GLOSSARY of Terms: Body Image. Body Dissatisfaction. Body Shaming. Body Acceptance.

refuse to miss out

Having a #bodypositivesummer may sound relatively straight forward; however some of the accompanying language may require a bit more explanation. This guide is meant to help break down some of the vernacular you come across within the #bodypositivesummer movement and in other similar discussions about body image.

Body image refers to the subjective picture or mental image of one’s own body. The key word being subjective. In other words, body image is how you see yourself.  Medical definitions of body image extend to include the individual’s emotional beliefs and attitudes about the image they perceive. The same feature might be experienced differently and thus, elicit different emotions from person to person. For example, to one individual, being tall might come with a sense of pride and a belief that his or her height is a strength, while another individual feels embarrassed about being tall and believes that it sets him or her apart in a negative way.  An individual’s body image state – negative or positive –  is shaped by lived experiences, peer groups, media and marketing, family, community and cultural attitudes, as well as other external sources of body ideals and expectations.

The divergence of one’s body image from sociocultural beauty ideals can lead to body dissatisfaction. Grogan (2008) defines body dissatisfaction as a person’s negative thoughts about his or her own body.  Negative feelings about body type, weight, body hair, and skin tone are known to be intensified during summer months due to an increased focus of marketing on these insecurities, greater body exposure due to warmer temperatures, and other socially influenced factors. Beauty standards (also referred to as the thin ideal or body ideal) are often narrow, unhealthy and down-right ridiculous for both women and men. These unattainable “standards” may also lead to dangerous behaviors, such as excess sun exposure, dieting, and potentially by extension, disordered eating. They also set the stage for forms of hurtful interactions such as body shaming.  Body shaming, also referred to as body bashing,  is any form of mocking, bullying, or insults focused on deviations from body or appearance “norms”. This type of bullying behavior can take place in person during face-to-face interactions or online across social media platforms. Body shaming is normalized and encouraged by advertisements that imply certain bodies are not suited for certain places (like the beach) or for specific articles of clothing (like shorts or a bathing suit).

The antidote to body dissatisfaction is body acceptance.  Body Acceptance is approving of and caring for your body despite it’s real or perceived “imperfections”.  This is inclusive of other terms like body positive, body neutrality and size acceptance.  Being body positive or working towards body acceptance, doesn’t mean you absolutely love the way you look all the time. It simply means you accept and honor all bodies – including your own – as good and worthy of care and respect.  It also means you are willing to confront your own internalized weight bias and challenge other stereotypes or assumptions based on a person’s appearance.

We live within a culture that encourages body dissatisfaction. But we have within us individually, the power to be body positive. In doing this for ourselves, we also create space for others, including friends and family members with eating disorders and/or serious body image disturbances, to re-engage in experiences they might be prone to avoid.

Be a part of the #bodypositivesummer movement.  Follow along on Twitter or Facebook for blogs, tips, resources and opportunities to tell us how you are creating a season of body positivity.

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Seasonal Depression: Fall-ing into Winter

Fall on the SP Campus...
Does the idea of darkness during your 5pm commute home from work get you down? You’re not alone if you’ve noticed that it’s not just the flowers in your garden but also your mood that has “wilted” with the cooler temperatures. During the fall and winter months, people may experience a shift in their mood as we collectively adjust to less sunshine and more cold weather. But it might be more than just “the blues” if it is a persistent sadness that feels present most days and is interfering with your ability to function or engage in day-to-day life. If this is a pattern that’s occurred for at least two years in a row and impacts you at the same time each year, it might be Seasonal Affective Disorder.

