Wednesday, December 16, 2015

Holiday Eating

Jean Fain, LICSW, MSW Reprinted with permission from The Huffington Post. 

Sadly, too many party goers are more focused on their ever-spreading mid section than spreading holiday cheer. If all you really want for Christmas is the secret to overcoming overeating, you're in luck. I recently discussed preventing seasonal weight gain with one of the leading experts on feeding our families and ourselves: Ellyn SatterBefore I devoured Satter's writing on food and family, I gobbled up her definition on normal eating. Even if you're familiar with Satter's un-American definition, it's worth rereading. 

As a psychotherapist and dietitian, Satter really understands why the great majority of us feel compelled to eat like there's no tomorrow. So when it came time for my annual interview on seasonal eating concerns, I could think of no better subject than the author of Secrets of Feeding a Healthy Family. What follows are questions and answers from my recent conversation with Ellyn Satter. 
Fain. How would you describe normal holiday eating?
Satter. Normal eating is all about trusting yourself to eat in a way that is right for you. The trouble most people have with holiday eating is they get caught up in what they should and shouldn't eat. They're anxious and ambivalent about eating. They might try to resist at holiday parties, but the table is laden with oh-so-appealing "forbidden foods," and they throw away all control and overdo it. Many times they come to parties over-hungry because they're trying to restrict themselves and lose weight. So the standard definition of holiday eating becomes eating way too much.

 Fain. How about your approach to healthy eating: "Eating Competence." How would you describe that?

Satter. Rather than haranguing yourself about what you should and shouldn't be eating, you trust yourself to eat food you enjoy. No food is off limits. Which isn't to say you eat like there's no tomorrow. With eating competence, you work with your hunger, appetite, and satisfaction by eating meals and snacks, and by paying attention while you're eating. You trust yourself to eat as much as or as little as is right for you. It sounds wild and strange, but lots of research tells us being eating competent works
Fain. What does eating competence look like at a holiday party?
Satter. You take your plate and pick and choose what you find most appealing. You sit down and eat if you can. If not, do what you need to do to enjoy your food: stand in a quiet place, attach yourself to a group that will let you eat in peace. Go back for more as many times as you want and eat until you feel satisfied. That's the opposite of standard party eating, where a person doesn't take time to eat. The food may taste good momentarily, but, because they're not really paying attention, it's just absent-minded munching.

Fain. When I suggest what you're suggesting, new clients say: "If I let myself eat whatever I want, I'd really pack on the pounds." What do you tell clients who are worried about gaining weight?

Satter. Competent eaters don't gain weight over the holidays because they're accustomed to eating as much as they want of the foods they enjoy all year long. Holiday eating just gives more opportunities to eat good food. It's not a big deal to go home too full because you probably won't be too hungry the next day. Conversely, controlling eaters say: "I really overdid it! I have to cut down today." They deliberately under-eat, which sets them up for another bout of overdoing it. Come New Year's, they gotta get back on the diet. This vicious cycle creates a lot of misery, and, in the long run, weight gain. The strange thing is that most people believe that being hard on themselves is somehow better than being positive and sympathetic.

 Fain. Can you say more about New Year's resolutions?

Satter. People say: "I'm not going to eat all those delicious foods I love. I'm only going to eat fruits and vegetables and other 'good' foods.” Fruits and vegetables are wonderful, but if you're eating them as penance, you're not going to enjoy them. Then when you throw away control and eat what you really enjoy, you neglect them. Instead, think in terms of nutritional judo: go with your desire to eat as much as you want of foods you enjoy rather than fighting against it. Provide yourself with structure and pay attention while you eat, and you are well on your way to being eating competent. 

Fain. How do you suggest parents help their children become competent eaters?

Satter.  Follow the division of responsibility in feeding throughout children's growing-up years. Have meals and sit-down snacks, and regularly incorporate "forbidden foods." Don't set up deprivation with sugary, fatty foods. Deprivation does the same things to children as it does with adult dieters -- they restrict, then overdo it when they can. When you serve dessert, serve everyone a single portion. Let everyone eat it when they want -- before, during or after the meal. Periodically, at snack time, get out the milk and a whole plate of cookies, and let children eat as many as they want. If they haven't been allowed to eat cookies, they'll eat a lot of them at first. But if you do this repeatedly, the newness will wear off. The child will eat a cookie or two and be fully satisfied. It works.

Fain. I can hear parents worrying their kids will get fat. What would you say to those parents?

Satter. Restricting kids doesn't work. Forcing them to eat healthy foods doesn't work. What works is following the division of responsibility in feeding, trusting children to learn to eat the food you eat, and letting chldren grow up to get bodies that are right for them.  
For more about eating food you enjoy all year long (and for research backing up this advice), see Ellyn Satter's Secrets of Feeding a Healthy Family: How to Eat, How to Raise Good Eaters, How to Cook.
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Wednesday, December 9, 2015

An Intervention Using a 'Serious Videogame' prior to CBT for Bulimia Nervosa

One patient had reduced impulsivity, and binge eating was greatly reduced.

Reprinted from Eating Disorders Review
November/December Volume 26, Number 6
©2015 IAEDP
Impulsivity is a common feature of bulimia nervosa (BN). The triad of behavioral disinhibition, impulsive decision-making, and emotional dysregulation often predicts relapse and dropout rates. A group in Spain recently used sessions with a "serious" videogame prior to cognitive behavioral therapy (CBT) to successfully treat a 34-year-old woman with BN (Frontiers in Psychology. 2015; July doi:10.3389/fpsyg.2015.00982).
Unlike conventional videogames, which are designed to entertain, serious videogames are designed to help improve skills, attitudes, and knowledge. For example, Playmancer™, a serious videogame, was developed to improve emotional regulation and impulsiveness in specific mental disorders and is currently being used by clinicians at the University Hospital of Bellvitage, Barcelona, Spain, to treat patients with eating disorders and addictions. 

