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

Tried and True Strategies for a Recovery-Focused Holiday – Part II

Each year we see many individuals with eating disorders, and even those in strong recovery, become increasingly anxious as the holidays approach.  Being on high alert for triggers or signs of relapse can be an effective way of staying recovery-focused and keeping yourself well. However, it’s also important to relax into the holiday and not allow the anxiety to overshadow what could be a very positive experience.

Yesterday in Part I, we shared strategies to help you plan ahead for a recovery-focused holiday.  Today in Part II, our staff share their top tips for making it through the actual day of a holiday with health and recovery intact.

Part II: The Day OF Thanksgiving…

Thanksgiving Mantel

  • RELAX - Focus on your breath, meditate, or listen to soothing music on your way to  he festivities so you start off the celebration in a positive place. If you show up in an anxious or negative mood right off the bat, it’s likely to affect those around you and be intensified.

Try to enjoy the holiday, not just survive it! Focus on what you would like to do and who you would like to do it with. Shift your attention from body image, food, and self-criticism and focus on what you want the meaning of the holiday to be for you.

~Kim Anderson, Ph.D., Therapist and Director of Psychology 

  • Check in with yourself about body comparisons. Believe it or not, we hear a lot about patients not liking family gatherings because they are comparing their bodies to other family members. For many people, these inter-family comparisons can be the most triggering or most intense body comparisons they face. If you find yourself going down that road, hit the pause button. Rewind, reconnect and consider engaging the person in conversation instead. See if you can find out something positive about them you never knew before. Remember that they are more than just their body and you are more than just yours.
  • Get grounded.  If you feel your thoughts drifting to food, body or weight, re-connect to something positive in the moment.  Sometimes wearing a special bracelet or keeping a special item in your pocket that you can reach for and touch/hold can help to ground you.  Connecting physically to an item can help you stay in the moment and tune out the eating disorder voice.
  • Cross generational boundaries.  Be mindful of the different support each generation of your family can offer.  Hanging out with siblings, cousins and others of a similar age to you can be a nice way to connect around common developments and gives you a chance to get support/empathy on specific life stage issues like being away at college, parenting stress, job hunting, retirement, etc. On the other hand, reaching out to older generations, like grandparents, is an opportunity to get outside of your own concerns, to see how priorities can shift throughout life and also to collect some family history. Consider sitting down with an older relative and asking them an open-ended question about their most memorable Thanksgiving.  Even the youngest generations have something to offer you in your recovery-focused holiday…

Spending time with the young children in your family during large family gatherings could be a good distraction from “grownup conversation”. Hang out with the kids, play games with them and ask them about themselves. You might even consider eating with the children and think about being a good role model for them.

~Lisa McCathran, LCPC,  CED Outpatient Therapist

  • Be the family photographer.  Grab your camera and put yourself in charge of documenting the day. Many extended families only have rare opportunities to spend time together.  Catching family memories on film will not only keep you focused on something other than the ED, it will give people around you a reason to smile and be mindful of the special moments throughout the day.
  • Hors d’oeuvres.  Food is often present at holiday gatherings long before the actual holiday meal is set on the table. Be prepared. When eating appetizers/munchies, instead of continually grazing and walking around with food, you may want to put all of your choices on a plate together at once so that you can see a total of what you are eating.  Then allow yourself to sit down and mindfully enjoy eating it.
  • Structure your time before and after the meal by preemptively volunteering to help out in ways you are most comfortable with. For example, ask if you could set the table instead of helping around the food in the kitchen. Instead of packing up the leftovers, consider offering to load the dishwasher or get the kids in their pajamas.
  • Be assertive in making sure you get seated next to your most supportive family member at the dinner table.
  • Use your support. If you took the effort to connect with a “safe person” in advance of the holiday, now you have to be sure to utilize them. It can be hard to ask for help in the moment but it will be worth it.

[Editors note: When we asked our dietitians to chime in on the "eating part" of the holiday and their best piece of advice, they all said the same thing...which means it's probably pretty important.  That's why we've included all of their input below without consolidating.  Even though it's repetitive, it's one of the most important things you can do to have a happy, safe and recovery-focused holiday while recovering from an eating disorder.]

  • Take the time to eat your three meals during the holiday.  Breakfast will be particularly important as it sets the stage for your hunger and fullness cues over the rest of the day.
  • Eat regularly!!! It’s the most important thing to do. This is not the best time to try a new eating schedule.
  • Do not skip meals! Do not plan to compensate for overeating later by skipping meals in advance.
  • Stick to the meal plan especially the day before the holiday and on Thanksgiving Day.

Have an adequate meal at each meal time prior to the Thanksgiving meal so that you’re able to enter the holiday meal hungry, but not ravenous.  When you skip meals or restrict during the day and then enter a meal ravenous, you’re much more likely to eat past fullness.  On the other hand, entering a meal with a natural level of hunger means you will be more likely to stop when you’re properly nourished and comfortably full.