Seasonal Affective Disorder (SAD)
Many people around the world suffer from SAD, now identified in the DSM-5 as Depressive Disorder with seasonal pattern. It is suspected that seasonal depression is, in part, caused by a reduced exposure to sunlight resulting in disruption to our natural circadian rhythm (the body’s “internal clock”), as well decreased levels of the hormones serotonin and melatonin which help to regulate mood, sleep and appetite. Not surprisingly, populations living farther from the equator experience higher rates of seasonal depression than places closest to it. Thus, this type of depression occurs more frequently in populations throughout the northern rather than southern parts of the United States. In fact, one study found prevalence rates to be 1.4% in Florida and a much higher 9.7% in New Hampshire. (1)  Much of the research also indicates younger people and women tend to be at higher risk for winter depressive episodes.

People who already struggle throughout the year with clinical depression or bipolar disorder may also experience worsening symptoms during specific seasons. For those with seasonal depression, the episodes of depression that occur in the fall/winter are significantly greater than those episodes that occur throughout the remainder of the calendar year. In any case, it’s important to pay attention to seasonal patterns in your mood so that you can prepare and seek appropriate treatment and support as needed.

Common symptoms of seasonal depression
Seasonal depressive episodes generally set in during late fall or early winter. Some of the most common signs and symptoms include:

  • decreased energy, lethargy
  • increased sleep, difficulty waking
  • social withdrawal and loss of interest in activities previously enjoyed
  • increased appetite, unintended weight gain
  • persistent sadness, hopelessness
  • difficulty concentrating or focusing on tasks

(Though less common, some people experience spring/summer depressive episodes and those symptoms can look a little different, more often encompassing sleeplessness, irritability, decreased appetite and weight loss, etc.)

How might seasonal depression affect people with eating disorders?
A depressive episode can impact eating patterns and thus, impact eating disorder recovery efforts.  Individuals suffering from seasonal depression often report increased appetite. Specific studies have indicated that individuals with SAD tend to experience more cravings for foods that are higher in carbohydrates and rich in starch and report increased consumption of carbohydrates when depressed, anxious or lonely. (2)  Combined with decreased energy and declining mood, these cravings can place one at higher risk for binge eating behaviors.

Other research has shown a seasonal component to depression especially for those individuals suffering from Bulimia Nervosa. (3)  The research revealed that patients with Bulimia Nervosa tended to experience seasonal patterns of mood and appetite similar to those described by many with SAD. (4)  Some research has further speculated with regard to a possible genetic link between eating disorders and susceptibility to changes in mood related to the season. (5)

Treatment Options for Individuals affected by seasonal depression
So what can you do when the light outside your window has turned to darkness and, perhaps, this has added fuel to the eating disorder fire as well? The good news is that there are many different treatment approaches that are helpful to those suffering from seasonal depression.

  • Light therapy or Phototherapy is a commonly prescribed treatment for individuals suffering from seasonal depression. In light therapy individuals sit in front of a “light box” for approximately thirty minutes daily or per their doctor’s recommendation. Research has shown that light therapy can relieve the symptoms of seasonal depression in as many as 70% of cases. (6)
  • Anti-depressant medications can also be helpful in treating winter depression and have been shown to improve mood, energy and sleep patterns. One of the ways in which these medications work is by increasing serotonin levels in the brain.
  • Evidence-based therapies for depression such as Cognitive Behavioral Therapy (CBT) can also be helpful for seasonal depression.
  • Behavioral interventions in your daily life can also be helpful in reducing symptoms of seasonal depression. Consider trying to incorporate some or all of these:
    1. Engage in activities with friends and family each day to ward off feelings of lonliness or isolation.
    2. Make a point to get outside in the sunlight for at least a portion of the day if possible. Schedule a walk with your colleague during break or sit outside instead of inside while you do your daily perusing of Facebook, however…
    3. Be mindful about whether online social networks make you feel worse instead of better OR if they take up large amounts of time that could be better spent connecting with people in person (see #1 above).
    4. Plan to get plenty of sleep on a consistent schedule; do your best to go to bed and wake up at the same times each day, and aim for 7-8 hours of sleep/day.
    5. Avoid the use of alcohol or other substances which can worsen depressive symptoms, complicate eating disorder symptoms and disrupt sleep.

