my own relationship with food and my body, and come to a sense of peace and contentment. The war that was originally waged against my self – the fat on my body – was more appropriately waged against oppressive attitudes about fat. I’m now on a mission to share what I’ve learned, both to support others in their personal journeys and to support social change. Our culture plays a huge role in fueling our disconnection with self and it’s critical we move towards a more just and compassionate world so that this struggle isn’t so normative. No one should experience the pain and body shame that I – and many others – routinely do.

Q: What are the most important tenets of Health at Every Size (HAES)?

LB: I see three aspects as being most important: 1) RESPECT, including respect for body diversity; 2) CRITICAL AWARENESS – challenging cultural and scientific assumptions; valuing people’s lived experience and body knowledge; and acknowledging social injustice as a hazard to health and well-being; and 3) COMPASSIONATE SELF-CARE – in eating, movement, and other areas. There’s a lot packed into those words, so here’s the simpler response: HAES is all about supporting people in moving towards greater acceptance and improved self-care, and advocating for the institutional and social change necessary to support that.

Free event in Baltimore on November 8th. Click image for details.

Q: Why do you think so many people continue to rely on dieting when the data isn’t there to back it up as an effective remedy for weight loss or improved health?

LB: I have a lot of compassion for dieters. The dieting belief system is so strongly a part of our culture and medical belief system, it makes sense that many people would buy into it and believe they are doing the right thing. And there is so much fantasy imbued in the results: the belief that one will be seen as attractive and successful, and that it will ameliorate disease. It makes sense many people grab onto it, and get a sense of hope when they try. And we’re taught to believe the “experts” rather than to trust our own experience. So when the diet fails to give them lasting results, the dieter blames him or herself, rather than the diet.

The diet is the problem and it’s the diet that fails, not the dieter. It takes courage to take our power back and recognize that the problem is out there, not in ourselves, that we have a system inside us well-designed to help us manage our weight, if only we trust it. The HAES journey is about helping people to understand that the source of their pain is not the weight itself – but the weight prejudice, and to reclaim their power to know what, when, how to eat, and a new attitude towards other self-care behaviors.

Not long ago, I had a very poignant experience of the damages of the diet mentality. I attended a wedding reception where there was a beautiful buffet of gourmet food. At one end of the buffet was the proud father of one of the brides. (I’m in California, where it’s legal for lesbians to marry.) He had helped plan this party; to him, sharing food was part of the ritual that brought his daughter’s friends and family together. At the other end, three women approached. One looked at the display and said, “Oh, I really shouldn’t.” Her friend commiserated, saying, “It really is tempting, isn’t it?” They all looked on sadly. This is the world we have created. These women are “good” dieters. For them, virtue lies in confronting the temptations of good food, exerting their willpower, and overcoming their desire.

This saddens me. I want a world where food is about nourishing us, body and soul, where we can celebrate with the shared ritual of eating. Where you eat what you want without guilt… and without bingeing. Where eating is uncomplicated by weight concerns.

Fortunately, that world is possible and the Health at Every Size movement helps to articulate it. I live in it myself, and I’ve tested it in a randomized controlled clinical trial. And my results have been reproduced by others. We have shown that people – yes, even “obese” people who are experienced dieters – can learn to dump the diet mentality and celebrate food, and that it results in improved nutritional choices and improved health outcomes. And that it does not result in that feared weight gain.

Q: In your new book, Body Respect: What Conventional Health Books Get Wrong, Leave Out, and Just Plain Fail to Understand about Weight, you and your co-author Lucy Aphramor write a lot about the influence of social justice on weight and health. What’s the most important thing you think people should understand about the impact of inequality and social differences on weight and health?

LB: I can sum it up in three words: “our stories matter.” Our experiences in the world get lodged in us on a cellular level. The experience of oppression, for example, triggers a chronic stress response, which in turn leads to weakened immunity and increased risk for many diseases. When we focus solely on an individual’s weight or health habits, we miss these structural and political inequities, and it stops us from addressing the policies and systems that have a far greater impact on our health. It also supports a culture of blaming individuals for their disease: e.g., “it’s your fault for getting diabetes; if only you ate better.”

How we get treated in the world has a huge impact on our health. Acknowledging the power of social status in determining health can help take the blame off of the individual and will have more significance for tackling health disparities than getting more people to stop smoking, or to be more active, or to eat more nutritiously. This doesn’t mean that we need to stop talking about behavior change: helping someone take better care of themselves is valuable. But it needs to be put in context. Once we understand this, it opens up new avenues for self-care and for how health care gets practiced.