~ Hannah Huguenin, MS, RD, LDN, CED Dietitian

  • Everyone needs a little alone time. Remember to take time by yourself to journal or relax during the day. If you’re staying with relatives and can’t find space inside the house to be alone, grab your coat, a cup of hot tea and step outside for fresh air, or consider volunteering to run an errand for your host
  • Play games. Don’t assume that your host will be prepared with distraction techniques for you - he or she will probably be pretty busy with holiday hosting tasks – so bring your own games to the party.  Grab a holiday-themed puzzle or some of your favorite board games that will encourage interaction. Need something quicker and easier?  Simply bring a deck of cards that you can use to play all sorts of different games with others or even by yourself.

Many people with eating disorders, especially those who’ve experienced trauma, may experience very intense emotions around the holidays. These strong feelings and stressors can be overwhelming but they don’t need to ruin or disrupt your holiday. Consider using a “containment strategy”. Write down the unpleasant thought or feeling on paper and put it “away” inside a designated containment box to be opened later when feeling safer such as in a therapist’s office or when the feeling has decreased in intensity.

~ Irene Rovira, Ph.D., Therapist & CED Psychology Coordinator

  • If you are not attending a family gathering it’s still important to plan a recovery-focused holiday.  In fact, it may be even more important to create structure and social opportunities that will keep you focused on the bigger picture and engaged in positive activities. This could include volunteering your time to other causes like a soup kitchen or a homeless shelter or it might mean finding another friend without plans and going out to a movie together.
  • You made a list, now check it twice. If you took the advice in Part I of this holiday blog series, then you should have a list of the top 3 most useful coping skills for you (this will be different for everyone).  If you’re going through the day and you’re struggling with eating disorder thoughts or urges to act on symptoms, refer back to your list and work through them again, making tweaks if necessary. For example, if you called or texted a friend who never replied, do it again but try someone else this time.  Just because the first person didn’t get back to you, doesn’t mean you have to give up.
  • RELAX and end your day with SELF-CARE.  Just as we suggest starting off the day with relaxation techniques, allow more time for yourself to decompress from the holiday as it comes to a close.  Breathe deeply, put on your favorite music playlist for the ride home, or take a few minutes to journal when you arrive home.  Regardless of how the day went, do something nice for yourself before you go to bed on Thanksgiving night. For some people, that might be taking a nice hot bath, reading a book, writing a supportive email to yourself, watching a favorite movie with your spouse or a best friend, or cuddling with your pet. Whatever it is, allow yourself to enjoy it.  Accept that you are deserving of self-care and able to bring your day to a close in a positive way.

We know this is a long list, and you can’t do every single thing on here ( and we don’t want you to overwhelm yourself by trying).  Just choose the ones that speak to you and that you think will be most helpful on your holiday.  Chat with support people and get their feedback regarding how these tips can fit into your specific family’s traditions and holiday schedules.

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Did you miss Part 1?  You can still go back and read the holiday planning and preparation tips here:  Tried and True Strategies for a Recovery-Focused Holiday, Part I: BEFORE the Holiday…

Find Part III here: Tried & True Strategies for a Recovery-Focused Holiday, Part III: AFTER Thanksgiving has Come and Gone

Have a good tip that we missed? Share your support and feedback on our Facebook page.

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Many thanks to the following CED providers who’ve contributed to this blog series:

  • Samantha Lewandowski, MS, RD, LDN
  • Hannah Huguenin, MS, RD, LDN
  • Jennifer Moran, Psy.D.
  • Kim Anderson, Ph.D.
  • Laura Sproch, Ph.D.
  • Irene Rovira, Ph.D.
  • Amy Scott, LCPC
  • Lisa McCathran, LCPC
  • Anne Holman, LCSW-C
  • Kate Clemmer, LCSW-C
  • Jennifer Lane, MS, OTR/L

 

 

 

Mindful Eating on Campus ~ Part 1

This is the 5th post in our 8-part blog series  about eating disorders on campus.

Nothing is 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 Mindful Eating 101store 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 Beyond by 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 television. 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.

Stay tuned for “Part 2″ about Mindful Eating on Campus with some more helpful hints. You can also see all of the previous posts in this blog series at, Battling Body Image Concerns and Disordered Eating on Campus.

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

Written by Jennifer Moran, PsyD, College Liaison at The Center for Eating Disorders at Sheppard Pratt

Is ‘MyPlate’ Missing the Mark?

In conjunction with Michelle Obama’s Let’s Move campaign, The US Department of Agriculture (USDA) released the federal government’s newest national food and nutrition icon on June 2nd.   The new icon, referred to as MyPlate, is actually the 7th in a succession of food guides promoted by the USDA over the past 95 years.  The most recent predecessor to MyPlate was MyPyramid, introduced in 2005, which most people are relatively familiar with.  The new MyPlate is arguably easier to interpret than the pyramid, particularly because MyPlate recommendations are communicated through a simplified visual that consumers use every day – a dinner plate.

Michelle Obama had this to say about the usability of the new icon, “When mom or dad comes home from a long day of work, we’re already asked to be a chef, a referee, a cleaning crew. So it’s tough to be a nutritionist, too. But we do have time to take a look at our kids’ plates. As long as they’re half full of fruits and vegetables, and paired with lean proteins, whole grains and low-fat dairy, we’re golden. That’s how easy it is.”   Easy as it may seem, we still have some reservations about the new icon, particularly the dietary suggestions and some of the interactive tools that accompany it.