Focus on the highlights of the changing season.
If you struggle with seasonal depression, a long autumn and the approaching winter can feel daunting. Holiday stress, can make things even more difficult for individuals who are triggered by tense family dynamics, elaborate meals and social gatherings. This year, Instead of focusing on the doldrums of the season or annual stressors, consider looking for positive seasonal activities in which to get involved. Now is the perfect time to go to a holiday parade, paint a room in your house a new color, volunteer for a new cause, plan a weekend getaway, attend a recovery event, build a snowman or read a winter-themed book. It could also be a great opportunity to finish your summer vacation scrapbook or try a new activity like snow tubing or ice skating. You can even practice guided imagery or meditation – just because there is snow outside it doesn’t mean you can’t imagine yourself relaxing on a warm beach.

Try not wish away the winter season.  Each season comes with its own set of challenges for individuals with eating disorders – just think of the onslaught of diet pressures throughout spring or the bathing suit saga of summer.  So the key is not to just “get through” each season (there will be a new set of stressors on the next calendar page after all) but to learn to live mindfully in each season and find ways you can enjoy what it has to offer.

Above all else remember to ask for help when you need it. Talk to your treatment providers about your seasonal mood changes and they can help to devise an individualized treatment plan that works for you. If you are seeing a Registered Dietitian now is the time to talk with them about the food cravings you might be experiencing and devise an approach to cope and integrate more variety into your meal plan. Remember to open up and involve your support system– let your friends or family be a part of the process by sharing with them what you are going through. With help and support, you’ll be celebrating the Vernal Equinox in no time and reflecting on a well-spent, memorable winter.

For questions about treatment for co-occurring depression and eating disorders, please visit our website at

Written by Amy Scott, LCPC



  1. Friedman, Richard A. (December 18, 2007) Brought on by Darkness, Disorder Needs Light. New York Times’’.
  2. Krauchi, K., Reich, S.,& Wirz-Justice, A. (1997). Eating style in seasonal affective disorder – who will gain weight in winter? Compr Psychiatry, Mar-April, 38 (2). 80-87.
  3. Lam, R.W, Goldner, E.M., & Grewal, A. Seasonality of symptoms in anorexia and bulimia. International Journal of Eating Disorders. 1996. Jan 19 (1): 34-44.
  4. Fornari, V.M, Braun, D. L., Sunday, S.R., Sandberg, D.E., Matthews, M, Chen, IL, Mandel, F.S., Halmi, KA & Katz, JL (1994) . Seasonal Patterns in Eating Disorder Subtypes.Compr Psychiatry. Nov /Dec; 35 (6): 450-456.
  5. Sher, L. (2001). Possible Genetic Link Between eating disorders and seasonal changes in mood and behavior. Med Hypothesis, Nov 57 (5): 606-608.
  6. Wein, Harrison ed. (2013). Beat the winter blues shedding light on seasonal sadness. NIH News in Health. Retrieved from


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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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


Eating Disorders and the “All-or-Nothing” Trap

There are several types of cognitive distortions frequently experienced by individuals who struggle with eating disorders. These negative thought patterns are often longstanding and can play an integral role in maintaining depressive thoughts, anxiety, low self-esteem and reliance on eating disorder symptoms.  One of the primary cognitive distortions identified by individuals who struggle with anorexia, bulimia and binge eating disorder is often referred to as “all-or-nothing” thinking.  Also called “black-and-white” thinking, this thought pattern is akin to the belief that “If I can’t do it perfectly, I might as well not do it at all.”

In the same way that all-or-nothing thoughts can perpetuate harmful eating disorder behaviors (ex: periods of severe restricting followed by frequent binging) , they can also sabotage efforts at recovery.  In this clip, recovery advocate Johanna Kandel talks about how all-or-nothing thoughts crept into her nutrition appointment…

Many individuals can probably relate to this experience in therapy where it becomes difficult/impossible to recover perfectly and immediately.  Setting insurmountable goals (i.e. perfection) makes it really easy to feel like you failed even when, by all other accounts, you are actually making progress.  This often leads to  someone feeling completely defeated and makes it easy to do a u-turn back towards the symptoms, isolation and secrecy that allow the eating disorder to spiral out of control.