A 34-year-old patient who binged and purged daily

Cristina Giner-Bartolomé and colleagues recently reported the case of a 34-year-old married mother of two with an earlier history of substance abuse problems until she was 21, when she received psychological treatment. With each pregnancy, the patient had steadily gained weight, until she her body mass index (BMI) was 34 kg/m2. During the 3 months before she entered the authors' study, she reported having daily binges followed by feelings of hopelessness and guilt, with episodes of vomiting. She also showed some classic traits of a Cluster B personality, with high levels of impulsivity, low tolerance for frustration, and poor emotional regulation. The woman also had occasional bouts of compulsive shopping. She had been treated with fluoxetine for the past 6 months.
At baseline, the authors obtained initial psychometric and neurophysiologic information, focusing on impulsivity levels measured with Conner's Continuous Performance II (CPT II), along with the Iowa Gambling Task (IGT), which evaluates decision-making, risk and reward and punishment. Eating and purging symptoms were recorded with food diaries kept by the patient. Other psychometric tests included the Eating Disorder Inventory 2 (ED-2) and the State-Trait Anxiety Inventory (STAI-S-T).
The second stage of the study involved 3 weeks of the use of the Playmancer videogame. Nine sessions of 26 minutes each were conducted and the 26 minutes were broken down as follows: 3 minutes of relaxing music, 20 minutes of the videogame, and 3 minutes of relaxing music. At the end of this stage the authors once more applied the CPTII.
One week after finishing the first intervention with the videogame, the authors once more measured the psychometric variables and levels of impulsivity (CPTII). A week after finishing the videogame intervention, the patient began group cognitive behavioral therapy (CBT). Three weeks after completing the CBT phase, the authors again applied the neuropsychological and psychometric tests. During each of the treatment stages the researchers recorded symptoms related to eating behavior, including the frequency of binge eating and vomiting.
At the end of treatment, the patient had lower levels of novelty-seeking, made fewer commission errors, had improved her ability for making decisions, and had fewer binge-eating episodes (the weekly average fell from 14.0 to 0.7). The authors noted that future studies might replicate their study with a larger sample of patients and add a control group. Although the patient was receiving an antidepressant, there had been no changes in her medication.

Intranasal Oxytocin Diminishes Food Intake, Improves Social Cognition among Bulimic Patients

The hormone had little or no effect on normal controls or patients with anorexia nervosa.

Reprinted from Eating Disorders Review
November/December Volume 26, Number 6
©2015 IAEDP
Oxytocin (Greek for "quick birth") is a mammalian hormone that acts as a neurotransmitter in the brain. Because oxytocin impacts social behavior, appetite, anxiety, and stress, researchers believe oxytocin may also be involved in the pathophysiology of eating disorders.
There is some prior evidence for this. Intranasal administration of oxytocin leads to changes that may be important in AN; for example, an AN patient's attention to food and body image stimuli is reduced by oxytocin administration. Fewer studies have examined the oxytocin system among people with bulimia nervosa (BN), although some of the features of BN or binge eating disorder (BED) also hint of possible dysfunction in the oxytocin systems. For example, the hormone is an important peptide for body weight regulation. Animal studies have added information about the complex effects of oxytocin, particularly its ability to inhibit the appetite for sugars and carbohydrates. Similarly, in humans, when oxytocin was administered to a group of obese men, food intake was reduced.

A study of oxytocin's effect on appetite and emotions

A recent Korean study of 102 women (35 patients with AN, 34 with BN, and 33 healthy controls) tested the effects of a single dose of oxytocin on appetite and emotion recognition. At Seoul Paik Hospital, Seoul, South Korea, neuropsychiatrist Youl-Ri Kim and colleagues designed a double-blind, single-dose, placebo-controlled cross-over study to test the effects of the hormone (PLoS ONE. 10 (9)e13514.9. doi:10.1371/journal.pone.0137514).
Subjects and controls received a single dose (40 IU) of intranasal oxytocin or placebo, and then performed a computerized emotion recognition task, followed by an apple juice drink 90 minutes after the intranasal dose. All subjects' food intake was then recorded for 24 hours after the test. 
 Patients with eating disorders were given meal plans with fixed-size portions during the time of the experiment, to mitigate the drug's effect on calories consumed over the 24 hours before testing. Patients with AN did not have any direct support for eating during the 24 hours after the experiments on the inpatient ward, while patients with BN had meal plans focused on preventing binge eating and purging. The healthy controls were instructed to continue their regular diet during the 24 hours after the experiment.

Some effects were noted among patients with BN

The oxytocin dose produced no significant change in appetite among the healthy controls, but oxytocin modestly diminished 24-hour calorie intake in patients with BN. Oxytocin produced a small increase in emotion recognition sensitivity in healthy controls and in the patients with BN. In contrast, among the patients with AN, oxytocin had no effect on the patients' emotional recognition sensitivity or on food consumption. 

These results are interesting, and emphasize the complex effects of oxytocin on behavior, as well as the potential role of ED diagnosis (for symptoms) in determining response to oxytocin. One potential study limitation not noted by the authors is that subjects received a single dose; perhaps ongoing administration would have made effects last longer.

Tracing Triggers of Purging Among Anorexia Nervosa Patients

 multi-center study highlighted the impact of binge-eating episodes.

Reprinted from Eating Disorders Review
November/December Volume 26, Number 6
©2015 IAEDP
In a recent study of adult women with anorexia nervosa, binge eating large amounts of food was the strongest predictor of purging, challenging the idea that loss of control is the most powerful aspect of distress in bulimia nervosa and binge-eating disorder. The researchers concluded that both loss of control and overeating appear to be important determinants of purging in patients with AN.
The multi-center study, headed by Andrea B. Goldschmidt, PhD, of the University of Chicago, studied behavioral, emotional, and situational factors linked to purging among 118 women with AN (Int J Eat Disord. 2015; 48:341). The women completed a two-week assessment protocol, including daily self- reports of eating disorder behaviors, mood, and stressful events. Prior to the study, the women spent two days practicing, to increase their familiarity with the protocol. Using a handheld computer, the women recorded their mood, stressful events, and behaviors after every binge-eating episode or AN behaviors such as binge eating and purging. 
The women responded to 6 daily semi-random prompts by investigators that occurred every 2 to 3 hours from 8 am to 10 pm. The women also were trained in standard definitions of events by the research staff and; they reported all body checking and purging behaviors. An abbreviated Positive And Negative Affect Schedule-Expanded (PANAS-X) form enabled participants to rate each reaction (such as nervousness or disgust) on a 5-point Likert-like scale, ranging from "Not at all" to "Extremely." Participants also recorded stressful events that occurred during the time from the last recording.

An unexpected finding

The researchers examined nearly 6,000 eating events from all the recordings, including 367 self-reported binge-eating episodes and 537 loss-of-control episodes, 152 overeating episodes, and 4,584 episodes that involved neither loss of control nor overeating (NE). Negative affect predicted purging after NE. A total of 112 purging episodes (34.5% of all purging episodes) were reported after NE.

The finding that self-reported binge eating most strongly predicted purging did not correlate with the authors' hypothesis that loss of control would be associated with purging. Prior studies have not included participants with AN, and thus the findings suggest that binge eating may differ among diagnostic eating disorder subgroups. The patient's subjective perception that she has consumed an "excessive" amount of food may be particularly important in AN, according to the authors.

A Spotlight on Weight and Disordered Eating Patterns

In a large Norwegian study, weight problems and disordered eating were not distinct from one another.