  • Blanket Assumptions. MyPlate’s overall recommendation is: “Enjoy your food, but eat less”.  This statement operates under the basic assumption that all Americans overeat which is simply not true.  What if the consumer already eats appropriate portions, or perhaps doesn’t eat enough to fuel their body?  “Eat less” sounds a lot like a universal prescription for restriction and leaves little room for honoring internal cues for hunger/fullness.
  • Is this just another diet? The reigning factor in MyPlate seems to be focused on control; control your diet and portions within the confines of the plate, and avoid too many of what MyPlate defines as “empty calories” (more on this term later).  Healthy, normalized eating involves trusting your own body’s hunger, fullness, and taste cues to help give you everything you need. The My Plate icon could be a helpful reminder of the importance of a balanced diet.  However, working overtime to make every meal fit precisely into MyPlate could be more harmful than helpful in establishing a peaceful relationship with food.  Furthermore, many of the associated online tools on the USDA website, including “analyze my diet”, food tracking and calorie counters seem to foster an unnecessary focus on precise counting/measuring of foods.
  • Essentially Missing. Fats and oils are not visually represented anywhere on MyPlate despite the fact that fats and oils are necessary for energy, transportation and absorption of vitamins, satiety, taste and texture, heart health, and cholesterol.  They are an essential nutrient, and a major component of all brain and nerve cells. The MyPlate website does state that “oils are not a food group, but are essential.”  If the goal is healthy and balanced eating, such an essential part of the human diet needs to be represented on this easy-to-read graphic as it was with the last two government food models. Showing healthy ways to incorporate dietary fat and oils into meals could help educate consumers on appropriate amounts of dietary fats and oils as opposed to just instilling a fear of them by ignoring them altogether in the icon.
  • Labeling Foods. Labeling foods as good/bad or healthy/unhealthy is a way of thinking that isn’t making Americans any healthier and can actually promote disordered eating.  Yet the USDA website where MyPlate lives continues to assign the  “empty calories” label to a long list of  foods.  A calorie is a measure of energy, equal to the amount of heat that is contained in food and released upon breakdown in the body.  All food provides energy to our body – glucose to fuel our cells, protein to build, repair, and maintain body tissues, and fat for healthy cell membranes and brain development. Remember that by incorporating different choices from all food groups, you will naturally be achieving an appropriate balance of calories – thus leaving room for the treats and extras that are physiologically and psychologically satisfying.  Removing labels on food, such as “empty calories”, and working to make all foods neutral lends itself to a healthier relationship with food, and helps with food habituation – when you’ve had a food item a multitude of times and can decide freely whether you’ll truly enjoy and taste the food when you have it.
  • Logic. The plate pictures protein, grains, fruits and vegetables with a side of dairy as an ideal meal. How would an average consumer translate this message? Perhaps strawberries just don’t make sense with your Chinese food meal.   Does this picture create the notion that every food group must be consumed at every meal? (i.e. veggies with your cereal?)  That feels like a lot of pressure.  And what about lasagna or casseroles when almost all of the food groups may be combined into one dish – where does that fit into the MyPlate icon?  Looking at an overall weekly balance of nutrients and food choices would be more appropriate than feeling as if the eating must be perfect on every plate at every meal.
  • Does it promote overeating? Does the plate send the message that someone should push past their satiety point just to incorporate that fruit or dairy serving? Not honoring the fullness cue could trigger feelings of shame and guilt (not to mention physical discomfort), which can lead to emotional eating or compensatory restricting.

So, the next time you sit down to a meal, take a look at your plate. Not in an effort to follow the MyPlate guidelines exactly, but more so to be mindful.  Are you choosing a variety of foods from each food group throughout the day or week? Do the food choices make sense and complement each other?  Are you able to stop when you feel full?  Choosing foods that nurture the body and the mind are all steps on your road to health, and a healthy relationship with food.

Do you have questions about MyPlate or other nutritional guidelines?  Ask our Registered Dietitians and we’ll post the questions and answers on our blog!  Submit questions by emailing kclemmer@sheppardpratt.org anytime before August 10th.  Add “ask the dietitian” in the subject line.


Submitted by Courtney Perkins, RD with contributions by CED’s team of Registered Dietitians

Jet Fuel and a Handful of No Regrets: The subtle reasons why Media Literacy is so important when it comes to messages about food and weight

Earlier this week we were prepping for a media literacy presentation when we came across a few examples that point to some of the very reasons why media literacy education is so important.  Of course, it’s always very easy to locate magazine ads that exemplify the ills of photoshopping (cue the recent ALDO billboard photoshop fail) or products that perpetuate an unhealthy body ideal and the sexualization of girls (cue the recent Abercrombie & Fitch push-up bikini for 8 year olds).  And, there’s certainly no shortage of  overtly harmful (and grossly inaccurate) claims about food and weight in ads for trendy diets and diet products.  These, unfortunately, very effective ads rake in more than $40 billion a year for the diet industry.  But some of the messages we get about weight, size and food are much more subtle and in many ways, that makes them even more detrimental.

Check out these two ads for almonds found in Men’s Health - a men’s fitness magazine.   Despite the magazine’s title and efforts at health-focused articles, most readers would agree, the general tone of the magazine is usually just as image-focused as any women’s fashion magazine.   Focus on health often seems secondary to the focus on rock-hard abs and a heavy dose of scantily-clad women.  However, we found the following almond ads were somewhat effective at marketing the product in a healthful and holistic way without focusing on the body. What do you think?

