Monday, September 29, 2014


by Melinda Parisi, PhD
Program Director, Center for Eating Disorders Care University Medical Center of Princeton at Plainsboro
Children with eating disorders appear to be increasing in number and decreasing in age.  Epidemiologic studies demonstrate that the prevalence of eating disorders in children and adolescents has progressively risen since the 1950s; what’s more, eating disorders are occurring at younger and younger ages (Rosen, 2010). At University Medical Center of Princeton at Plainsboro we work with children as young as age 8, and eating disorders can be seen in even younger children. Children with eating disorders present a unique set of challenges related to recognition, assessment, and treatment: They are not just smaller versions of adults or even adolescents, and treatment must be tailored to children’s particular developmental needs. It is especially important to provide effective, age-appropriate care when one considers the substantial toll that eating disorders take on children’s physical, psychological, and social growth and development; furthermore, good outcomes are very possible, especially with early and determined intervention. This article outlines some of the diagnostic and treatment issues involved in working with eating disordered children (essentially those under age 13), though some of this discussion may be extended to adolescents.

Challenges to assessment and diagnosisBlurred boundary between normal and abnormal. One of the first complications to recognizing eating disorders is that there is not a clear dividing line between normal and abnormal eating behavior in children. Many children go through “picky eating” phases that are developmentally normal, and they usually grow out of them over time and without intervention.  How, then, does one determine whether a given behavior, though likely troubling to parents, is likely to be transient, or whether it is an indication of a more problematic condition? Bryant-Waugh and Nicholls (2011) offer a useful framework to help assess whether problematic eating behavior is clinically significant:
  • Nutritional adequacy: Is the child’s diet nutritionally sufficient to prevent physical risk in the short- and/or longer-term?
  • Impact on physical development: Is the child’s eating behavior likely to impact weight, growth, and physical development?
  • Impact on social development: Is the child’s eating behavior impacting social and emotional development (such as causing the child distress or causing the child to avoid social experiences)?
  • Impact on relationships: Is the child’s eating behavior affecting family functioning and relationships with caregivers?
These authors suggest that problems in any one of these areas provide appropriate justification for intervention.
Differences in expression. An additional challenge to the early recognition of eating disorders in children is that they often present quite differently from older patients. Children have not fully developed their verbal and abstract reasoning skills, limiting their ability to understand and describe their thoughts, motivations, and behavior (Bravender et al, 2007).  Accordingly, despite engaging in behavior that explicitly contributes to weight loss, children often do not endorse fear of fat and cognitive distortions about weight/shape; indeed, these very concepts have limited validity in this age group. Instead, they may refuse food based on claims that they are not hungry, that they feel bloated or nauseated, or that they are afraid of vomiting or choking. Children may also demonstrate a very strong movement compulsion (O’Toole, 2014).  Just as it does in older patients, this may present itself as excessive exercise. However, other children may instead exhibit persistent, compulsive activity and an inability to sit for any length of time. For example, a child might stand or even run in place during typically sedentary tasks such as watching TV or doing homework.
ARFID. With the publication of DSM-5, Avoidant/Restrictive Food Intake Disorder (ARFID) replaced the previous DSM-IV diagnosis Feeding Disorder of Infancy and Early Childhood, which required an age of onset prior to age 6 in order to make the diagnosis. The new ARFID diagnosis expands the previous category and identifies individuals presenting with various clinically meaningful restrictive eating disturbances, such as:
  • Refusal to eat due to problems with the sensory characteristics, such as smell or texture, of food
  • Significant anxiety about eating following an event such as choking or vomiting, resulting in food refusal
  • General absence of interest in eating or desire for food
While ARFID is likely to present in infancy or childhood, it can also present or persist into adulthood (Kenney & Walsh, 2013). The new ARFID diagnosis provides a diagnostic alternative for those children with restrictive eating that is not related to fear of weight gain. Ultimately, however, treatment considerations are much the same as for those with other eating disorders: Full weight restoration and normalization of eating behavior is essential.