Reprinted from Eating Disorders Review
November/December Volume 26, Number 6
©2015 IAEDP
While eating disorders such as anorexia nervosa, bulimia nervosa, and binge eating disorder affect from 5% to 10% of the population, an even larger group has disordered eating patterns or subthreshold eating disorders. A general population study of 27,252 Norwegian women 19 to 99 years of age recently revealed a wealth of information, including a 12% prevalence of disordered eating, especially in women with weight problems (BMJ Open 2015; 5:e008125. doi:10.1136/bmjopen-2015-008125).
Trine Eik-Nes, MD and colleagues at the Norwegian University of Science and Technology, Trøndheim, and Levanger Hospital, Levanger, Norway, recently reported the findings from their cross-sectional community study. The information about disordered eating patterns emerged as part of the third survey from the Nord-Trøndelag Health Study (HUNT3). The HUNT survey provides information from the total population, 14 years of age and older, in Nord-Trøndelag County, Norway. The entire county is invited to participate and at the last survey 93,860 women were invited and 52% agreed to join the study. For young adults, the researchers used a shortened version of the Eating Attitudes Test (they termed it the EAT-8) that involved two factors: 'oral control' and 'bulimia and food preoccupation.'

Results: a majority were overweight or obese

The mean body mass index (BMI, kg/m2) was 26.9 for the more than 27,000 women (mean age: 53 years) who participated. Of all women in the sample, 61.1% were either overweight or obese, and 32% were in the obese category. Two-hundred and forty-two women were in the underweight category, and 966 women had a BMI <20. BMI increased with age, and obesity (BMI ≥30 kg/m2) and extreme obesity (BMI ≥35 kg/m2) were most prevalent in women 60 to 70 years of age.
Among women younger than 30 years of age, 11.8% reported disordered eating. Weight problems were associated with disordered eating overall and with oral control and bulimia and food preoccupation. Underweight women had almost 5 times higher odds of high oral control than did normal-weight women, while women in the obese category were more likely than normal-weight women to show symptoms of bulimia and food preoccupation. As for dieting, 58.8% of the entire group reported being dissatisfied with their current weight, and women dissatisfied with their weight were 7 times more likely to be dieting than not. 
More than half of the women in the study reported dieting and treated dieting as a normal practice; dieting was largely dependent on weight dissatisfaction and not on BMI. In fact, the authors noted that a sizeable number of women were dissatisfied with their weight even when their BMIs were within a normal healthy range for their weight.
Disordered eating was not associated with younger age among women 19 to 30 and the authors found no association between age and weight dissatisfaction. Dr. Eik-Nes and colleagues' overall conclusion was that weight problems and disordered eating were not distinct from one another. In addition, they concluded that prevention and treatment for disordered eating and weight control among women should include an assessment of body image as well.

Is the Brain's Microstructure Important in AN?

One study examined the role of the subcalloseal cingulate cortex. 

Reprinted from Eating Disorders Review
November/December Volume 26, Number 6
©2015 IAEDP
Increasingly researchers are exploring the brain to find clues to the development of anorexia nervosa (AN). Within the brain the subcallosal cingulate cortex (SCC) regulates affect, and thus may play a role in the pathophysiology of AN. 
Recently developed magnetic resonance imaging techniques such as diffusion tensor imaging allow researchers to assess whether white matter connections are intact or disrupted. A group of neuroscientists and psychologists at the University of Toronto recently used diffusion magnetic resonance imaging (dMRI) and multi-tensor tractography to compare the anatomic connections and microcircuits among 8 women with treatment-resistant AN and 8 sex- and age-marched healthy controls. The women with AN were also clinically assessed before and after deep brain stimulation (Brain Stimulation. 2015; 8:758). All subjects underwent implantation of bilateral electrodes in the SCC followed by MRI.

Different patterns in healthy subjects and patients

As the authors reported, subcalloseal connectivity was different between AN patients and controls. The most marked differences were increased connectivity to the ipsilateral parietal cortex and decreased connectivity to the thalamus bilaterally in the AN patients. The scans also showed many equally connected regions in both groups of subjects. 
The main relationships between clinical affective measures and dMRI were seen in the left fornix crus, inferior frontal occipital fascius (IFO), and right internal capsule, or the anterior limb of the internal capsule, or ALIC, among the AN patients. The abnormalities were consistent with a central role for dysfunctional affective processing and broad clinical changes, particularly changes in processing of affective stimuli, self-perception, and interoception, according to Dr. Dave J. Hayes and colleagues.
The findings should be viewed as preliminary and the sample was small — but among those with AN differences in connectivity and intact circuits were seen. Furthermore, dMRI metrics predicted a deep brain stimulation response. The authors are correct in noting that such preliminary findings may point the way toward the development of sophisticated predictors of treatment response.

Gauging Distress in an Adult AN Patient's Partner

Distress was lowest when both partners agreed on the need for change.

Reprinted from Eating Disorders Review
November/December Volume 26, Number 6
©2015 IAEDP
Being in a romantic relationship with a patient with anorexia nervosa (AN) can be challenging. And, for patients with AN, their romantic partners may be their main interpersonal relationship. Such relationships can endure significant amounts of strain, but it is still unclear what influence a partner's level of distress has upon the partner with an eating disorder.
In one of the first empirical studies to use data from direct observations of adult female patients with AN and their intimate partners, University of North Carolina researchers found that the partners experienced the least distress when their attempts to get the patient to change harmful behaviors fit well with the patient's perception of the negative consequences of the illness and her motivation to change the behaviors (Int J Eat Disord. 2015; 48:67). Partners had the least amount of distress when they tried to promote changes in AN behaviors and also attempted to show understanding of the patient's experience.
Melanie S. Fischer and her fellow researchers in the Departments of Psychology and Psychiatry at the University of North Carolina at Chapel Hill examined cross-sectional relationships between self-reports of patients' perceived negative consequences of AN, their partners' level of caregiver distress, negative affect, satisfaction with the relationship, and use of promoting change and acceptance/validation. Sixteen adult patient-partner pairs were studied as they started a couple-based intervention for AN. The couples had to have been in a committed relationship and living together for at least one year. In addition, the patient had to have a body mass index greater than 16 kg/m2

Working as a team lessens distress

When both partners worked as a team to promote change and work toward recovery, partner distress was less. Those partners who displayed higher acceptance/validation reported less negative affect. It seems logical that this would be well-received by patients and assist in coping with illness strains. However, the researchers also noted that if partners have negative affect, it might be difficult for them to show understanding and to validate the patient's struggles with AN.