For others, all-or-nothing thoughts may be an initial barrier to seeking treatment.  Its not unusual for individuals to hold off on making that first appointment until they are absolutely, positively, completely 100% ready to get well. Sound familiar?  As Johanna discusses in this clip, very few people are ever really going to be 100% ready for recovery but the good news is that you don’t have to be…

Identifying all-or-nothing thoughts that are impacting you and your recovery is an important step towards change.  Once you identify the cognitive distortions, you can begin to challenge them during therapy sessions, thought logs, journaling, and reality-testing.  If you aren’t sure where to start you can use the simple questions listed in this previous post to test validity of any suspected all-or-nothing thoughts. When you start exploring your negative thoughts you might be surprised at how many of them simply don’t stand up to the test.  Once you free yourself to think outside of the automatic negative thoughts you will learn, as Johanna did, that you are not an exception;  you CAN recover and you DESERVE to get better.

How did you overcome all-or-nothing thinking?  What role did it play in your eating disorder?  Join the discussion on CED’s Facebook page or leave a comment below.

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This was the third of several recovery blogs inspired by the February 2011 presentation by Johanna Kandel at The Center for Eating Disorders at Sheppard Pratt. Follow CED on  Facebook to stay tuned as we continue to post additional recovery-focused blogs and video clips.  Johanna shares more about her own recovery journey in her highly influential book, Life Beyond Your Eating Disorder,  and continues to support others through her role as the Executive Director of The Alliance for Eating Disorders Awareness, a non-profit organization based in Florida. You can learn more about Johanna and her incredible book in these previous blogs as well:

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.

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

Updates & Evidence-Based Nutrition Guidelines in the Treatment of Eating Disorders, with Marcia Herrin, EdD, MPH, RD, LD

On September 25th, Dr. Marcia Herrin will be one of six multi-disciplinary experts to converge in Baltimore as featured speakers for the highly anticipated professional symposium, Eating Disorders: State of the Art Treatment. This event is a unique opportunity to learn directly from some of the field’s most knowledgable and innovative professionals from around the world.

Marcia Herrin, EdD, MPH, RD, is the founder of Dartmouth Colleges nationally renowned nutrition programs and has served as a nutrition consultant to a variety of universities and school systems, including the school of the American Ballet Theatre. Currently, Dr. Herrin conducts a busy private practice in Lebanon, New Hampshire where she specializes in children and adults with weight issues and eating disorders. Dr. Herrin is the author of several books including, Nutrition Counseling in the Treatment of Eating Disorders, a detailed treatment manual for professionals. On September 25th, Dr. Herrin will provide a training entitled, “Updates and Evidence-Based Nutrition Guidelines in the Treatment of Eating Disorders” which will be of great interest to novice and veteran treatment providers alike. In advance of her presentation, we asked Dr. Herrin about the significance of nutrition therapy, important indications for the treatment team and a little preview of her upcoming presentation! Dr. Herrin’s answers follow:

Q & A with Marcia Herrin, EdD, MPH, RD LD

Can you provide a brief description of the impact of nutritional deficits on cognitive and/or emotional functioning?

MH: Research shows that many nutrients, such as vitamin B12 and iron, are essential to human brain function and that deficiencies in these nutrients and others can lead to impaired cognitive function and impaired memory and concentration. Nutritional deficits are also directly related to impaired emotional functioning, i.e., irritability; apathy; withdrawn behavior; decreased ability to focus, to listen, and process information; and to fatigue. Deficits in nutrients and calories lead to preoccupation with food. We also know that nutrition deficiencies affect cognitive function and can be associated with anxiety, depression, and obsessive-compulsive disorder.