Assessing weight and target weightVariability in the degree and timing of height and weight changes during puberty presents a further challenge to the assessment of children (and a related treatment issue of determining an appropriate target weight). Many children present not with weight loss, but with failure to gain weight while actively growing, and some children will experience stunted growth as a result of malnutrition. There is a lack of expert consensus on how to determine both expected body weight and target weight in children and adolescents (Golden, Jacobson, Sterling, & Hertz, 2008; LeGrange, Doyle, Swanson, Ludwig, Glunz, & Kreipe, 2012). Measures based solely on height and weight (such as absolute BMI) are not optimal for this age group, as these parameters change with normal maturational processes. Consideration of a child’s BMI percentile for age and gender is of much greater utility; however, even a child with a normal-looking percentile can be very ill, if that percentile represents a significant drop from the child’s previous growth curve.  O’Toole (n.d.; 2014) outlines several important factors to consider when determining an appropriate target weight, taking into consideration the child’s degree of pubertal development, the child’s weight before the onset of the eating disorder, and whether the child is growth-stunted. She advocates for weight gain to the point of resumption of a healthy state, whereby the child returns not only to normal medical parameters (such as heart rate, blood pressure, temperature), but also to a normal developmental trajectory, including physical (resumption of growth and the advancement of puberty) and psychosocial (such as returning to school) aspects.
Additional treatment challengesChildren’s psychological immaturity. As previously noted, children have not yet developed sophisticated cognitive and emotional skills. As a result, one can’t have adult-level expectations for treatment engagement. It is important not to wait for the child to express desire to get well, but to take action regardless of the child’s intrinsic motivation. Furthermore, interventions must be developmentally appropriate. Psychotherapy is not likely to be the instrument of change early in treatment, if at all; instead, diligent refeeding is the essential treatment strategy. Parents are central to this process, and, for most children, some form of family-based intervention should provide the core of treatment.
Sense of urgency. The urgency of full weight restoration/ symptom interruption in children can’t be overstated. Returning a child to a normal developmental trajectory as quickly as possible is critical, as prolonging the illness has significant negative (and potentially enduring) implications for children’s physical and psychosocial growth and development. It is therefore necessary to establish and adhere to an appropriately aggressive rate of weight gain. O’Toole (2014) recommends setting clear benchmarks and avoiding negotiating with the eating disorder, noting that without weight restoration, there can be no recovery.
Hospitalization. Many children will do very well in outpatient settings. However, eating disorders are severe illnesses, and despite the best efforts of patients, families, and outpatient clinicians, there are times that hospitalization is necessary. Inpatient treatment allows for medical stabilization, prompt weight restoration, and symptom interruption, as well as intensive psychosocial interventions for both patients and families. The American Academy of Pediatrics (Committee on Adolescence, 2003) has established the following criteria for hospitalization:
  • Anorexia Nervosa
    • Less than 75% ideal body weight or ongoing weight loss despite intensive management
    • Refusal to eat
    • Body fat less than10%
    • Heart rate
      • Less than 50 beats per minute during the daytime
      • Less than 45 beats per minute at nighttime
    • Systolic pressure less than 90
    • Orthostatic changes in pulse (greater than 20 beats per minute) or blood pressure (greater than10mm Hg)
    • Temperature less than 96°F
    • Arrhythmia
  • Bulimia Nervosa
    • Syncope
    • Serum potassium concentration less than 3.2 mmol/L
    • Serum chloride concentration less than 88 mmol/L
    • Esophageal tears
    • Cardiac arrhythmias including prolonged QTc
    • Hypothermia
    • Suicide risk
    • Intractable vomiting
    • Hematemesis
    • Failure to respond to outpatient treatment
Hospitalization may occur in primarily medical or mental health settings, and will often have a specialized eating disorders treatment component.
Summary and additional resources
Children have the best prognosis when the disorder is identified early, and intervention is applied rapidly and aggressively. Effective, age-appropriate assessment and treatment is therefore essential. The assessment and management of children with eating disorders is clearly a broad and complex topic. The following resources can provide additional helpful information:
  • Eating Disorders: A Parent’s Guide by Rachel Bryant-Waugh and Bryan Lask
  • Eating Disorders in Children and Adolescents: A Clinical Handbook Edited by Daniel Le Grange and James Lock