The authors are correct in thinking of their findings as "exploratory." It was a single study and the sample was small. Still, this is potentially highly valuable work as it expands our knowledge relative to treating adults with AN, an area of greater need. 

Analyzing the Cost of Inpatient Treatment for Anorexia Nervosa

A recent Canadian study sheds light on inpatient treatment costs for AN, as well as on caregiver and societal costs.

Reprinted from Eating Disorders Review
November/December Volume 26, Number 6
©2015 IAEDP
Inpatient treatment is the choice for medically unstable teens with anorexia nervosa (AN). However, one downside is that such stays can be both lengthy and costly. Hospitalization can have an impact on normal adolescent development, and interfere with academic and social functioning. Parents and caregivers face high levels of psychological and financial stress. 
Noting that the economic impact of eating disorders is great but still under-researched, Alene Toulany, MD, and colleagues at the University of Toronto designed a cohort study involving all adolescent patients aged 12 to 18 who were admitted for treatment of AN at a tertiary child and adolescent eating disorder program in Toronto between September 1, 2011 and March 31, 2013 (CMAJ Open. 2015. doi:10.97778/cmajo.20140086; published online). 
Data collected from 73 teens were included in this study. The researchers collected data on patient age, sex, place of residence, presence and age of siblings, patient body mass index (BMI, kg/m2), comorbidities, duration of AN symptoms, prior treatment for AN, length of hospital stay, and time spent on the wait list for admission. In addition, the team estimated caregiver costs associated with hospital visits. 
Most of the teens (89%) were females, and the mean age was 15.2 years. The mean BMI of the 73 participants was 16.1 (range: 11.3 to 26.2 kg/m2). Most of the patients were either admitted to the inpatient unit directly from the hospital's emergency department or from a unit at another hospital. Thirty percent had at least 1 comorbid medical diagnosis and 34% had at least one comorbid psychiatric diagnosis at admission. The mean length of time patients stayed in the hospital was 37.9 days, and hospitalization ranged from 9 to 153 days. 
Based on the mean hospital stay of 37.9 days the authors estimated the hospital, caregiver, and total societal costs (in Canadian dollars) at $1450 per admission day ($355 hospital, $95 caregiver, respectively).

The significance of admission BMI

The patient's BMI at admission was the only individually significant predictor of hospital costs, according to Dr. Toulany. For every unit increase in BMI, the authors found a 15.7% decrease in mean total hospital cost, after controlling for wait time between referral and start of inpatient treatment. In a second model that included previous AN treatments and comorbid medical conditions, BMI was once more the only significant predictor of costs.
From a societal perspective, the cost of hospitalization for AN was a mean of $54,932 (in Canadian dollars). The societal perspective is less commonly used in such analyses than the third party payor perspective (which only counts medical costs, not family and patient costs). Using the societal perspective is a strength of this study, as it provides fallen picture of costs reported here fall within the range described previously.
An important implication of this study is that finding cases earlier, and initiating treatment earlier in the course of weight loss, appear to diminish costs. This seems to make a strong case for aggressive early treatment.

The Rise of Eating Disorders in Asia

Trends don't mimic the West but instead are unique to each geographic area.

Reprinted from Eating Disorders Review
November/December Volume 26, Number 6
©2015 IAEDP
Two Columbia University researchers report that the increasing incidence of eating disorders in Asian countries is not due solely to "Westernization" but more often is due to forces independent of Western influences.
Drs. Kathleen M. Pike and Patricia E. Dunne of New York State Psychiatric Institute have written a very thoughtful and thorough review of the rise of eating disorders in Asia, including Japan, China, Malaysia, and India. Their overall findings show that eating disorders are "not culture-based or culture-specific, but culture-reactive" (J Eat Disord. 2015; 3:33).

According to the authors, the rise in disordered eating throughout Asia is actually a result of unique cultural transformations in each country, including increased industrialization and urbanization, shifts in population, changes in the food supply, new gender roles, and alterations in traditional family structures. Eating disorders have spread in tandem with economic changes, led by Japan, then Hong Kong, Singapore, Taiwan, and South Korea, according to the authors. Here are a few of the trends.

Japan: a relatively stable increase in eating disorders

Proliferation of eating disorders in Japan coincides with industrialization and urbanization and changes in gender roles and in the traditional family. Most eating disorders are reported among teenage girls, and prevalence estimates range from 25.2 to 30.7 cases per 100,000 population. According to the authors, while conventional forms of anorexia nervosa (AN) have been the norm, unique differences among individuals have emerged. For example, in one study of patients with AN, three distinct groups emerged: 200 women had typical AN, 86 had non-fat-phobic AN, and 97 had AN related only to body shape and weight. The three groups had widely differing durations of illness, body mass index ranges, and EAT scores (Int J Eat Disord. 2011; 1:130).

Singapore: one well-meant program backfired

Starting in the 1990s, eating disorders became increasingly common in Singapore, according to Drs. Pike and Dunne. Body dissatisfaction has been particularly common among university students and Singaporean Chinese schoolgirls, even though rates are relatively lower than in the West. In one 8-year review of persons with AN seen at an eating disorders clinic, a large majority were female, but males accounted for 8.7% of patients seen during 1994 to 2002. Malays made up 4.8% of cases, compared to 84.1% who were Chinese and 7.9% who were Indian. 
In an attempt to address rising obesity rates among schoolchildren, the government in Singapore established a compulsory (and ultimately unsuccessful) school-based weight-loss program, "Trim and Fit." The social stigma and teasing from peers doomed the program and may even have contributed to an upsurge in eating disorders in vulnerable children. One outcome of the program was that 11% of the individual AN patients seen during 1994-2002 had participated in the program and reported social stigma as a result of it.

Hong Kong: a unique form of AN

In their research into eating disorders in Hong Kong, the authors found a variant of AN in which the usual fat phobia and distorted body image were absent, very unlike the pattern usually seen in western patients. In this form of AN, patients attributed their restriction of food intake solely to somatic complaints, such as bloating, abdominal/stomach pain, or to lack of hunger/appetite (Int J Eat Disord. 2003; 3:423). Also unlike the case of the typical AN patients in the West, these patients had fewer bulimic symptoms and tended to have lower pre-morbid BMIs. Over time, reports of this type of AN have decreased while bulimia nervosa and fat-phobic AN have steadily increased.