What are the overarching goals of nutritional counseling for patients and families affected by eating disorders? Who is qualified to provide nutritional counseling for this population?

MH: The most important goals of nutrition counseling are to correct disordered beliefs and behaviors about food and exercise; enhance motivation to restore healthy eating; and to establish a normal, carefree approach to eating and weight control.

The fundamental credential for practicing nutritionists is the RD (registered dietitian) degree. Registered Dietitians are uniquely qualified to provide medical nutrition therapy in the treatment of eating disorders. RDs are skilled in nutritional counseling, able to recognize clinical signs related to eating disorders, assist with medical monitoring, and are cognizant of psychotherapy and pharmacotherapy treatments. While other health professionals may be able to assess dietary intake and identify areas where change is needed, the expertise provided by RDs adds impact and credibility to the nutrition information and advice. Unfortunately, the therapeutic skills required to provide effective nutrition treatment are not routinely included in dietetic education programs.

Why is it important for all members of a treatment team to have a thorough understanding of nutrition and the metabolic processes involved in eating disorder treatment/recovery?

MH: When relevant scientific facts are disclosed and explained by all team members to eating-disordered patients it can motivate patients to discontinue eating-disordered thoughts and behaviors. To have the most impact, team members must have accurate information delivered in a confident manner. Enumerating the health consequences of unchecked eating-disordered behaviors indicate that providers take eating disorders seriously. It is motivating when providers can point out that most, if not all, the physical symptoms patients suffer from can either be avoided or reversed with weight restoration or cessation of purging.

What are the mains topics you will be expanding upon during your September 25th presentation for professionals in Baltimore, Maryland?

MH: I will be discussing specific nutritional approaches for patients with anorexia nervosa, bulimia, and binge-eating disorder and nutrition techniques derived from Motivational Interviewing, Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, and Family Based Therapy.

Many thanks to Dr. Herrin for her time and clinical expertise in providing these responses. You can visit our blog to find out more about Dr. Herrin and the other symposium speakers.

If you would like to register to attend the September 25th symposium in Baltimore, please visit Don’t delay! Space is limited and early-bird and student discounts expire on September 17th.

You may also download and print the PROGRAM BROCHURE (pdf) or call (410) 938-4593 with any questions.

*Eating Disorders: State of the Art Treatment is approved for 7 cme/ceu credits for physicians, nurses, psychologists, counselors, social workers and registered dietitians.

Read our other 2010 Speaker Q & A Blogs here:

Cognitive Process & Remediation in Anorexia Nervosa – Q&A with James Lock, MD, PhD

Utilizing Transference & Countertransference to Deepen the Treatment of Eating Disorders – Q&A with Kathryn Zerbe, MD

In Search of…

One of the most frequently used phrases in marketing to mothers is “How to get your body back… .” The ending varies and generally goes something like, “How to get your body back…after pregnancy…after baby…after having children…,” but the specific ending is less important than the underlying message.  When women are told repeatedly that they will need to “get their bodies back” after pregnancy doesn’t that seem to imply that their bodies are lost, damaged or missing as a result of the pregnancy?

The truth is, a pregnant body does not represent a loss of one’s body or even a damaging of it (despite a recent celebrity comment which seems to suggest this).  To the contrary, pregnancy can actually be a very visible expression of the body’s resourcefulness, strength and utility, and that is beautiful. You’ve owned your body the whole time, and it’s been doing important things for you and your baby.  During pregnancy, the body does go through changes, albeit sometimes difficult or painful ones that are a necessary part of pregnancy and childbirth, but it is still your body – the same one that climbed the jungle gym when you were five years old, the same one that walked up on stage during graduation and the same one that embraced a friend when they needed a hug.  Bodies are not lost; they don’t disappear because they change size or shape or because they’ve accumulated stretch marks or c-section scars.  Bodies work hard and deserve to be cared for, respected and appreciated.