Ten Things I Wish Physicians Would Know About Eating Disorders

by Edward P. Tyson, M.D., Austin, TX

The most important things physicians need to know have to do not with technical aspects of assessing or treating physical aspects of an illness, although those are important. It is about the physician first addressing his or her own attitudes about eating disorders and those who have those illnesses.
1.  Physicians are lucky to have people with eating disorders as their patients. People who suffer from eating disorders are a special group. Almost without exception, they are empathic, creative, intuitive, hard working, and usually gifted in at least one of the following (and quite often in all 3): academics, creative expression, and athletic endeavors. When these sufferers are free of their illness, they are incredible people to know and be around. And their recovery encompasses all the reasons why, hopefully, most doctors go into that profession.
2.  Don’t be afraid of an eating disorder.  It is an illness, with signs and symptoms and causes, and really good treatment. What other illness would a physician feel so inadequate about and also not seek the advice of colleagues or the literature? Sadly that happens so frequently and it is the topic of sufferers, family members, and professionals in the eating disorder field. Please do not be one of those people we talk about like that. Get educated or get help, but do not ignore, dismiss, or fail your professional responsibility.
3.  Eating disorders will test one’s ability to be humble. These are some of the most complicated illnesses there are, as they involve both complex medical and psychiatric issues. In addition, there are not that many medical experts around, so, yes, most doctors will feel like they are in unchartered territory. And you will make mistakes; we all do. But learn from them and approach the problem in the way that patients expect of physicians—with a cool head and keen mind, unfettered from a sensitive ego.
4.  You will likely need help at some point. A physician cannot know all details about every illness, especially ones as complex as eating disorders. As with any illness one encounters as a physician, the professional approach is to determine what the best assessments and treatments are. Again, be humble enough to ask for or seek advice.  One can seek opinions of experts in the field in any number of ways—a phone call (a so-called “sidewalk consult”), go to the literature, use the AED medical guide, or any number of texts on the subject (consider the books by Mehler & Andersen, and Birmingham & Treasure, or, maybe even my chapter in the book by Maine, McGilley & Bunnell).
5.  You will not be able to successfully separate out the physical from the psychiatric. Both must be treated at the same time. It is no longer appropriate to say, as a physician, that these are psychiatric illnesses. Nor is it permissible for psychiatrists to say that they are not the ones to deal with the medical. Again, if you do not know, do not reject the patient—instead, call in a consultant and work with that other physician.
The same applies to medical and psychiatric hospitals. Eating disorder patients should never be placed in a medical “no-mans land” where they are ping-ponged back and forth from one to the other, each claiming they cannot treat an eating disorder. These hospitals, by the way, do not have a sign outside saying, “WE TREAT EVERYTHING…except eating disorders.”
6. Keep checking every organ system every time. Use screening tools and a consistent pattern to the history and physical to make it easier, faster, and more likely not to miss something important. Use a BMI graph in those who have restricted to predict how serious the decline is, as the more dramatic the drop or angle of decline on the graph, the more likely that cardiovascular complications are present. A dramatic drop of the BMI can be very alarming and convincing to family members and to patients (see example). As I say often in those cases, “Imagine you’re flying Southwest Airlines and this is how the plane is going down. What would you want the pilot to do about now?” The answer is universally:  “Pull up”…How soon?  “Now!”
7.  While they are complex, eating disorder’s medical complications follow specific, predictable physiological patterns resulting from the ED behaviors. However, physicians must consider the specific circumstances of that individual patient and what behaviors and conditions can predict certain medical (or psychiatric) complications. If they are purging, for example, they could have bleeding, electrolyte and dehydration issues, and signs and symptoms consistent with those conditions. Always consider cardiac complications, and in those who are restricting, screen for Refeeding Syndrome. Those who restrict should have signs of hypometabolism, with low body temperature, bradycardia, capillary refill delay, acrocyanosis, and such.
8.  Check lab values frequently, including electrolytes and especially phosphorus and magnesium in those at risk of Refeeding Syndrome. Purgers are at risk of bleeding, so the CBC needs to be followed. The AED medical guide provides a good summary of labs needed.
9.  Remember that many of the psychological issues may be a result of medical issues and vice versa. What one may think is anxiety or panic could easily be hypoglycemia. What may appear to be depression, bipolar disorder, or personality disorder may actually be malnutrition, brain starvation, and such. And the medical issues will tend to worsen what psychiatric issues are present.
10.  Athletes can get eating disorders, too. Don’t assume because the patient is a high performing athlete, that physical findings that would be considered abnormal in others is due just to the patient being an “athlete.” A common mistake is to assume that one’s bardycardia (slow heart rate) is due to being a fit athlete. However, if the resting heart rate is below 50, evaluate if hypometabolism and energy conservation are ongoing, and not due from a fit heart but one that is losing its exercise capacity.
Do not be surprised how many calories it takes to refeed someone who has been malnourished, especially one who was exercising heavily with their eating disorder. It can be enormous calories and the patient may only then slowly gain weight at first. This is because the metabolism has to be reversed and turned from hypometabolic to hypermetabolic and that requires enormous calories, fat, protein, and carbohydrates. It is not uncommon for someone at a very low weight to be eating 5,000 calories per day at a treatment center and very slowly gaining at a rate of 1 or 2 pounds a week after a few weeks of no weight gain or even weight loss.
If a physician were to follow just the above, he or she would know more about eating disorders than 95% of other physicians. We are not looking just for experts; we’re looking for volunteers to care for these deserving patients.

When Poor Body Image Persists After Recovery

A trait that overcomes internal cues and affects the sense of the bodily self.

Reprinted from Eating Disorders Review
July/August Volume 25, Number 4
©2014 IAEDP
For some patients, negative body image persists even after they have recovered and are back at a healthy normal weight. According to results from recent studies by a team of British and Australian researchers, increased malleability of the bodily self may be a trait phenomenon in people with eating disorders (In J Eat Disord. 2014; 47:400).
According to the authors, few studies to date have considered the bodily self in people who have recovered from an eating disorder. Instead, more often the focus has been on physiological functioning. Ertimiss Eshkevari, PhD, from Kings College, London, and colleagues at the Australian National University, Canberra, used the rubber hand illusion test and several self-report questionnaires to study 28 individuals with eating disorders, 28 former patients who had recovered from an eating disorder, and 61 healthy controls. The goal was to learn whether changing body image is a state phenomenon or a persisting individual trait that outlasts the acute period of an eating disorder. 