South Korea, China, and Thailand

In South Korea, increases in rates of eating disorders and associated risk factors occur in conjunction with dramatic and pervasive social changes from the early 1960s through the late 1990s, matching the country's rapidly accelerating economy. Although eating disorders reported in South Koreans have clinical profiles very similar to those of the West, body dissatisfaction and internalization of the thin ideal may be more widespread in Korea than in the West, according to the authors. Another interesting finding from a study of three generations of Korean women (including one group of Korean-Americans) suggested that native Korean values may inadvertently promote eating disorders, due to an "emphasis on appearance rather than ability or talent as the crucial factor to a woman's success in marriage and career" (Int J Eat Disord. 2006; 39:198).
Among women in mainland China, a significant but more recent increase in eating disorders has emerged. Drs. Pike and Dunne note that the first reports of eating disorders in mainland China appeared in the early 1990s, and the hallmark "fear of fat" was the underlying stimulus. Later, mass migration from rural areas to cities and the effects of sociocultural transformation, including economic stress and competition, resulted in many of the cases reported later. Other factors include concerns about body shape and size, preference for a thin body, a history of child abuse, elevated anxiety levels, and newly hostile relationships with parental figures. As more recent and larger-scale community-based studies have concluded, the incidence of eating disorders may be relatively low but subclinical and/or partial eating disorders and maladaptive eating behaviors are widespread. 
The results of a 1999 study gave a good illustration of the effects of industrialization upon eating disorders when it compared three groups: high school girls in urban Hong Kong, high school girls living in the largely rural Hunan province, and schoolgirls of the same age living in Shenzhen, a semi-urban and rapidly growing area. Girls in Hong Kong had the most marked eating disorders, followed by girls in Shenzhen, and last by girls in Hunan Province (Int J Eat Disord 1999; 1:505).

Fiji, Pakistan, and Taiwan: The effects of media

Traditionally, the Fijian ideal of beauty was a robust female body shape, and eating disorders were so rare that only a single case was reported prior to the mid-1990s. However, once Western media, especially television, became available in the 1990s, cases of disordered eating surged among ethnic Fijian women. The trend continues today, and the specific modeling of behavior upon western television characters may reflect a desire for women to position themselves competitively in their rapidly changing culture. Fijian men report increasing pressure to achieve a muscular body ideal. Studies by Becker and colleagues of eating disorder symptom prevalence before and after the arrival of Western television are often cited as evidence for the role of media in development of eating disorders (Cult Med Psychiatry. 2004; 28:533). Dr. Becker's work is very important because he studied eating disorders and body image in Fiji before television reached the island.
In Pakistan, a more conservative society traditionally closed and with less exposure to western media, fashion, and advertising, has been affected by increasing industrialization and modernization. Males as well as females may be facing growing risk of developing eating disorders. In one 2008 study that examined body dysmorphic disorder in a sample of 156 medical students (slightly more than half were females) revealed that 78.8% of students had some degree of dissatisfaction with their bodies. 'Being fat' was a concern for 40.4% of the women, while the males were more concerned with being too thin (BMC Psychiatry. 2008; 8:20).
In contrast to the evidence of increased risks of media exposure and rising eating disorders incidence, data from Taiwan suggest clinical eating disorders are less common than in Western countries. However, risk factors associated with development of eating disorders, such as body dissatisfaction and dieting, are increasing and may now be common among teens and young adults. Younger teens were more likely to watch television, to use the Internet, and also to snack while watching television-increasing media exposure and risk of exposure to the thin ideal.
The authors concluded that even as Asian countries become more urbanized and developed, we cannot assume each country will automatically will follow the path of Westernized countries to greater obesity and increased eating disorders.

New Behavioral Treatment Approach Targets Neurobiology of Adults with AN

Family therapy focusing on AN-specific temperament, cognition, and eating behaviors.

Reprinted from Eating Disorders Review
November/December Volume 26, Number 6
©2015 IAEDP
Information about neurobiological factors in AN that may cause the disease to be long-lasting and relapsing continues to grow. A group at the University of California, San Diego, has developed a new treatment approach for adults with AN that attacks the neurobiology of the illness. Neurobiologically Enhanced With Family Eating Disorder Trait Response Treatment (NEW FED TR) aims to reduce core symptoms among adult AN patients by using behavioral approaches to target disease-specific mechanisms. 
Stephanie Knatz, PhD, and her colleagues report that NEW FED TR targets AN-specific temperament, cognition, and eating behaviors because the underlying traits are stable and pervasive, instead of transitory, in individuals with AN (Dialogues Clin Neurosci 2015; 17:229). The NEW FED TR technique is used to teach patients with AN and their families and caregivers (carers) to manage AN symptoms by using these traits in a constructive way. Results from neuroimaging studies suggest that the mechanisms underlying anticipatory anxiety, reward insensitivity, and/or deficits in awareness of homeostatic needs (interoceptive awareness) are major contributors to the illness. 
Establishing a neurobiological basis as the primary etiologic cause of AN reduces blame and increases empathy, both of which are critical for enlisting support of patients and the people caring for them. These psychoeducational activities are then followed by related skills training. Patients are asked to follow a routine, predictable structure for meals and snacks that specifies specific times, foods, food exchanges, and other details surrounding meal times. Using such a highly predictable and repetitive structure makes use of the patient's personality strengths, such as enhanced inhibition and self-control, while taking into account deficits in the ability to tolerate uncertainty and to shift sets.

Two stages of treatment

Treatment is delivered in two phases that are conducted with the patient and her or his carers. The first phase is an intensive course of 5 consecutive days of 8 to 9 hours of treatment daily. This phase involves joint meetings with multiple families, following the theory that intense, repeated and focused live practice is the key to changing biologically driven avoidance behaviors. Learning is maximized by massed practice and close monitoring of compliance. 
The second phase involves weekly outpatient follow-up sessions focused on monitoring weight and symptoms, while helping patients and carers practice skills learned during their 5-day intensive training. Patients are asked to follow a routine and predictable structure for meals and snacks that specify specific times, foods, exchanges and other mealtime details.
The authors explain that the concept of neuroplasticity suggests that increased treatment frequency and intensity are essential to achieve behavioral change. For example, treatment models for anxiety dictate that intensive, repetitive, and focused "live" practice is key to changing biologically driven avoidance behaviors. According to the authors, one possible reason for failure with current treatment approaches for AN is that the once-weekly treatment format is simply not repetitive enough. 

 A program aimed at adults

While family-based therapy is helpful for adolescents because of its focus on weight restoration by empowering the family to take control of refeeding, implementing this is obviously difficult for adults. However, support for carer involvement in adult AN is growing. For example, "Uniting Couples in the Treatment of AN," based on cognitive behavioral couples therapy, is showing promise for improving communication and reducing marital distress. Patients and carers learn about the neurobiology underlying AN and the most effective ways to respond to and manage symptoms. They also learn skills to help reduce dietary restraint and concerns about shape recovery around meals. For example, carers learn to establish a pre-meal routine that will distract the patient from negative internal states that anticipate the effects of food and to help reduce anxiety about exposure to food. Meal coaching helps carers redirect patients from ruminating when anxiety or obsessions invariably occur.
The authors report that a multi-site clinical trial is now under way to develop and test the efficacy of the NEW FEF TR treatment program, with six intensive multifamily programs scheduled throughout 2015. This approach seems to reflect the revised approach to treatment development supported by the National Institutes of Mental Health, in which treatment design is guided by underlying neurobiological or psychophysiologic aspects of illness. NEW FED TR appears to be an early attempt to put this new approach into practice.