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Interested?  Want to learn more about Dr. Bacon’s research and how the focus on weight can obstruct us from achieving health?  Read more in Body Respect Q&A with Linda Bacon: Part II.

Then join us in Baltimore on November 7th and 8th to see her speak. Visit our Events Page to reserve your seats.


 

Body Respect Q&A with Linda Bacon, Ph.D. ~ Part II

Welcome to Part II of our discussion with internationally acclaimed author and researcher, Linda Bacon, Ph.D.  If you missed Part I, you can find it here

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Q&A with Linda Bacon, Ph.D. ~ Part II

 

Q: What are some of the repercussions of evaluating a person’s health by their weight?

LB: One key repercussion is misdiagnosis. Some thin people get the diseases we blame on weight – and they often don’t get diagnosed until later when they’re more advanced and harder to treat – and many heavier people never get the diseases we blame on weight. And then of course, it introduces the nocebo effect: tell someone they’re going to get sick and they probably will. So it’s just bad medicine. (And expensive! Those excessive costs attributed to “obesity” can be better attributed to weight bias.) Fat or thin, the conflation of weight and health imbues people with a fear of fat and distracts us from what really matters. It brings stigma, a problem of social justice, into health care. It’s both ineffective AND damaging.

 

Q: How could a focus on weight, or on weight loss, get in the way of effective healthcare? Can you give a specific example?

LB: My knee has been bothering me a lot lately, and that provides for an easy example. My father suffered from similar knee problems. However, he was fat (I use that as a descriptive term, stripped of pejorative connotations) and I’m not, resulting in very different treatment from our orthopedists.

My doc told me to first try physical therapy, that stretching and strengthening the muscles around the joint can help. Surgery was also presented as an option.

But what did my father’s doctors recommend? They put him on diets – over and over again. He never developed a regular exercise habit and struggled with weight cycling and disordered eating his whole adult life.

Carrying more weight may have aggravated my dad’s joint problems; no doubt there are ways it’s hard to be in a fatter body. (I should add parenthetically, that there are also ways it confers health advantage, but that’s a much longer blog post.) But trying to lose that weight is no kind of solution. I can assure you, my father – almost all heavier people – they’ve tried already.

My dad went to his death with knee pain. That’s just not effective healthcare. Even if fat is a causative factor and weight loss may be helpful in reducing symptoms, that doesn’t mean that prescribing weight loss is an effective or helpful solution. (Note also that it’s well documented in the literature: prescribing weight loss is more likely to result in health-damaging weight cycling than sustained weight loss.)

My advice in training health care professionals in respectful care with larger people is to start by considering how they would treat someone in a thinner body. Appropriate exercise? Meds? Surgery? Then do what you can to support your patients in implementing your advice and handling the challenges posed by their particular body.

It’s important to remember that good health habits benefit everyone, across the weight spectrum. And that you can’t diagnose someone’s health habits by looking at them. My father – and people of all sizes – could also have benefited from eating disorders screening. Appropriate eating disorders treatment may – or may not – have a side effect of weight change.

 

Q: On November 7 and 8 you will be speaking at two events in Baltimore, one for the community and another specifically for health professionals. What are some of your main goals for each of those talks and who do you think could benefit from attending?

LB: More than anything else, I want to inspire people. For the general community, I want attendees to leave with a sense of hope, that they can lose the guilt and shame and instead take pleasure in eating, that they can look at their bodies kindly. And I want the health care professionals to leave with a greater sense of agency, feeling empowered that they know how to be helpful for people. I want all of us to walk away with a stronger sense of community, feeling that we’re part of a committed group of people helping to make this a more just and compassionate world.

 

Q: Are you hopeful that our medical community, or even our society in general, will be able to make a paradigm shift away from a focus on weight? What helps you stay focused on and inspired by this goal?

LB: I do feel quite hopeful. I’ve watched the transition that’s been happening over the years, how my message resonates with the medical community, once exposed. Most professionals are feeling disillusioned with the old system, and I’m frequently told that coming to hear me talk is a relief. It allows them to take their disquiet seriously and they feel empowered to be presented with solutions that make sense.