“A Handful of Good News…because they’re packed with great stories to tell. Like how just a handful a day gives you 6g protein, 3.5g fiber and can even help you maintain healthy cholesterol levels.”

“A handful of jet fuel. Grab a snack that’ll give you a boost anytime, anywhere. A handful of heart-smart, nutrient-rich California Almonds with 6 grams of protein power can be just the lift you need. It can even help you maintain healthy cholesterol.”

To be honest, we were fairly surprised to see an ad for anything in this men’s fitness magazine that didn’t include a photoshopped close-up of a chiseled body.  But we were  pleasantly surprised to see these ads focusing on health vs. weight and even highlighting the utility of the body vs. how it looks.  Eating for nourishment and strength to do the things that we enjoy – for example, playing with your kids – is a healthful concept that we fully support and one that is also important throughout the eating disorder recovery process.

We were fully prepared to give this company an A+  for their marketing messages until we found the ads’ female counterparts in Real Simple, a women’s magazine that generally delivers a better-than-average display of body/size diversity and emphasizes physical and mental well-being.  Notice the difference in the  marketing  of the same exact product when it is targeted towards women?

“A handful of chocolate-covered permission. Looking to maximize goodness and minimize guilt? Satisfy more than just your sweet tooth with the antioxidant-rich duo of dark chocolate and California Almonds.”
“A handful of no regrets…Want a simple snack without the guilty aftertaste? Make sure your heart-smart, nutrient-rich California almonds are always within reach. Just a handful a day can help you maintain healthy cholesterol levels.”

Internal feelings of “guilt” and “regret” are introduced to the female consumer where previously existed “good news” and “fuel”.  A very different message gets portrayed – one that implies women should rely on external permission to have a snack instead of their own body’s internal hunger cues and legitimate need for nourishment and strength.  These ads also suggest that women should feel guilty or experience regret if they eat certain foods.  These are not uncommon experiences for individuals who struggle with disordered eating*, and it is often this very cycle of eating and the subsequent guilt/regret that perpetuates chronic dieting and many of the symptoms involved with anorexia, bulimia and binge eating disorders.  While extreme dieting and eating disorders are a growing problem for both females and males, this marketing campaign clearly capitalizes on the female experience.

Ads such as these do not cause negative body image or disordered eating by themselves.  However, they help to perpetuate unhealthy beliefs within a culture that is already saturated with mixed message about food, weight and an obsession with unrealistic beauty ideals.  Most interesting in this example may be the clear distinction between the two genders.   It’s essential to educate youth and adults about media literacy so we can collectively begin to protect ourselves and our families from the repercussions.  It’s also important to remember that sometimes the very subtle messages about how we “should” relate to food are even more invasive than those with obvious intentions to mislead us.

Be a critical viewer of the media.  Question the images and the advertisements you come across.  Compare ads that are targeted to different genders, ethnicities and ages.   Ask yourself what messages they are sending and what effect they might have.

Do you consider yourself to be media literate?  How do you resist subtle messages like the ones discussed above? Leave a comment below or join the conversation on our Facebook Page and follow us on Twitter.

*Disordered Eating: A significant deviation from normalized eating patterns that may include dieting, fasting, bingeing, or skipping meals. Disordered eating disregards internal regulation of hunger and fullness and provides the body with much more or much less than the body needs to function properly.  Instead of feeling good after a meal, someone who has disordered eating will often experience feelings of guilt, shame, discomfort, fear or discontent.

Support for Parents & Families: Navigating the World of Eating Disorder Treatment & Recovery

Join us on Thursday February 24th, 2011  to hear from a panel of parents who’ve been through the treatment process in various forms with their own children.  Listen to their stories and join the conversation during a special Q/A with the panel members and several treatment specialists from CED. You can read more about the event and meet our panel members below, then download the Event Flyer or visit our website to register for this free event.

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For someone with an eating disorder, the positive role of the family in the recovery process cannot be underestimated.  Parents, spouses, siblings and close support people can make a world of difference for someone who is struggling with an eating disorder, especially as they work towards recovery.  But its not easy.  It takes a lot of patience and presents many challenges for parents and support people who have never before been forced to learn about the complexities of an eating disorder or navigate the world of treatment. Just as the individual with the disorder experiences intense fears, personal hardships, and emotional angst throughout the illness and recovery, so too do those who support them.  It can be torturous to have an eating disorder but in many ways, it can be just as difficult to care deeply for someone who does.

Parents in particular, despite the age of their son or daughter with an eating disorder, can be met with incredible fear, stress and frustration as they try to weed through a completely new landscape of physical and mental health complications, what to say and what not to say to someone in treatment, and how to respond to irritability, refusal to get treatment, or general isolation from the rest of the family.  And while each family has their own unique experience, two things are very common when approaching the recovery process with a loved one:  1) you will have a lot of questions, and 2) you may feel very alone.  That being said, it can be very beneficial to talk with other families who understand what you’re going through and can offer knowledgeable, experienced support.