Using Telemedicine to Deliver Family-based Treatment for Teens with AN

A new project fulfills a need for patients and families without good access to therapy.

Reprinted from Eating Disorders Review
November/December Volume 26, Number 6
©2015 IAEDP
An ongoing project is testing the power of telemedicine to deliver family-based treatment (FBT) for adolescents with anorexia nervosa (AN). Drs. Kristen E. Anderson, MD, and Daniel Le Grange and three co-workers at the University of California, San Francisco, recently reported that they have completed the first steps in a two-year study designed to deliver FBT to adolescents and their families in remote, rural, or underrepresented areas of the US (J Eat Disord. 2015; 3:25).
AN is still the most deadly psychiatric illness, and compared with their peers of the same age, individuals with AN have nearly a 12-fold greater risk of death from all causes, along with a 57-times greater risk of death from suicide. FBT is currently the most effective treatment available for teens with AN. However, there are relatively few FBT therapists in the US, and most work in urban areas (there is 1 certified FBT therapist for every 2000 adolescents with AN in the US). Families have traditionally traveled long distances to get such therapy.
Dr. Anderson and her team are currently in the midst of a treatment development study to address the needs of families and teens with in remote, rural or underrepresented areas of the US. They are currently enrolling teens aged 13 to 18 who have DSM-5 criteria for AN and who are at or below 87% of expected body weight. Candidates for the telemedicine program have to be medically stable enough for outpatient treatment and if receiving psychotropic medication must have been on a stable dosage for at least 8 weeks. Teens are excluded who require hospitalization, or who have a psychotic or other mental illness, or dependence on drugs or alcohol, or any physical condition that might influence eating or weight. Teens who have had previous FBT treatment for AN are also excluded.

Establishing a safe health portal

The researchers have established a Cloud-based health portal that will allow the therapist to connect with the family via a secure videoconferencing stream. Participating families will also be able to communicate with the therapist with a messaging system that is similar to email. Because of the importance of patient confidentiality and security, the authors are using HIPAA-compliant software. 

A standard battery of tests will be conducted at baseline, and then at a midway point, at the end of treatment, and at 6 months follow-up. Each assessment will be completed using the Cloud-based health portal's videoconferencing feature. Even the numerous questionnaires will be filled out online.
The first of two case series has been completed, and the second series is underway. The authors report that the study has already enrolled 80% of patients and is on track to have all participants enrolled by the end of December 2015. In the second wave of the study, families will have access to a digital weight scale that they can use to access real-time weight-restoration programs online. The team is also addressing some technological issues; for example, not all families have good Internet connections or supported web browsers. 

Tuesday, December 8, 2015

Combatting Bone Loss in Anorexia Nervosa: Nine Reminders

Reprinted from Eating Disorders Review
November/December Volume 26, Number 6
©2015 IAEDP
Bone loss is a common and potentially devastating medical complication of anorexia nervosa (AN). At least half of young women with AN will develop osteoporosis, and their bone loss often occurs relatively early in the disease. It also may not be fully reversible, at least with currently available treatments. It is important to remember that we may not yet appreciate the full impact of osteoporosis in AN. Given the increased prevalence of AN in the last 40 to 50 years, the majority of people who have - or did have - AN may not have yet reached the age when osteoporosis complications are most common and problematic. For this reason, gaining more knowledge about preventing and treating osteoporosis in AN is critically important.

1. Anorexia and Bone Health: A Complex Relationship

In AN patients, bone resorption increases without a corresponding increase in bone formation, leading to a net loss of bone. Levels of bone resorption markers such as N-terminal telopeptide (NTX) and deoxypyridoline may be elevated, but bone formation markers such as osteocalcin are not (Eur J Clin Nutr. 2004:1257. Because significant bone loss can occur so early in AN, even within the first year, early diagnosis and intervention are important.
Baseline screening is recommended for all patients who have had AN or amenorrhea for 6 to 12 months or longer. The Osteoporosis Foundation recommends screening all women under age 65 who have low body weight (Geriatrics. 2000 May; 55:31), and the American College of Sports Medicine recommends screening for osteoporosis in athletes who have a history of low estrogen levels or disordered eating for 6 months or more, or those with a history of stress fracture or any fracture from slight trauma (Med Sci Sports Exerc. 2004;36:1985; Med Sci Sports Exerc. 2007; 39:1867). 

2. Peak Bone Mass Forms between 11 and 14 Years of Age

While peak bone mass is reached by the third decade of life, from 40% to 60% of a woman's bone mass is gained during the pubertal bone surge from ages 11 through 14, also the time when symptoms of AN often appear. The predictive relationship between bone mineral density (BMD) and short-term fracture incidence is unclear in premenopausal women. For these reasons, the International Society for Clinical Densitometry recommends against the use of T-scores to categorize BMD measurements in premenopausal women. Instead, the Society recommends using Z-scores, which compare women to an age-matched reference population. Young women with BMD Z-scores below — 2.0 should be categorized as having BMD that is "below expected range for age," and those with Z-scores above — 2.0 should be categorized as having BMD that is "within the expected range for age" ( 
Drs. Madhusmita Misra and Anne Klibanski at Harvard Medical School point out that as many as 50% of adolescent girls with AN have Z-scores less than -1 recorded at one site and 11% have Z-scores less than -2 recorded at a minimum of one site (Clin Obstet Gynecol. 2013; 56:722). There are no longitudinal prospective studies relating BMD by dual-energy x-ray absorptiometry (DXA) scans to fractures in premenopausal women.
Bone tissue is always in a state of change; old bone is reabsorbed and new bone laid down by osteocytes. During childhood and early adolescence, the osteocytes lay down new bone cells faster than they are being absorbed, leading to peak bone mass. This continues to about age 30, when bone production slows down and bone mass shrinks by about 1% each year afterward.
As Dr. Kathryn Teng of the Cleveland Clinic has written, it is essential to optimize bone mass during these years because even small difference in BMD can have significant implications later. She notes that just a 5% increase in bone density significantly decreases fracture risk, whereas a 10% decrease in adult BMD is associated with twice to three times the risk of fracture (CCJM. 2011; 78:50). After the third decade of life, skeletal mass begins to decrease and is accelerated after the menopause, where the rate of bone loss exceeds that of bone formation. Failure to attain sufficient bone density during adolescence leads to osteopenia, or a bone density between 1 and 2.5 standard deviations below average on Z scores for young adults of the same gender, and is a risk factor for osteoporosis. 