But I’m not naïve. As much as I’d like to have faith in the inevitability of justice being done, and the old paradigm being tossed by the wayside, I’m just not confident that’s going to happen large-scale in the mainstream anytime soon. But I find it very liberating to consider that maybe the point isn’t victory, as much as we would like to see that done. Maybe the real issue is that by speaking my truth, I sleep better at night and it gives me hope.

Desmond Tutu offered this advice as rationale for the work of a freedom fighter: You don’t do the things you do because others will necessarily join you in doing them, nor because they will ultimately prove successful. You do the things you do because the things you do are right.

Dr. Linda Bacon

So I try to let go of the preoccupation with outcome, and find fulfillment in my involvement in something worthwhile, and being a part of this greater community. I look forward to being at Sheppard Pratt soon, and connecting with more people committed to a more just and respectful world.

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Many thanks to Dr. Linda Bacon for sharing her time, expertise and compassion with our online communities.  Please join us November 7th in Baltimore when Dr. Bacon will offer an in-depth training for health professionals and then again on November 8th for an inspiring free community event. Find out more and register for both events here.

See Also: BODY RESPECT Q&A with Linda Bacon: Part I

What is ARFID?

In the last few months, you may have heard people talking about the “DSM-5” which was just published in May 2013 – this is the latest edition of the manual that mental health clinicians use for diagnosing psychiatric disorders. Formally, the DSM-V is The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.  The newest addition includes several changes to the way eating disorders are categorized and diagnosed.  This post will delve into one of those changes, specifically a new diagnosis called Avoidant / Restrictive Food Intake Disorder (also known as ARFID).

When a person is diagnosed with any type of mental health disorder by a treatment professional, it essentially means they meet a certain number of diagnostic criteria set forth by the DSM-V, in much the same way that someone would meet criteria and be diagnosed with a medical ailment such as heart disease or diabetes. The goal of diagnosing specific disorders is not to label or stigmatize a person but to capture their specific struggles and unique characteristics. This allows treatment providers to develop the best possible treatment plan and apply evidence-based interventions.

The DSM-V provides the following diagnostic criteria for ARFID:

A. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:

1.  Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
2.  Significant nutritional deficiency.
3.  Dependence on enteral feeding or oral nutritional supplements.
4.  Marked interference with psychosocial functioning.

B. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.

C. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.

D. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.


So what does all this mean in plain English?

Individuals who meet the criteria for ARFID have developed some type of problem with eating (or for very young children, a problem with feeding). As a result of the eating problem, the person isn’t able to eat enough to get adequate calories or nutrition through their diet. There are many types of eating problems that might arise – difficulty digesting certain foods, avoiding certain colors or textures of food, eating only very small portions, having no appetite, or being afraid to eat after a frightening episode of choking or vomiting.

Because the person with ARFID isn’t able to get enough nutrition through their diet, they may end up losing weight. Or, younger kids with ARFID might not lose weight, but rather may not gain weight or grow as expected. Other people might need supplements (like Ensure or Pediasure or even tube feeding) to get adequate nutrition and calories. And most of all, individuals with ARFID may have problems at school or work because of their eating problems – such as avoiding work lunches, not getting schoolwork done because of the time it takes to eat, or even avoiding seeing friends or family at social events where food is present. A good example would be a young boy who almost choked on a hot dog one time, but now refuses to eat any type of solid food and can’t eat school lunches or even enjoy a taste of his own birthday cake. Another example might be a young girl who seems to have no interest in food, complains that “I’m just not hungry” and, as a result, eventually ends up losing weight.

What ARFID is not

It is important to be sure that the person’s problem with eating is not due to a lack of food or “food insecurity”. In other words, children living in poverty who don’t get enough to eat (and as a result are not growing as expected) would not be given the diagnosis of ARFID. An individual living in a famine (who loses weight because they are starving) would not be given the diagnosis of ARFID. It is also important to remember that the eating issues in ARFID are not related to a normal cultural or religious practice. For example, a person who is fasting during a religious holiday (such as Lent or Ramadan) would not be given the diagnosis of ARFID.

We know that individuals with anorexia or bulimia struggle with distortions in how they see their bodies and that they have significant concerns about their weight. But this type of thinking does not occur in ARFID – kids with ARFID typically don’t fear weight gain and don’t have a distorted body image. Also, in ARFID, the problems that people have with eating are not related to underlying medical problems. For example, a child going through cancer treatment might lose her appetite and avoid food because of chemotherapy – but this child would not be given a diagnosis of ARFID. Another example might be a teenager who is obsessed with a fear that he is going to ingest germs and get sick, and therefore refuses to eat any uncooked foods – this teenager would probably be given a diagnosis of obsessive-compulsive disorder rather than ARFID.