It can be very easy to fall into a pattern of rebelling against weight gain and other physical changes that accompany pregnancy and childbirth.  That is after all, the strategy most often proposed by our image-obsessed media, a relentless diet industry, and even sometimes further encouraged by well-intentioned family members or friends.  But in reality, it’s not helpful to spend significant time and energy in search of a body you’ve been told you lost.  This quest too often ends up spiraling into years of yo-yo dieting, excessive exercise, negative body image or even serious eating disorders – all of which can be detrimental to physical and emotional well-being.  Too much time spent focused on “getting your pre-baby body back” can also have the unfortunate and undesired consequence of interfering with important bonding time between mom and baby.  This might be one reason why authors, Claire Mysko and Magali Amadei, named the phrase “get your body back” to their list of the top 5 most detrimental tabloid catch phrases for new and pregnant moms.

Search no more.  Trust your body’s natural changes and processes, including hunger and fullness cues and your unique set-point.  Nourish yourself appropriately.  Respect your body’s journey and its accomplishments; appreciate your body for what it allows you to do, not solely for how it looks.  Remind yourself that nurturing your body with enjoyable movement, adequate rest and unconditional kindness is the best way to be a healthy and beautiful mom.

If you enjoyed this blog, you may want to read these previous entries from CED’s Nurture Blog Series:

Want to receive blog updates? Follow The Center for Eating Disorders on Twitter and Facebook:

Adding Up, Weighing In, and Counting Down: Five Ways to Cope with the Numbers Game of Pregnancy


The Center for Eating Disorders is honored to be able to feature Claire Mysko and Magali Amadei as guest bloggers in our Nuture series for moms and mothers-to-be.   Their book, Does This Pregnancy Make Me Look Fat? The Essential Guide to Loving Your Body Before and After Baby, offers a refreshingly realistic and healthy perspective on body image during pregnancy. Recently, we asked Claire and Magali to offer their best advice to women, especially those who have struggled with eating disorders or disordered eating, on how to navigate the adventures of pregnancy without over-focusing on weight and size.

This is what they had to say…



Pregnancy is a time of great anticipation. It’s also a time that is measured meticulously from start to finish—in weeks on the calendar, milestones on the sonograms, and numbers on the scale. And for those with histories of disordered eating, all that counting can be dangerous territory. Here are five tips to help every expectant mother get beyond the numbers game.

 Tip # 1:

Take weight out of the equation. This might seem like a radical suggestion considering that pregnancy weight gain and post-baby weight loss are such hot topics of conversation among mothers-to-be and new moms. To add fuel to the fire, weigh-ins are often the center of every visit to the doctor. But truthfully, there really isn’t any reason you need to keep track of your weight. If you know that it could become an unhealthy fixation, tell your OB or midwife that you prefer not to discuss the number unless it becomes a medical issue. Step on the scale backwards and remind the physician’s assistant that you don’t want to be told your weight. Then enjoy the looks on people’s faces when they ask you how much you’ve gained and you respond, “I don’t know.” As a bonus, you’ll soon discover that there are plenty of other interesting—and more substantive–things about becoming a mother that you can talk about.

Tip # 2:

Choose a health care provider who is sensitive to food, weight and body image issues. Women who have struggled with poor body image and/or disordered eating need to find prenatal healthcare providers who are knowledgeable and compassionate when it comes to these issues. We’ve heard from many women who ended up in the examination room—and sometimes even the delivery room—feeling belittled and unsupported by their own doctors. The best way to avoid this scenario is to push through whatever shame you might be feeling and be upfront with your OB or midwife about your history and your pregnancy-related body image fears. If you’re met with criticism or any other reaction that makes you feel uncomfortable, remember that you are well within your rights to walk out that door and find another doctor who will treat you with more respect. Of those we surveyed, 73% of pregnant women with body image issues and histories of eating disorders and disordered eating said they had not discussed this history with their OBs or midwives. It’s time to break that dangerous silence.  