3. Young Patients with Prolonged Amenorrhea Have More Severe and Longer-Lasting Bone Defects

Younger AN patients are at greater risk because often they haven't reached their peak maximum peak bone mass. Beyond the low DXA measures of BMD, teens with AN have weakened bone microarchitecture. For example, the volume of trabecular (spongy) bone and trabecular thickness are lower and trabecular separation greater in girls with AN than in healthy controls, even when the BMD measurements are the same. This breakdown and weakening of bone microarchitecture is of concern because of the increased risk of fracture risk independent of BMD. 
Young women with amenorrhea should be evaluated to determine if the amenorrhea is primary (absence of menarche by age 16) or secondary (absence of menses for more than 3 cycles or a past history of amenorrhea for more than 6 months). In a study of 73 women with AN, having the illness for 20 months was an important cutoff point: after this, the most severe form of osteopenia was seen (J Endocrinol Metab. 2009; 95:470).Weight gain and resumption of menses led to a 3% annual gain in BMD at the spine and a 2% gain at the hip, compared with a decrease in BMD of about 2.5% at both sites in persons who did not recover. As Drs. Misra and Klibanski point out, however, residual deficits can persist and make it impossible for patients to catch up to normal bone density.

4. Hormonal Changes Also Impact Bone Loss

AN patients also have important endocrine changes in hormonal axes that can affect bone loss. These include the hypothalamic-pituitary-gonadal axis, the growth hormone insulin-like growth factor (IGF-1) axis, and the hypothalamic-pituitary-adrenal axis. (J Clin Endocrinol Metab. 2004; 89: 4920). Many familiar hormones impacted by the patient's energy status, including peptide YY (PYY), leptin, ghrelin, insulin and adiponectin are affected, and in turn may affect bone health. 
Teens with AN have higher-than-normal serum and urinary cortisol levels, and increased cortisol is associated with a lower body mass index and fat mass and lower glucose levels. According to Drs. Misra and Klibanski, this is an adaptive response to malnutrition, as cortisol is gluconeogenic. But, higher cortisol levels are also associated with lower BMD and inversely with bone turnover markers (J Clin Endocrinol Metab. 2004; 89: 4920). These higher cortisol levels are predictive of lower spine and hip BMD, as well as lower extremity lean mass in AN, which may also impact bone health (J Clin Endocrinol Metab. 2005 95;2580). The hypoestrogenic state noted in AN, a direct result of the effects of hypothalamic amenorrhea, is further worsened by changes in estrogen metabolism.

5. Weight Restoration is the Cornerstone of Treatment

According to Dr. Teng and others, weight restoration is the cornerstone of treatment for low BMD due to AN. All AN patients should be referred to a nutritionist to develop a meal plan. Treatment goals for patients with disordered eating are designed to optimize the patient's nutritional status, normalize her or his eating behavior, change unhealthy thoughts that maintain the disorder and treat emotional issues that are contributing to the disordered eating.
Restoring weight and with it menses are two of the most important goals of treatment because young women with AN can lose as much as 2% to 6% of their bone mass each year they have AN. While previous studies have shown that BMD increases as the patient recovers, long-term follow-up studies show that loss of bone density may not be completely reversible, even when menses resumes and the patient regains weight. 

6. Estrogen Replacement Is Ineffective

Unlike the positive effects among postmenopausal women, where estrogen therapy maintains or improves BMD and may help reduce the incidence of fractures, the same pattern has not been seen in premenopausal women with osteoporosis. Estrogen Replacement seems to have little independent effect on correcting or preventing osteopenia in AN (Eur J Endocrinol. 2002; 146:45). Some researchers report that this is due to the possibility that the natural cycle of estrogen may be important to bone recovery. In postmenopausal women, estrogen therapy appears to work by impairing osteoclast-mediated bone resorption, but it has only slight effects on bone formation. In premenopausal women with anorexia, in contrast, bone loss appears to be due to a unique "uncoupling" of osteoblastic and osteoclastic functions, according to Dr. Teng and others (Int J Eat Disord. 2001; 29:11). This uncoupling of osteoblastic and osteoclastic functions results in reduced bone formation and increased bone resorption—estrogen may not improve this.
The American College of Sports Medicine recommends considering estrogen therapy if there is evidence of a decline in BMD in an athlete older than 16 years of age who also has persistent functional hypothalamic amenorrhea despite adequate nutritional intake and weight regain (Br J Sports Med. 2014; 48:289). However, the Society also acknowledges that restoring regular menstrual cycles with oral contraceptives will not normalize metabolic factors that impair bone formation, health and performance, and again note that it is unlikely that estrogen will fully reverse low BMD in these patients.

7. Bisphosphonates Are Not Approved for Premenopausal Patients with AN

The FDA has approved use of bisphosphonates only for premenopausal women who are also taking glucocorticoids. The bisphosphonates do increase BMD in young women with AN but at the same time are teratogenic and have a long half-life that enables the drugs to affect bone turnover for up to 2 years after they are stopped (Am J Med. 1997; 103:291). For patients who purge via vomiting, the bisphosphonates also increase the risk of esophageal ulcerations. Thus, for the time being, the bisphosphonates do not represent a major treatment option for osteoporosis in patients with AN.

8. Calcium Supplements Do Not Increase BMD

The National Osteoporosis Association has recently issued a statement in response to the discussion about the need (or not) for calcium supplements. Noting that calcium is needed for strengthening collagen in bone tissue and for many other functions, the organization recommends attempting to get "the recommended daily amount of calcium from food first, and to supplement this as needed to make up for the shortfall." (For the Association's full statement, see .) The organization also mentioned that calcium and vitamin D were recently reaffirmed by the 2015 U.S. Dietary Guidelines Advisory Committee as nutrients of public health concern because their under-consumption has been linked to adverse health outcomes. ( 

9. Always Monitor Exercise, Particularly In Patients Who Are Also Athletes

Strenuous exercise is a major factor in maintaining and developing normal bone mass; however, the benefit of exercise on bone loss in anorectic patients is still a topic of debate. The amount of exercise has to be monitored to help limit further weight loss. In addition, abnormal plasma estradiol concentrations may limit the positive effects of exercise on bone density (Calcif Tissue Int. 2000; 67:277). 