Filling in the gaps

Although ARFID is being presented as a new diagnosis, it might be more useful to simply consider it as a way of describing symptoms more specifically. A lot of patients with eating disorders don’t “fit” perfectly into a diagnosis of anorexia nervosa or bulimia nervosa – and so, prior to the release of the DSM-V, clinicians would often give those folks the diagnosis of Eating Disorder, Not Otherwise Specified (EDNOS). Unfortunately, if you say that someone has EDNOS, it doesn’t really give us much information about the person’s symptoms, other than that they have some kind of eating disorder.

In the past, before the DSM-V, kids with ARFID might have been diagnosed with EDNOS. They also could have been given another diagnosis called “Feeding Disorder of Infancy or Early Childhood” (although most clinicians didn’t use that diagnosis especially since one of its requirements was that the age of onset has to be before age six). But what about those kids or adults who have restrictive eating not related to fear of weight gain, who may or may not be a normal weight, and whose lives are severely impacted by their symptoms? This is where ARFID can fill in the gaps and help us to better understand those individuals.

As ARFID is officially still a new diagnostic category, there is little data available on its development, disease course, or prognosis. We do know that symptoms typically present in infancy or childhood, but they may also present or persist into adulthood. It is possible that some individuals with ARFID may go on to develop another eating disorder, such as anorexia nervosa or bulimia nervosa, but again, no research is available yet to give a clear picture of what happens down the road for these individuals. We also are still learning about effective treatments for individuals with ARFID. Although research is just beginning, we believe that behavioral interventions, such as forms of exposure therapy, may be useful. And of course, as in other eating disorders like anorexia or bulimia, treatment of underlying conditions such as anxiety or depression is crucial.

Many kids develop different or strange patterns of eating at some point in their life – refusing to eat vegetables for a few months, or wanting to eat only chicken nuggets for dinner – but for most individuals, those patterns eventually resolve on their own without intervention. For the small subset of individuals who have persistent or worsening problems with food intake, however, the introduction of ARFID means we are now able to better diagnose and describe their symptoms, which should ultimately result in better clinical outcomes.

The most important takeaway point in all of this? Eating disorders come in all shapes, sizes, and symptoms, and if you have questions or concerns, just ask.

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References:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: American Psychiatric Association, 2013.

Kenney L, Walsh B. Avoidant/Restrictive Food Intake Disorder (ARFID) – Defining ARFID. Eating Disorders Review, Gurze Books, 2013; Vol 24, Issue 3.

 Written by Heather Goff, M.D., Child & Adolescent Psychiatrist

 

More, More, More: The Dangers of Excessive Exercise

There is such a thing as too much exercise

Media messages encouraging us to exercise away our “flaws” are rampant, particularly in these summer months when many people are self-conscious about wearing bathing suits and dressing for warmer weather.   We’re nearly halfway through summer but the seasonal cultural pressures to attain the “perfect” beach body are still in full swing. The relentless marketing often focuses on incorporating the most strenuous new workouts, squeezing in more time at the gym, pushing just a little bit harder and faster every step of the way.  When it comes to exercise, the message almost always seems to be more, more, more.

It’s true that staying active and engaging in exercise is a positive activity that can have long-lasting benefits for physical and mental health.  However, it becomes increasingly important in our “faster, longer, harder, more” exercise culture to ask ourselves, can you have too much of a good thing? The Answer:  Absolutely.

 

More is not always better.

Exercise can quickly become unhealthy when taken to extremes or when the body is not equipped with proper nourishment.  Individuals who struggle with perfectionism, rigidity, obsessive/compulsive behavior, addiction or eating disorders are particularly at-risk for engaging in over-exercise (also referred to as exercise abuse or obsessive exercise.)  These individuals often start out with moderate exercise goals in an attempt to change their weight/body shape but can easily slip into patterns that become compulsive.

Often, the same messages that promote extreme exercise also encourage people to ignore their body’s cues – to push past pain and exhaustion in order to reach goals.  But when you override your body’s need for rest, healing, or even medical attention, it can have long-term negative consequences on health, not to mention on overall fitness and athletic performance. Furthermore, exercise and weight loss goals may gradually become more and more extreme, and thus more and more dangerous. It’s important to note that even individuals who do not appear underweight, may be exercising obsessively or working out beyond what is healthy for their body.  Even high caliber athletes are at risk.