This year, in honor of National Eating Disorders Awareness Week, The Center for Eating Disorders at Sheppard Pratt will be hosting a Panel Presentation and Q/A event featuring parents who’ve experienced the difficult job of supporting a loved one with an eating disorder.  This free event is designed to create a safe place for families and support people to gather, ask questions and seek feedback from those who’ve been in the trenches themselves.  The panel will also include specialists from the Center for Eating Disorders who will answer questions about the treatment process, types of therapy, health and medical concerns,  nutrition issues, and all things affecting recovery.

All of the parent panel members come to the table with different experiences, different strengths and different outcomes but they all have an important story to tell and a hopeful message to share.   If you have questions about supporting a loved one, or you would just like to listen and know that you are not alone, please join us for this special event in Baltimore on Thursday February 24th at 7:00 pm.

~  MEET The PANEL ~

PARENT & FAMILY Panel Members:

Jane Cawley – Jane and her family helped her daughter, then age fourteen, recover from anorexia nervosa with family-based treatment in 2004. Ever since, she’s worked tirelessly as an advocate for eating disorders, actively helping parents find and better understand information on eating disorders and the treatments available.  She co-chairs Maudsley Parents and serves on the steering committee of NEDA’s Parent, Family, and Friends Network.  She was also recently interviewed for a PsychCentral blog entitled, What Parents Need to Know About Eating Disorders: Q&A with Jane Cawley

Katherine BloomKatherine is the loving mother of Kira Bloom, who lost her struggle with bulimia nervosa on May 21, 2009 at age twenty-five.  Katherine now speaks out to honor her daughter’s memory, the importance of treatment and to share what she has learned in hopes of sparing another family a similar tragedy.

Jean R. – Jean and her family learned to navigate the world of eating disorders when their daughter was diagnosed with anorexia nervosa in 2000.  Through their daughter’s journey they became acquainted with an ANAD support group, and in the spring of 2007, she volunteered to be on the Eating Disorder Network of Maryland board.  Jean has also been involved with Supporting Each Other, a support group for family members and friends of those who have loved ones struggling with disordered eating.  As an educator, Jean sees the importance of education to spread awareness and understanding about this dangerous disease.

TREATMENT SPECIALIST Panel Members:

Steven Crawford, MD – Dr. Steven Crawford is a board certified psychiatrist and Associate Director of The Center for Eating Disorders.  Dr. Crawford has spent over 20 years devoted to the treatment of individuals and families impacted by eating disorders.  He remains committed to providing the best possible treatment for every patient at CED, ensuring a comprehensive continuum of care, state-of-the-art programs and a staff of highly qualified, specialty trained practitioners.  Dr. Crawford also serves on the faculty at the University of Maryland where he trains medical students on prevention, identification, early intervention and evidence-based treatment for eating disorders.

Dina Wientge, LCSW-C – Dina Wientge has been a part of the CED staff for more than 14 years. She received her Masters in social work from the University of Maryland and trained at Johns Hopkins University .  Dina provides family therapy for patients in CED’s inpatient program and oversees all aspects of the Center’s family therapy programming.   She is one of a select group of clinicians from across the country who have been specially trained and certified to provide Family Based Treatment (FBT) for eating disorders.

Debbi Jacobs, LCSW-C – Debbi Jacobs earned her MSW from the University of Maryland, Baltimore, School of Social Work in 1999.  Prior to joining the team at The Center for Eating Disorders, she provided individual, couples and family therapy at the Jewish Family Services in Baltimore with a particular interest in trauma and loss.  Debbi currently provides individual and family therapy at CED’s outpatient department with a concentration in providing support for families engaged in the Maudsley method of re-feeding.

Samantha Lewandowski, MS, RD, LDN – Samantha Lewandowski received her BS in Nutrition from the University of Delaware and her Masters in Health Promotion Management from The American University.  Samantha, a Registered Dietitian, joined the CED staff in 2006, and her main role is working on nutritional goals with patients and their families in the outpatient setting.  As Nutritional Care Coordinator, she also supervises the outpatient nutrition staff, coordinates nutrition programs and provides community workshops and professional trainings on the prevention and treatment of eating disorders.

All family members, support people and health/mental health professionals are welcome to attend.  Download the Event Flyer or visit our Events Page to pre-register and reserve a seat.

If you have questions about this panel or any of our other NEDAWeek events, please call The Center for Eating Disorders’ Outreach Coordinator at (410) 427-3886.

The Resolution Solution

The end of a calendar year brings with it endless conversations of new year’s resolutions.  Setting these notoriously lofty goals is often an attempt to pull oneself out of the seasonal funk that can settle in with shorter days, colder weather and a barrage of holiday stressors.  When people make resolutions, it is often done with the intent to completely overhaul their life.  They look to make a sweeping change that will fix all that is wrong, and get them back on the “right track”.  Unfortunately, this particular type of goal setting usually backfires – as evidenced by the fact that most people end up making the same exact resolutions year after year.

New year’s resolutions also send a message that today doesn’t count – it gives us permission to stay unhappy or unhealthy ”just a little bit longer” until January 1st rolls around. This could mean different things for different people depending on whether you are working towards recovery from an eating disorder, still struggle with chronic yo-yo dieting or are trying to quit smoking.  So, how do you pull yourself out of the winter blues without jumping on the resolution bandwagon?  Here are a few ideas to get you started…

1.  Don’t wait.  Start making small adjustments today that have nothing to do with food, eating, or your weight. Creating small but positive disruptions in your daily routine can help you stay grounded and may even help to break a cycle of negative thoughts or eating disorder symptoms that are associated with certain places or a time of day.