Tip #3:

Clean out your closet. One of the kindest things you can do for yourself is to pack up anything in your wardrobe that would qualify as “form-fitting” as soon as you see that plus sign on the pregnancy test. You will start gaining weight before you start showing, so this is a surefire way to avoid the agony of trying to squeeze into something that’s too small. And we’re not kidding about packing it up. Put those clothes in a box, and seal it up tight. Personally, we advise you not to open it again until a year after you’ve given birth. You know what they say about nine months to gain the weight, nine months to take it off? Well, we’re adding a few extra months for good measure. That’s a lot of seasons in fashion-speak, so chances are good that you won’t even be interested in some of those clothes once you dig that box out again. For sanity’s sake, pregnancy is a time when you must let go of your attachment to a specific clothing size. As someone who is about to become a mother, your sense of self-worth cannot hinge on whether you can fit into whatever size you think is “ideal” for you. Is that a belief you would want your child to absorb? What’s really ideal is to find clothes that are flattering, comfortable, and versatile. Sizes vary from store to store, so don’t have a heart attack if you end up wearing sizes that seem beyond what you imagined you would wear. That goes for pregnancy and it applies for after delivery, too. The number on the scale doesn’t define any of us, and neither does the number on the tags of our clothes. If it’s making you that miserable, take a pair of scissors and cut those labels out of sight and out of mind.

Tip #4

Be aware of the triggers of pregnancy. The incessant counting, comparing, and measuring that happens during those nine months and beyond can tap into some of the very vulnerabilities that are linked to eating disorders and food and weight obsessions. Perfectionism, loss of control, feelings of isolation, and memories of childhood often bubble right to the surface. But if you’re getting the support you need, you’ll have a better chance of weathering those storms without resorting to self-destructive habits. Resist the urge to shut down or close off.  Remember that there is nothing shameful about asking for help. It’s the most courageous thing you can do for yourself and your baby. Look at your recovery as an ongoing process that will help you reach your full potential as an individual and as a mother.

Tip #5

Break the cycle of body hatred. Allow yourself to celebrate the fact that your body is working some serious magic right now. Before you get stymied by stretch marks or focused on flabby skin, take time to reflect on how you will teach your child—in your words and in your actions—that you appreciate your body because it brought them into the world. We have the power to help future generations grow up placing a higher value on good health than on weight and physical appearance. But before we can pass along those positive attitudes, we must first embrace them for ourselves.

Make your commitment now by signing the  Healthy Beauty Pledge for Mothers and Mothers-to-Be.

Visit Claire Mysko’s website  for more empowering and encouraging blogs about body image.

* * *

Adapted from Does This Pregnancy Make Me Look Fat? The Essential Guide to Loving Your Body Before and After Baby by Claire Mysko and Magali Amadei

Pre-Baby Body Love: Nurturing Your Body Image Foundation

If becoming a mom is something you’re considering, what comes to mind when you think about the possibility of that life-changing experience?  Do you wonder about what your baby would look like, how it might feel to hold him or her?  Do you feel excited about raising a child and anxious at the thought of sleepless nights and parenting decisions?  Or, are you feeling anxious about the changes that will take place with your body?  Do you worry a lot about what you would look like pregnant, how much weight you will gain or how quickly you will lose the weight afterwards?

If you are like a lot of women, when you think about becoming a mom you probably experience a combination of both excitement and worry, some of which might revolve around the potential changes to your body. However, if you find yourself mostly occupied by these thoughts and fears about weight gain or other body changes, its important to address them.  When negative body image thoughts or an overarching fear about weight gain are preventing you from otherwise enjoying  a journey towards motherhood, or if those fears are the primary reason that you are postponing important things in your life, it may be a good time to reflect on and work towards a more positive body image.  If having children is something you are considering or if it is a possibility at any point in the future, developing a foundation of body acceptance before you go through the emotional and physical changes of pregnancy and motherhood is ideal.