“It is no secret among athletes that in order to improve performance you’ve got to work hard. However, hard training breaks you down and makes you weaker. It is rest that makes you stronger. Physiologic improvement in sports only occurs during the rest period following hard training.” [Overtraining Syndrome]

 

Signs & Symptoms of Excessive Exercise
Because exercise is such a socially acceptable and culturally applauded behavior, it can be difficult to identify when someone is engaging in healthy activity and when they may have crossed the line to over-exercise.  It’s particularly important for coaches, trainers, fitness instructors and other professionals in the exercise industry to be aware of the warning signs and red flags that someone may be struggling with obsessive exercise.  These are just some of the signs that an individual may have an unhealthy relationship with exercise:

  • Exercises above and beyond what would be considered a normal amount of time (For athletes, prolonged training above and beyond that required for the sport)
  • Refusal to build in days of rest or recovery; Exercises despite injury or illness
  • Athletic performance plateaus or declines (Overtraining Syndrome)
  • Rigidity, inflexibility regarding exercise schedule
  • Excessive concern with body aesthetic
  • Withdrawal effects (sleep/appetite disturbance, mood shifts, intense anxiety) and feelings of depression or guilt when exercise is withheld
  • Exercise is prioritized over family, work, school or relationships (sometimes to the point of neglecting important responsibilities or obligations)
  • Exercise is the person’s only way of coping with stress
  • Deprives self of food if unable to exercise (feels he/she has not “earned” or “does not deserve” the calories)
  • Defines overall self-worth in terms of exercise performance
  • After workouts, is plagued by thoughts like “I didn’t do enough” or “I should have done more”
  • Rarely takes part in exercise for fun. Activities like hiking, paddle boarding, etc, don’t seem like “good enough” exercise.

If you or someone you know identify with this list, it may be time to step back and take an honest assessment of the exercise relationship.
Excessive exercise not only interferes with an individual’s daily life and interpersonal relationships, but it is also dangerous. Excessive exercise can easily result in overuse injuries and stress fractures which could be temporary or permanent.  Women may have menstrual irregularity and men may experience a decrease in testosterone.  Among the many other potential consequences, exercising too much can lead to decreased immunity and frequent colds or illnesses.  Over-exercise is often a sign of an underlying eating disorder.  Furthermore, recent research found that the frequency of over-exercise predicted suicidal gestures/attempts and concluded that excessive exercise should be noted as a potential warning sign of suicidality among individuals with bulimia. [source: Eating Disorders Review,  May/June 2013]

If your body is telling you that it needs a rest…
You should never exercise when you are sick or injured. When you have a fever, fatigue or muscle injuries, take the day off to help your body heal.  Even a very healthy body needs adequate rest in between workouts.  It’s recommended that you take at least two days off a week to allow your body time for healing and recovery.  Also, make sure that you are properly providing your body with enough carbohydrates, dietary fats, proteins and water to fuel your workouts. Proper hydration is critical when working out.  Dehydration can lead to overheating, muscle fatigue, headache, nausea and it impairs your body’s ability to transport oxygen.

Maintain a Healthy Relationship with Exercise
There are many ways to have a healthy relationship with exercise. First, it is extremely important that you have spoken to your doctors and they have all cleared you for exercise. Just like many things in life, moderation is the key to success.  Focus on establishing a balance between working out and other experiences, relationships and responsibilities in your life.  Consider combining a variety of activities that you enjoy and are convenient to your lifestyle instead of becoming overly attached to one type of exercise for a specific amount of time each day.  Hiking, golfing, dancing, biking, tennis, kayaking and taking your dog for that much needed walk are great ways to be active in different ways. Remember that the goal of healthy exercise is not to change your body but to care for your body so that it will allow you to enjoy your life.

If you think you may be struggling with excessive exercise, we encourage you to talk with someone close to you and seek help to establish a healthier relationship with exercise. You can also visit www.eatingdisorder.org or call us (410) 938-5252.

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Additional Resources:

The Exercise Balance: What’s Too Much, What’s Too Little, and What’s Just Right for You! By Pauline Powers M.D. and Ron Thompson Ph.D.

In response to Dr. Drew ~ Exercise bulimia is not a mild mental health issue (on the CED blog)

 Blog contributions by Amy Gooding, Psy.D., CED Therapist