  • Try taking a different route to work or school.  This small change could open up new possibilities, even if its just observing the new scenery or discovering a park along the way that you never knew existed!  Who knows, you may even find out that your new detour involves less traffic or fewer lights.
  • Do some interior designing.  Consider rearranging some furniture or updating a picture wall inside your house or apartment.  Visible changes such as these can offer a sense of renewal without the obligation or pressure.
  • These are just a few examples…you can come up with your own ideas for “minor adjustments” and share them on our Facebook page.

2. Setting goals is a great thing but not if the goal is unrealistic, unhealthy, too vague, or involves intense pressure to succeed.  All of these characteristics can make it very difficult to follow through with a resolution.  Instead, focus on taking small, concrete steps forward in the direction of balanced living.

  • If you tend to make resolutions that are unrealistic and unhealthy…“I have to get myself to the gym.  I’m going to purchase a membership and force myself to go everyday, no matter what.”
    • Try this instead: “I will commit to going to one or two community yoga classes by the end of the month and work on developing a positive and supportive relationship with my body.”
  • If you tend to make resolutions that are vague and counterproductive… “I need to lose weight by the summer so I’m really going to stick to my diet this year!”
    • Try this instead: “I give myself permission to stop dieting and to trust my body. If I need the help of a professional nutritionist to do this, I will seek one out.”
  • If you tend to make resolutions that leave no room for error and put a lot of pressure on you to succeed…“As of January 1st, I am never going to act on my eating disorder symptoms again.”
    • Try this instead: “Before the week is over, I will call and schedule an appointment to begin seeing a therapist.” This is an example of a small but very meaningful task that can result in long-term change.  If you already see a therapist, consider this instead: “In the next week, I will use at least one new support or coping skill that I’ve never tried before.” Examples include: attending a support group, journaling, or enrolling in art therapy.

3. Now that you’ve resolved NOT to make a resolution, how are you going to cope with everybody else who feels inclined to talk about resolutions, weight loss and diets all of the time?

  • Be the bearer of accurate news.  When your friends start discussing the new diet they will begin on January 1st, inform them about why diets don’t work and be sure to let them know that 98% of the people who go on diets gain all of the weight back and that half of them gain back more than they lost.
  • Try out the “shock and awe” technique. As others start to bemoan their hips and curse their thighs while resolving to change their bodies in the new year, employ the element of surprise – say something  NICE about yourself and your body. Body bashing has become such an accepted form of conversation (especially around the holidays) that when someone (You!) is able to reflect positively on their own body, people are seriously caught off guard and may think twice about their own statements.  Try one of the comments below or come up with a few of your own!
    • “I am so grateful for all of the things my body allows me to accomplish.”
    • “I’m much more concerned about feeling strong and healthy than I am about fitting into a particular size.”
    • Even if you are not at a point in your life, or in recovery, where you actually believe these statements, say them anyway.  Saying them out loud helps move you in the right direction toward real change.  You will not only have helped yourself, but you will steer the conversation away from a negative place and become a role model for positive body image.  This is particularly important if children and adolescents are within earshot of the conversation.

Here’s to a hopeful 2011 full of balance and mindfulness!

If you have any questions about eating disorders, please call our admissions coordinators at (410) 938-5252 to speak confidentially about your concerns and treatment options.  Additionally, you can visit our website at www.eatingdisorder.org for more information, including an interactive on-line quiz that can help determine whether you, or someone you care about, might have an eating disorder that requires professional treatment.


Body Image, Eating Disorders & Intuitive Eating… A Special Pre-Event Q&A with Evelyn Tribole, MS, RD (Part 2)

Evelyn Tribole, MS, RD,  co-author of Intuitive Eating: A Revolutionary Program That Works, answered some important Intuitive Eating questions for us in yesterday’s post, What is Intuitive Eating? (Part 1).  Readers found out, perhaps surprisingly, that research shows Intuitive Eaters are actually healthier, both physically and mentally.  Today’s post (Part 2) is a follow-up Q&A with Evelyn and delves a little deeper into the intersections between body image, eating disorders, recovery and Intuitive Eating.  Evelyn will be presenting “Intuitive Eating: Making Peace With Food” at a free community event in Baltimore on Sunday, November 21, 2010.  All are welcome.  Her talk will be followed by a book signing and casual reception.  Please visit our Events page for more information.

Q & A with Evelyn Tribole, MS, RD (Part 2)

In your book, you have a chapter entitled “Respect Your Body” – what kind of role does body image play in becoming an intuitive eater?

Body image is often at the core of people’s struggle with eating and weight because their initial desire to lose weight or change their body in some way may have been the catalyst for their first diet.  Unfortunately the first diet often leads to more diets, and a long relationship with dieting and weight fluctuations can wreak havoc on a person’s metabolism, their relationship with food and their overall self-esteem.  As mentioned above, diets have also been shown to result in increased weight gain (rather than the intended weight loss) which can perpetuate further body dissatisfaction. In other words, as stated in the book, “body vigilance begets body worry, which begets food worry which fuels the cycle of dieting”.