A test of an illusion made real

In the rubber hand illusion, subjects view a rubber hand placed in front of them in the same position as their own hand (but not visible to them). When the fake hand is stroked synchronously with stroking the participant’s real (and unseen) hand, the participant feels the touch on the fake hand as if the fake hand were real. This test thus evaluates touch, vision, and proprioception. In an earlier rubber hand illusion experiment, the authors found that persons with eating disorders felt the illusion to a far greater degree than did normal subjects. The authors’ more recent study was an attempt to study this phenomenon further.
Study participants were recruited from student and staff members at a tertiary care institution in the United Kingdom, from an eating disorder research volunteer database, and from individuals who responded to posters advertising the study. All participants completed the Structural Clinical Interview for Diagnosis, Research Version (SCID-1), the Eating Disorders Inventory-3 (EAD-3), and the Self-Objectification Questionnaire, a 10-item self-report assessment of how much individuals view their bodies in observable, appearance-based objectified terms versus non-observable, competence-based, non-objectified terms. Of the 28 patients with histories of eating, 20 had AN, 6 had BN, and 2 had EDNOS. The control group included 68 persons with no history of eating disorders.

Recovered patients and those with current eating disorders had higher stress, depression, and anxiety

While there were no significant differences between groups in age, years of education, or handedness, the healthy controls had significantly higher body mass indexes (BMI, or kg/m2) and significantly lower levels of body dissatisfaction than did the ED and recovered (REC) groups. The ED and REC groups were significantly more stressed, depressed, and anxious than were the healthy controls, and the ED group was significantly more depressed, stressed, and anxious than were the REC group. The REC and ED group reported greater drive for thinness, bulimia, interoceptive deficits, and emotional dysregulation than did the healthy controls.
The results from the rubber hand test provide some evidence for malleability of the self as a trait. On other measures, recovered patients scored between acutely ill patients and controls, suggesting a stored quality to some disturbances. This suggests that eating disorders involve a trait vulnerability associated with heightened sensitivity of visual information about the body. 

Some possible clinical applications

The authors feel that these results may help improve understanding of what causes eating disorders and why they persist. For example, it may be that before the onset of illness a person may have heightened sensitivity to external visual information—relating to the thin ideal. The authors also feel that their study results suggest that an imbalance between internal and external representations of the body is a trait of eating disorders rather than just a feature of the disorder in the acute state. Because of this, the eating disorder patient continues to experience a disturbed body self despite regaining weight. Sensory of kinesthetic training may be helpful for reversing these effects and improving accuracy of body image.

Delayed Diagnosis of Eating Disorders in Men

Lack of recognition and a hands-off attitude by clinicians, family, and friends play a role.

Reprinted from Eating Disorders Review
July/August Volume 25, Number 4
©2014 IAEDP
Why don’t men with eating disorders seek help sooner? One reason may be the popular misconception that eating disorders are only found among young women, according to two researchers from Great Britain (BMJ Open. 2014; 4:e004342).
Drs. Ulla Räisänen and Kate Hunt, of the University of Oxford, Oxford, UK, and the University of Glasgow, Scotland, first interviewed 29 women and 10 men with eating disorders. Some of the material the authors hoped to cover included: “How do men make sense of their early (and later) signs and symptoms of disordered eating?” Additionally, they asked the men how they decided treatment might be needed, what ordinarily gets in the way of seeking help, and what their experience with help-seeking had been like.

An early pattern of restricting food (AN) or purging after large meals (BN)

Most of the men diagnosed with anorexia nervosa (AN) described an early pattern of skipping meals, selling their school lunches to others, restricting their food intake, and eventually going for days without food. Patients diagnosed with bulimia nervosa (BN) described a different course, starting with “comfort eating,” and then on to a pattern of purging after unusually large meals. Over months these actions gradually became a “daily routine.”
At first many of the men did not recognize that they had an eating disorder, and attributed this to their misunderstanding about eating disorders as a problem of “fragile teenage girls” only. The men also viewed their disordered eating as a personal coping mechanism rather than as an underlying pathology. Some had never heard of BN, and thought binge eating and purging were their own invention. And it wasn’t just the men who didn’t recognize that they had an eating disorder—their family and friends seldom connected the unusual behavior to a possible eating disorder. One of the interviewees was investigated for gastric problems for years, during which no one, parents and physicians included, suspected the true cause for the man’s gastric problems and weight loss. 

How the eating disorder was recognized

Typically, the men’s symptoms and behaviors continued for months or years before they began to realize that they did have a serious problem. Some men gradually realized they had a problem, while others reported that a sudden physical event had led them to seek help. Another barrier to getting help was the men’s fear of not being taken seriously by healthcare providers. Others reported secrecy, fear of treatment, or fear of being judged.