Claire Mysko and Magali Amadei, authors of “Does This Pregnancy Make Me Look Fat?”report  that 78% of women they surveyed who don’t have children yet or are not planning to have children, said that they had concerns about how pregnancy and motherhood could change their bodies.  Furthermore, 79% of the ones who expressed these fears said that gaining weight and not being able to lose it after delivery was their number one fear. Clearly, this is not an uncommon thought, especially as media outlets continue to shine a spotlight on pregnant bodies and proceed to publicly judge women based on their rate of return to pre-pregnant form.  This pressure can be a lot to contend with but we want women to know that it is possible to feel good about yourself and your body – it has nothing to do with changing your body and everything to do with changing how you think about and treat your body.  Learning about and working towards a positive body image now, will not only prepare you to accept and appreciate the changes that come during pregnancy but will also help you to be a positive body image role model for others, especially any future children that might come along. 

There are a lot of on-line resources claiming to provide helpful hints for improving body image pre and post-pregnancy.  While perusing these resources, remember that the definition of positive body image is not dependent upon being a specific weight or size, nor does it require any physical deviation from the way your body is right now.  If you ever come across “helpful body image hints” that encourage you to do things for rapid weight loss,  or if they are very focused on fitting you into your pre-pregnancy jeans as soon as possible, it’s probably not a helpful resource for body image or for your health. 

If you are thinking about or planning a pregnancy, or if you are currently pregnant or parenting, these are some strategies that can help you resist negative cultural messages about women’s bodies and move towards acceptance and appreciation for the body that you have!

  • Focus on your health, not your weight.  Healthy can come in any size and shape and the same goes for unhealthy.  Attempt to stop judging your health status (and other people’s health) based on weight or outward appearance.  In fact, research shows that focusing on health – without regard to weight – consistently leads to better physical health outcomes.
  • Throwing out (or donating) your bathroom scale can make it a lot easier to focus on incorporating healthy behaviors for health’s sake as opposed to perpetually being tempted to strive for an unrealistic or unhealthy number on the scale.  Leave the weigh-ins for the doctor’s office.
  • Evaluate your reading material.  After just 3 minutes of looking at a women’s fashion magazine, 70% of women feel significantly worse about themselves. Remember that pregnancy and parenting magazines are not immune from our retouched and photoshopped culture – many of the pregnant bellies and even the babies (yikes!) in these magazine photos have been significantly altered to appear “flawless”.  Do some self-check-ins occasionally to make sure you aren’t comparing your own real body to those that have been digitally created.
  • On a daily basis, attempt to consider and appreciate the utility of your body instead of simply placing value on how it looks.  Instead of labeling wrinkles an unfortunate byproduct of aging, consider them proof of all the smiling you have done and wear them proudly.  This will be an incredibly important mindset to adopt prior to, during and following pregnancy when women’s bodies go through natural and amazing changes in order to support a baby.  Widening hips during pregnancy are often the focus of much discontent among pregnant women who no longer fit into their jeans.  But if you take the time learn about how and why your hips are widening, you will be better able to develop an attitude of understanding and gratitude for your body and move away from the loathing and self-criticism that has, unfortunately become so normalized among new moms.
  • Close your eyes and picture five to ten women who have been the most influential in your life.  Perhaps you look up to them for their strong morals and values, their attributes as a parent or as a professional, or because they inspire you to reach your own goals.  They might be relatives or friends, famous or not famous, younger or older than you.  As you visualize these women ask yourself a few questions…Do they all look the same?  Are they shaped the same? Do they all wear the same size or have the same skin color?  Are they all exactly the same height?  In most cases, the answer to all of these questions is going to be no.  No, because beautiful people come in all shapes and sizes, including you. 

If you continually struggle with negative thoughts about your body, have persistent or intense fears about gaining weight (related or unrelated to a pregnancy),  or experience significant distress as a result of a preoccupation with your weight or size, you may want to consider seeking professional support.  If you have any questions about therapy to help improve body image, please visit or call The Center for Eating Disorders at (410) 939-5252.