That being said, in order to move towards becoming an intuitive eater you really have to learn to respect your body.  Respecting your body doesn’t necessarily mean immediately liking every aspect of your body.  Respecting your body means treating it with dignity, and meeting its basic needs.  It means accepting your genetic blueprint, getting realistic about what is a healthy weight for you and letting go of the unrealistic and unhealthy weight expectations you’ve set for yourself along the way. Chapter 12 in my book and my presentation in Baltimore on November 21st will delve into some more specific steps involved in this process.

Can someone who has had an eating disorder become an Intuitive Eater?

Yes they can, however, timing and readiness are key factors that must be considered in order to do so safely and in a way that does not create risks for relapse.  When an individual is in the throes of an eating disorder, he or she is not capable of accurately hearing biological cues of hunger and fullness.  In this situation, their “satiety meter” is broken, a consequence of complex interactions of mind-body biology and malnutrition.  In the beginning of treatment, nutrition rehabilitation usually requires some sort of eating plan (often under the direction of a nutrition therapist). With proper treatment and input from their providers, individuals with eating disorders can determine the best timing and their readiness to begin transitioning from a structured eating plan to more intuitive eating. Ultimately, when a person recovers from an eating disorder, she trusts her inner body wisdom. She/he is at peace with mind and body, and finally, enjoys the pleasures of eating according to natural hunger and fullness cues and without guilt or moral decree.

In your experience, what are some of the most frequent reactions or responses people have had after learning about and incorporating intuitive eating into their lives?

One of the most common reactions from people who make the shift into Intuitive Eating, is that they marvel at their new sense of freedom and peace—freedom from:

  • Worrying about every single morsel they put into their mouths.
  • Judgment from their incessant food-police critic.
  • Worrying about what other people think about their food choices.
  • Pre-occupation about eating the “right” or “wrong” food.
  • Counting—calories, carbs, or points.
  • Guilt, judgment, and self-worth related to food and body.

Consequently, their anxiety is markedly decreased, and they can participate in life—on what’s happening — right now, in the moment.  No more distraction.  When someone is constantly worried about what they eat—it’s akin to talking on the phone to a person who is simultaneously emailing or surfing the net.  The distracted person is saying the right words, but the connection is missing.

I never tire of hearing the genuine surprise of “taste discovery”, when someone finally gives herself unconditional permission to eat.   It’s not unusual for some to discover that they really don’t like a particular food that they have lusted after, and felt guilty while eating it.  When you have unconditional permission to eat—you really get to taste and experience the food, without judgment.

When someone embraces Intuitive Eating (and “gets it”), it is very empowering—because ultimately, the individual becomes self-attuned, and the expert of his or her own body.

Who could benefit from attending your workshop on November 21st, 2010 at The Center for Eating Disorders at Sheppard Pratt?

This will be a great opportunity for individuals who’ve struggled in anyway with their relationship with food or weight including those who struggle with yo-yo dieting, compulsive overeating, weight fluctuations, restrictive diets, disordered eating or any type of general anxiety about food and weight.  This will also be a helpful presentation for parents or caregivers who are looking for ways to help their families develop an emotionally and physically healthy relationship with food.  Professionals who work with individuals around eating and weight can also benefit from learning more about Intuitive Eating.

In addition to attending your workshop on Nov. 21st and reading your book, Intuitive Eating: A Revolutionary Program That Works, can you recommend any other supportive resources or additional strategies for individuals or families who are interested in intuitive eating?

On my website I have an entire collection of articles, interviews, research, trainings, and supportive resources related to Intuitive Eating. I would suggest starting there. You can also sign-up for my e-newsletter to receive ongoing news and research about intuitive eating.

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If you missed Part 1 of this special Q & A with Evelyn Tribole, we suggest you take a moment to go back and read it here.   Part 1 is important to understanding what Intuitive Eating is all about and provides links to additional research supporting the intuitive eating principles set forth by Evelyn Tribole, MS, RD and her Intuitive Eating co-author Elyse Resch, MS, RD, FADA.

You may also be interested in some of these past entries from The Center for Eating Disorders at Sheppard Pratt Blog:

What is INTUITIVE EATING? A Special Pre-Event Q&A with Evelyn Tribole, MS, RD (Part 1 of 2)

On November 21st, The Center for Eating Disorders at Sheppard Pratt will  host registered dietitian and bestselling author, Evelyn Tribole, MS, RD  as the 2010 keynote speaker at our annual Fall Outreach  Event. Tribole will be speaking at the free event where she will be de-bunking diet myths, sharing important nutrition information and discussing practical ways individuals and families can move toward becoming Intuitive Eaters (even as the food-focused  holidays approach).   Over 200 people have already registered to attend next Sunday’s event, and its created a lot of intuitive eating buzz here in Baltimore.  In case you don’t know what all the excitement is about, Evelyn agreed to answer some of our general questions about Intuitive Eating in advance of  her presentation.  Consider this a sneak peak, come back tomorrow for Part II, and then join us for the main event…Intuitive Eating: Making Peace With Food on Nov. 21st.  