Once the men sought treatment, the initial consultation seemed to be particularly important and also dictated whether the men would remain in treatment. Some men had positive experiences, which led to treatment. Others, however, described going to their general practitioners several times before they were taken seriously or referred for care and, in a few instances, the diagnosis was missed or the problem misdiagnosed. The quality of specialist care also could be lacking—one man had prolonged vomiting leading to severe weight loss and underwent lengthy physical examinations before his gastroenterologist told him to “man up,” and to “‘be strong and deal with the problem.”
The authors concluded that early detection is imperative to improve the prognosis for men with eating disorders. Primary care physicians are critical to this early recognition. And, finally, the authors suggest that improved awareness of eating disorders at a social level will help correct the misconception that eating disorders affect only young women.

Recognizing Exercise Addiction

Reprinted from Eating Disorders Review
July/August Volume 25, Number 4
©2014 IAEDP
It’s a dilemma. Your patient is an elite athlete, and regularly exercises at a higher-than-normal pace. However, you are concerned that the level of daily exercise may actually be harmful. What is the difference between exercise as a healthy lifestyle choice and exercise as an addiction? As Dr. Kim Dennis explained in her recent International Association of Eating Disorders Professionals webinar presentation on exercise addiction (“Exercise: Addiction or Healthy Lifestyle Choice?”), there are definite differences and steps that help make the distinction. 
While the prevalence of exercise addiction in the general population is only about 3%, rates are higher among some groups, such as ultra-marathon runners and sports science students. One of the highest rates is among people with eating disorders. Dr. Dennis, who is Medical Director of Timberline Knolls Residential Treatment Center, Lemont, IL, notes that from 39% to 48% of people with eating disorders also have exercise addiction (also termed secondary exercise addiction).1
Exercise addiction appears to cluster with food disorders, overuse of caffeine, work addiction, and shopping addiction as well.1 When exercise addiction and eating disorders co-occur, the danger is that only one disorder will be treated. The eating disorder, where symptoms are better known, usually is the focus of treatment, and the secondary disorder, exercise addiction, remains hidden and thus untreated, said Dr. Dennis. And, because of this, despite an improved relationship with food, patients will not gain weight because they are controlling their weight and/or shape by increasing their exercise regimens.1

Is the Exercise Level Healthy or Not?

The healthy lifestyle model of exercise involves exercise linked to improved health and cognition, or prevention of osteoporosis and greater overall satisfaction with life. It is regular and has positive effects on mental and physical well-being. This is true for all ages. Healthy exercise often involves a social activity versus solitary or secretive exercise. It promotes fun and relationships, not an ideal body shape or a targeted weight. 
Exercise becomes problematic when the individual begins to plan his or her day around their exercise regimen. The regimen may become more and more rigid, and exercise becomes a means to alter mood; it also becomes a primary organizing principle. That is, where the increased activity originally helped an individual cope, now it makes life unmanageable. Daily functioning is impaired, and often the person can no longer meet his or her usual obligations at home and at work. 

Exercise’s Effect on Mood

There is ample evidence that exercise has mood-altering effects. Exercise serves to increase positive affect, such as increasing self-esteem and decreasing the negative affect associated with depression and anxiety.2 At least three possible biological mechanisms connect improved mood and exercise. The first, the thermogenic hypothesis, holds that exercise increases body temperature, and thus reduces somatic anxiety. Decreased anxiety is related to increased temperature in certain regions of the brain.3 The second hypothesis states that exercise releases catecholamines, which are strongly implicated in control of mood, attention, and movement, as well as endocrine and cardiovascular responses linked to stress. The third hypothesis involves endorphins. Exercise releases endorphins, which are naturally occurring opiates. This can have unplanned consequences because with regular intense exercise, the brain counteracts by down-regulating endorphin production. Because of this, an individual will need to continue increasing exercise to maintain the natural balance of endorphins in the brain.4
Just as with other addictions, exercise addiction has a reward pathway. Some of the primary brain structures that participate in this pathway include the ventral tegmental area (VTA), the nucleus accumbens, and the prefrontal cortex. A new area of research involves a transcription factor, the protein, ΔfosB. This protein accumulates in the nucleus accumbens and dorsal striatum (brain regions important for reward and addiction) after chronic exposure to all drugs of abuse, but importantly also after chronic consumption of so-called natural rewards, including high levels of activity.5 The protein has long-lasting effects, and one hypothesis is that lasting brain changes are related to relapse potential in substance addiction, behavioral addictions, and eating disorders as well.

Who Is At Greatest Risk?

Patients who may be at greater-than-normal risk include those with low self-esteem, those who have undergone traumatic life events, those who have co-occurring disorders, including eating disorders and substance abuse, and those with depression and anxiety disorders. One group at particularly high risk includes gymnasts, figure skaters, cross-country runners, rowing crew members, and cheerleaders. A family culture of excessive exercise is also a risk factor and, according to Dr. Dennis, there may be a genetic component as well. Living with parents who abuse substances can also increase the risk.

Table 1. Some Physiologic Effects of Exercise Addiction

Decreased anabolic (testosterone) response
Loss of emotional vigor
Autonomic sympathetic insufficiency
Decreased maximum oxygen uptake
Decreased levels of blood lactate
Increased cortisol response (muscle wasting)
Hypothalamic dysfunction
Adrenal exhaustion
Some of the physiologic repercussions of exercise addiction can be seen in Table 1. These side effects include decreased anabolic (testosterone) response, loss of emotional vigor, immunosuppression, decreased maximum oxygen uptake, decreased blood lactate, and increased cortisol response (muscle wasting). Over time the patient needs increased amounts or increased intensity of exercise to get the same effect. When he or she withdraws from exercise, depression can set in. The exercise addict may describe feeling like “jumping out of his skin” when exercise is taken away.

First, Assess Medical and Nutritional Status

The first step in intervening, according to Dr. Dennis, is a thorough assessment of the patient’s medical and nutritional status. Then, it is helpful to carefully look at the individual’s relationship to exercise, food, and his or her body. Is the individual restricting or purging, in addition to over-exercising? At this point it may also be helpful to determine whether the patient is exercising to promote health or to interfere with good health. A number of standardized scales can be used to screen and monitor these patients. One is the Exercise Dependence Scale-21, an instrument that uses a 6-point scale to measure possible dependence on exercise.6 The scale, scored on a Likert-like scale from 1 (never) to 6 (always) includes such items as “I would rather exercise than spend time with family/friends” and” I am unable to reduce how intensely I exercise.”
Once the diagnosis of exercise addiction is established, a treatment team can be assembled; the team often includes an internal medicine specialist, psychiatrist, therapist, exercise specialist, nutritionist, and support groups of family members and coaches. Next, it is important to assess the patient for co-occurring disorders such as substance use disorders, depression or anxiety. According to Dr. Dennis, another key to successful therapy is avoiding anorexogenic agents, wellbutrin if the patient has a history of anorexia nervosa or bulimia nervosa, as well as benzodiazepines.7

Guidelines for Reintroducing Exercise

At some point, when the patient is medically and psychologically stable, it will be appropriate to reintroduce healthy exercise. Initially, all exercise should be planned for a group setting or monitored closely; a good initial schedule includes 20 to 30 minutes of exercise up to 3 times a week. Dr. Dennis stressed that ongoing monitoring and support are critical, and if the patient’s physical or psychological status worsens, exercise should be discontinued until the patient is more stable.

It is also important to define goals of healthy exercise. An often overlooked maxim is that rest can be potent medicine. [Note: Some inpatient and residential programs use benzodiazepines to help the patient settle and rest. This isn’t in the Practice Guidelines, but is more of a clinical approach.] Some therapists have had success with "mindfulness/meditation, emotion management skills, and interpersonal effectiveness training (dialectical behavior therapy). Finally, having access to support groups in group therapy or 12-step support will help patients maintain the advances they have made.