Q &A with Evelyn Tribole, MS, RD (Part I)

What is Intuitive Eating, and what are some of the general benefits for individuals?  For families?

Intuitive Eating is an approach that teaches you how to create a healthy relationship with your food, mind, and body–where you ultimately become the expert of your own body.   You learn how to distinguish between physical and emotional feelings, and gain a sense of body wisdom.  It’s a process of making peace with food–so you no longer have constant “food worry” thoughts.  This means that meals are not a moral dilemma resulting in feelings of guilt and shame, but rather a place to practice tuning into one’s inner needs and fulfilling those needs in a healthy, nurturing way. While there are many ways of incorporating the process of Intuitive Eating, there are three core characteristics:

  • Unconditional permission to eat.
  • Reliance on internal hunger and satiety cues.
  • Eating for physical, rather than emotional reasons.

There are many benefits for individuals and families who eat intuitively. Unfortunately, one of the myths or misconceptions about intuitive eating is that it is unhealthy because people often fear that if you allow yourself to eat whatever you want, you’ll just a eat lot of “junk food” and you won’t be able to stop.  The truth is, there are studies that show Intuitive Eaters are actually healthier, both physically and mentally.  Here are two that illustrate these conclusions:

In 2006, Dr. Stephen Hawk, from Brigham Young University evaluated 343 college students and found that Intuitive Eating does not lead to poor nutritional food choices.  To the contrary, he found that Intuitive Eaters consume a greater diversity of foods, take greater pleasure in eating and have healthy body weights.

A larger study on nearly 1300 college women by Tracy Tylka*, from Ohio State University, found that Intuitive Eaters are more optimistic, have better self-esteem, and a lower body mass index (BMI), but without internalizing culture’s unrealistic thin ideal.  (That part is important, because if you desire or value an unrealistically thin body, it increases your risk for eating disorders).

How does Intuitive Eating compare to our current societal norms and cultural messages around food/eating?

The pleasure of eating has become a lost art in the USA. Instead, eating is commonly viewed as something that will kill you, cure you, or make you fat. This is where we can take a lesson in the pleasure principle from France. An international study found that Americans worry the most about their health and enjoy eating the least. In contrast, the French are the most food-pleasure-oriented and least food-health-oriented. [1] Notably, France has nearly half the obesity rate compared to the USA, for both adults and children [2].

When food restrictions are placed on a chronic dieter, or on a person who chronically feels guilty about eating, it increases the “forbidden food” burden. Consequently, rigid food rules interfere with the individual’s ability to “hear” or be attuned to the eating experience of his or her body.

Can you briefly explain the “diet mentality” you refer to in your book?  From a nutrition perspective, how do diets affect weight and health?

Many times, “healthy eating” or “better nutrition” is code for dieting. Consequently, if you focus solely on these factors, without considering your internal body cues or what would best satisfy hunger, you can easily feel deprived. This in turn may increase cravings and thoughts of food, overeating, dieting, and heighten anxiety around snacks and meals.

There are compelling studies, which indicate that dieting actually predicts weight gain (and often binge eating). While most people know that diets don’t work, not many are aware of the weight-gain hazard. For example, a team of UCLA scientists reviewed 31 long term studies on dieting and concluded that [1]:

  • Dieting is a consistent predictor of weight gain.
  • Up to two-thirds of the people regained more weight than they lost.
  • Diets do not lead to sustained weight loss or health benefits for the majority of people.

A prospective study on nearly 17,000 kids ages 9-14 years old, found that dieting predicted binge eating behavior and concluded that, “…in the long term, dieting to control weight is not only ineffective, it may actually promote weight gain” [2]. Recently, a five-year study on teens, found that dieters had twice the risk of becoming overweight, compared to non-dieting teens [3]. (Notably, at baseline, the dieters did not weigh more than their non-dieting peers.)

I consider dieting a form of “nutritional trauma”. It might sound a bit dramatic, but once your body experiences the biological and psychological deprivation from dieting, your body gets smarter. Consequently, it gets harder to stick with each new diet, because your cells know what to do. When dieting, hunger becomes a feared sensation, rather than a natural process that gears up and down, depending on when, and how much you ate. And if you eat just until the hunger goes away, you will likely be hungry sooner, which sets up a cycle of constantly thinking about food and what to eat. This is a big part of the “diet mentality”. Conversely, if you learn to eat intuitively and feed your body on a regular, consistent basis, by honoring your hunger, it will help build “body-trust”.

…part 2 is now available here:  “Body Image, Eating Disorders & Intuitive Eating”…A Special Pre-Event Q&A with Evelyn Tribole, MS, RD

In Part II of this Q & A, Evelyn answers questions about body image and eating disorders as they relate to Intuitive Eating.  Follow CED on Facebook for additional updates about our blog and upcoming events.  You can also visit our Events Page for more details on how to register for the Intuitive Eating event on November 21, 2010.

In addition to co-authoring the groundbreaking bestseller, Intuitive Eating, Evelyn is also an award-winning registered dietitian in private practice in California and a nationally recognized nutrition consultant;  She has appeared on hundreds of interviews, including: CNN, Today Show, MSNBC, Fox News, USA Today and the Wall St. Journal.  For more info about Evelyn Tribole, click on her picture above or visit her website at www.evelyntribole.com.