10 Things to Know About Eating Disorders and College Life

10 Things to Know About Eating Disorders and College Life
By Robin Boudette, Ph.D., Princeton University Eating Disorders Team Coordinator,
Anne. M. Slocum McEeneaney, Ph.D., ABPP, CGP, Eating Disorders Team Leader at New York University
The college years are a time of great growth and development for most students. It is a time when people explore and define who they are, and to what they wish to devote their life’s time and energy. While this is exciting, it can also be challenging, especially for those who feel less comfortable or confident about these tasks.
1.  The college and graduate school years are a time when people are at the high risk for struggling with an eating disorder. According to the National Institute of Mental Health, the mean age of onset of Anorexia is 19, of Bulimia is 20, and of Binge Eating Disorder is 25.  Because we live in a culture which defines much of who we are by how we look, and which has very unrealistic ideas about how we “should” look, it is not surprising that the challenges of finding your place in a broader world might lead some to become over-focused on body and appearance, which is a significant risk factor for developing an eating problem.
2.  Most students who go away to college do not gain 15 pounds. The common fear of gaining weight at college may also lead students to become overly focused on eating or weight. However, research shows that while first year college students do tend to gain some weight, it is usually much less than 15 pounds (typically, it is less than 5 pounds). And, over time, they lose much of the weight gained (Karasu, S. The gravity of weight. Psychology Today 9/10/13).
3.  But, how and what they eat does become different for many when they first go to college. For most students, there are significant changes in how they eat when they go to college. For many, eating in a dining hall, or in one’s own apartment, puts them, usually for the first time, solely in charge of what they eat when. For some this can be difficult, and can result in either overeating (because there is access to so many choices at each meal) or undereating (because of fear of the quantity of food or of not knowing how it is prepared). If students then get overly concerned about minor weight changes, they may be unable to resume regular eating from a range of foods, and move to developing either disordered eating, or an eating disorder (Karasu, S. 2013).
4.  The stress of transition to college may increase vulnerability to relapse. Students who have experienced, but recovered from, an eating problem may find that the challenges of college life leads them to want to control their eating or weight more again (as a way of feeling more “in control” emotionally).  In fact, some of the students who developed an eating problem earlier in life may still be struggling with symptoms, either because they never sought therapy (they may have never even told anyone, but carried this burden on their own), or because they have continued to struggle while  in treatment. It’s important to remember that eating symptoms begin as a way to cope, and may return when a student’s stress levels increase (as they do for all of us at major life transitions, even ones to which we are very much looking forward). It’s important for all who care about those with eating concerns (including the students themselves!) to track their focus on eating, weight and bodies and reach out for help, or to express concern, if they notice these increasing.
5.  It’s important to remember that eating and body image problems can impact students of any gender, race or ethnicitySadly, no group is immune from the multiple factors (of individual, cultural, and familial origin) that contribute to the risk for eating problems. (Levine M. and Smolak, L. in Agras, W. S., Ed. (2010), The Oxford Handbook of Eating Disorders.)
6. There are resources to support recovery on campus. The range of services available in campus health centers is quite wide. Most colleges have experience with assessing disordered eating issues and working with students or referring for appropriate treatment.  Some health centers have a multidisciplinary team, typically including medical staff, psychiatrists, counselors, dietitians, and sometimes an athletic trainer.  Each member of the team has a distinct role:  the medical staff is responsible for assessing medical risk and monitoring medical conditions; the psychiatrist would evaluate and monitor any use of psychiatric medications; counselors provide individual or group therapy; the dietician focuses on meal planning, establishing healthy eating behavior and can be especially helpful in negotiating the challenges unique to the campus lifestyle; the athletic trainer is primarily involved in working with student  athletes and may consult on the role of exercise in maintaining health and balance.  If the health center does not have a team, they may have individuals who are responsible for working with students who present with eating concerns and can refer students off campus for more specialized care.
It would be prudent to call the health service before arriving on campus to learn about available services.  If the student is currently in treatment, these providers are often in a good position to make recommendations about what is needed to support recovery and prevent relapse. When a consent to release information is given, treatment providers can discuss recommendations with health center staff to ensure continuity of care.  Some students chose to continue with home providers via phone therapy and meeting over breaks while at the same time using some of the services on campus such as group therapy or intermittent individual therapy. It is a good idea to have a contact on campus in the health center.
7. The level of treatment provided on different campuses varies. Most health centers will provide an evaluation.  After the evaluation, a determination is made about providing services on or off campus.  Some centers offer short-term treatment on campus and referrals to off campus providers for longer-term treatment. Individual counseling and groups are often offered at counseling centers.  Although students may initially be hesitant about groups, groups are typically popular.  Being a part of a group breaks the sense of isolation that often comes with eating issues and offers a safe place to talk openly about daily struggles.  Students find that groups help them feel more comfortable with themselves and their peers. Groups may focus on eating disorder recovery, healthy body image, life-skills training or other topics related to health and healing.
8. When longer-term therapy is anticipated, it may be beneficial to seek services off campus.  While on campus services may be offered at no cost to students, services are often time-limited and constrained by the academic calendar.  Seeing a provider off campus allows for unlimited sessions, as well as flexible and consistent scheduling. There are commonly off campus providers who specialize in working with students and eating issues near campus, in some cases, walking distance. It would be wise to meet with a counselor to explore different options and the counseling center could provide referrals to off campus services.
9. Concerned parents may contact the health center and inquire about services. Launching off to college is often an exciting and scary time for both students and their parents.  While all services at health centers abide by the guidelines of confidentiality, there are ways parents may be involved. Parents can learn about resources and services available and request to meet with providers and the student to discuss plans for treatment. Parental support of treatment and attention to both progress and relapse plays an essential role in the recovery process. Another resource for parents may be a campus-life staff.  There is often a dean, staff member or resident advisor directly involved in dormitory living that can listen to concerns, address the needs of the student and access resources.
10. Recovery while in college is possible.  Although disordered eating can be a part of college life, recovery also happens.  The college years are a time of challenge, self-discovery, growth and transformation.  With the proper encouragement, support and treatment, students can establish a healthy relationship to food and eating, develop a sense of confidence, cultivate effective habits of living and thrive.  There is a web of support on campus committed to working flexibly and creatively to ensure that students get all they need to be healthy, engaged and successful in their college experience. For parents and students, it is critical to be aware of the risks inherent at this time of change and to be proactive in identifying resources and bringing the right supports together early in the process.

Going Away to College

Going Away to College

By Marcia Herrin, EdD, MPH, RD, FAED
Apart from summer camps or similar limited experiences, when young people go away to college, it may be the first time they have lived away from home and on their own. This big change, compounded with new food choices, crazy schedules, rigorous academic demands, and new social challenges, makes it no surprise that the first several years of college are considered to be a time of high risk for the development of an eating disorder. Recent surveys indicate that the rate of eating disorders among college students has risen to 10-20 percent of women and 4-10 percent of men.
If a student has recently recovered from an eating disorder or is currently struggling with one, parents need to first evaluate whether it is safe to go away to college. Knowing that entering college is contingent upon making progress in recovery can be motivating. If parents, in consultation with treatment providers, decide it is safe to enter college, it is their responsibility to ensure that the student has support and resources needed at school or in the nearby community.
Even recovered students may struggle with the new freedom to eat or not to eat now that they are beyond Mom or Dad’s watchful eyes. Other students have difficulty making food choices among the large array of delectable foods offered in campus cafeterias, or they founder when they find they do not have the same access to foods they are comfortable eating. For all of these reasons, parents should be particularly watchful as a child enters college. At the conclusion of this article is a “Guide to College Eating”.
Ideally, colleges have an adequately staffed eating disorder program right on campus, which will include experienced physicians (nurse practitioners and physician’s assistants also can provide competent medical monitoring), therapists, nutrition counselors, psychiatrists and support groups. Some colleges provide all or some of these services free of charge to enrolled students. Others limit the number of visits students can make each semester. Still other colleges refer students who need these services off-campus. Some colleges leave it up to the family to find community resources if their child needs that kind of support. The 2013 Collegiate Survey Project Eating Disorders on the College Campus: A National Survey of Programs and Resources commissioned by the National Eating Disorder Association (NEDA) lists the eating disordered-related services for 165 colleges. To read the full study results, download a directory of colleges with eating disorder programs and services, visit the Collegiate Survey Project homepage (
If a student needs continuing support at college, parents are wise to arrange either a visit with or a phone call to the college’s health service or counseling center to ascertain the scope of services. Once a student is working with a professional on or off campus, the main responsibility of parents is to make sure their child is making and keeping medical, psychological, or nutritional appointments. Students over 18 years of age are afforded the same confidentiality as adults. But, this does not mean that parents cannot or should not let the professionals who are involved know their concerns.
Some college students do well with nothing more than regular phone/skype/email check-ins with their parents or hometown nutritionist, therapist, or physician. Others do best making a connection with a professional either at college or in the surrounding community. When students know that staying in college is contingent upon taking care of their bodies and overcoming some of their eating-disordered behaviors, many seem to be able to marshal personal resources (though they may need substantial family and/or professional help as well) to overcome even a serious eating disorder. This approach works if parents hold firm to their decrees. Students who do not make progress or relapse may be required by the college to take a medical leave of absence.
Students and parents should know that is not unusual for first-year college students to gain 10 to 15 pounds or more, and in some cases grow in height as well. This phenomenon has been labeled the “freshman 10” or the “freshman 15.” The substantial weight gains some first-year college students experience during fall semester can be explained several ways: College freshmen, often for the first time in their lives, are given the complete freedom to eat or not eat as they please at a time when many have not yet learned to manage their own eating. Some freshmen gain weight because they are taking in additional calories in the form of alcohol and/or party foods, which are found in abundance at the many food-related social events associated with college life. For others, the freedom of being away from home may trigger a latent binge-eating problem. Sometimes, the awareness that a student is gaining weight, for any of these reasons, is so demoralizing that he/she compounds his/her problem by consoling himself/herself through food.
Another explanation is that the college years are a time during which many adolescents finish growing. This is the time that many gain the pounds and even inches they need in order to reach their adult size and shape. While weight gain may seem to happen all at once, often because it is compounded by the dramatic change in eating habits I described earlier, when eating patterns settle down (as they usually do later in that first college year) weight gain stops. The average female college student usually fully develops by the end of her sophomore year, arriving at her adult height and the weight that would be safe for her to maintain as an adult. For males, development may continue through senior year or beyond.
This is a sensitive issue around which parents sometimes should tread lightly. The adage I recommend as a guide for parents and others when faced with a potentially sensitive weight increase is: “When in doubt, say nothing.” While no good ever seems to come from harping about weight gain, severe weight loss, on the other hand, carries with it serious medical risks and should be discussed.
Now a few words to directly to the students themselves:
There is no shame or harm in getting plenty of support. It is better to have more support than you need. I recommend to my patients going off to college to check-in with me or another member of their treatment team when they are home on breaks. I also recommend the food plan I developed for Dartmouth College students when I was a college nutritionist (see below). First, think about the food groups you need at each meal. Pick a decent serving of each group. Remember that you can try that tasty new food next time it shows up on the menu and it will show up again and again. Don’t skip meals. You will notice other students with eating disorders. It can feel that they are getting away with it. Remember you are the lucky one. Untreated eating disorders ruin lives.