Wednesday, December 2, 2015

The body’s response to adequate fuel in anorexia

By Jaimie Winkler, RD, LDN and David Alperovitz, Psy.D.
Research on the refeeding process provides us with parameters regarding resting metabolic rate, body composition, and hormone composition as someone restores weight.  This knowledge can provide comfort to those in physical and psychological pain during refeeding. The degree and amount of knowledge people are given during this process is important as individuals have different preferences for how involved they want to be in knowing the specifics of their treatment.  There are indications that for some individuals too much information about the refeeding process can provoke more social comparisons, a greater need for reassurance, negative self-evaluation (for not meeting the standard), and can fuel the sufferer’s intolerance for uncertainty and discomfort. The core symptoms of an eating disorder consist of: fear of weight gain (fullness, fatness, or discomfort), fear of uncertainty, desire for predictability, a need for reassurance, discomfort, and avoidance. All of these symptoms need to be addressed with skill development as well as information.
Science and clinical experience both reveal that the refeeding process may be uniquely painful for each individual – independent of weight. Refeeding can be as physically and psychologically uncomfortable for someone who is overweight, as it can be for someone of average weight, or for someone who is underweight.  This article speaks to the weight gain process. Even those not on formal weight gain plans may recognize themselves in this description. 
The timeline we provide is drawn from a compilation of clinical experience and is supported by research studies that address singular parts of this complicated process. To understand what happens during refueling, we first we need to look at what happens during the malnutrition process. The key things to know are:
  1. Energy Reallocation. This is the “metabolic rate decreases” fact that scares many people. Let’s call it what it is: when there is not enough energy to properly run the body, energy gets allocated from less important processes and structures to the most important ones. Energy is delivered to muscles, organs, and tissues only as they relate to surviving, not toward optimal function. At this stage you may not realize just how poorly you are functioning until you have adequate energy and are able to compare the difference. 
  2. Increased Interest/ the “pull” toward food. Whenever you avoid food, you are more drawn to it. It is important to differentiate interest in food from actually enjoying food.  Interest often translates to the experience of seeing food everywhere, noticing when others are eating, and worries that if you start eating you will never stop. When this occurs, social interests, intellectual pursuits, and life enjoyment typically take a backseat to food. 
  3. Emotional Insufficiency. When food is the primary objective of each day, the helpful emotions that guide you through social interactions and safety situations are frequently absent. Some people prefer to turn their emotions off or “numb out” by restricting food. This process can be both conscious and unconscious.  It is important to note that the process of restriction suppresses both positive and negative emotions equally. We have come to know that emotions can be seen as critical data for navigating the world and making decisions.  With limited access to emotions one becomes significantly handicapped in navigating life.

Phase 1:  Immediate Changes: Going against the current

Immediately upon eating more your body relishes the extra energy and quickly begins to put this energy to work. Metabolic rate (calorie using capacity) rises as you provide adequate nourishment. Calories are the trigger to an increase in metabolic rate. 
The serious risks associated with “refeeding syndrome” are directly related to the way that the body immediately starts to make more energy when it doesn’t have enough nutrients to meet demand. The consequences of refeeding syndrome, which is different from the refeeding process, can range from low lab values to mild edema to heart failure.  
When in a state of malnourishment, hormone levels that regulate tissue growth are decreased and cells become resistant to their effects. The net result is that more glucose becomes available for vital organs and vital movement. A malnourished body assumes that this movement is aimed toward getting food to eat – not with the goal of exercising or burning more calories. Your arms and legs can still carry you to a job, class, or an appointment because energy has been allocated to those limbs to get them to work for hunting and gathering food. The fact that these activities are possible may have you think that things are OK.  Nothing could be further from the truth.  Survival mode must be differentiated from “OK.”
The same hormones that contribute to building lean body mass and body fat remain ineffective when you begin eating more. At this point, energy and nutrients are primarily directed toward restoring function to vital organs.
The first step is for the body to gain water weight to achieve normal hydration. Here the body is moving from a dehydrated state to a hydrated state. This can occur suddenly and can be severely uncomfortable because the change is immediate. For instance, you can gain several pounds of “water weight” overnight because you drink several pounds of fluid in a day to stay adequately hydrated. The same does not hold true with food, you cannot gain several pounds of body weight overnight because much of the food eaten gets converted to energy and leaves the body via heat, energy, carbon dioxide, or water (through the nose, sweat, or urine). 
Dehydration occurs for many reasons: laxative or diuretic abuse; decreased intake of glucose, protein, and electrolytes; refusal to drink water; as well as excess consumption of protein or caffeine intake. 
A danger here is that one of the eating disorder’s core beliefs/fears will appear confirmed: That you cannot eat normally without “blowing up.”  However, weight gain is not and should not be seen as a maladaptive response to food.  Weight gain is a normative process and the body’s logical and correct response to the reintroduction of food that the eating disorder sought to avoid. 
Restrictive eating patterns can cause abdominal pain and bloating. Important daily maintenance to the body’s intestines is sacrificed when intake is restricted. Many repairs are often needed before the system begins to work optimally. Low caloric intake slows down and delays the emptying of stomach contents leading to nausea, slow digestion, and constipation. Both restrictive eating and low caloric intake can leave you feeling fuller with less food. It is both normal to begin to feel hungry or to feel excessively full at this point. Hunger may become obvious once your body starts using and requesting more energy. However, depression, stress, and anxiety can still be potent appetite suppressants even as your body demands food.
When you begin to eat more there is no way to direct the allocation of energy to a specific body system. This initial period of refeeding often is associated with a feeling of “wrongness” that you are not listening to body cues. The eating disorder logic/fear of “once it starts it will never stop” can be present, in an attempt to thwart recovery. Individuals often have the experience of fearing that each new uncomfortable physical symptom will never cease. It follows that this occurrence is often filled with high anxiety and can be one of the most fearful moments of the entire recovery process. 

Phase 2: No solid ground

During the weight gain phase of refeeding, three types of weight gain occur: continued restoration of normal fluid balance, lean body mass gain, and body fat gain. Research studies consistently demonstrate that weight gain from body fat is only part of the equation. To create new body fat there must be an excess of calories. Each day during weight gain, important and small amounts of lean body mass and body fat gain are being created.  Simultaneously, daily fluid shifts of between 1 to 5 pounds are occurring. It is impossible to know which aspect of weight is increasing on any given day. This is an important area to practice tolerating the discomfort associated with uncertainty.  Variations in fluid weight can be more pronounced during the weight gain process.  Fluid fluctuations relate to daily sodium and carbohydrate intake, the amount of fluid necessary to excrete the byproducts of repair through urine, as well as fluid retention to support tissue growth.
During the weight gain phase, individual appetite experiences can vary dramatically. Some report prolonged “fullness” and lack of appetite. Fullness often can get confused with gas or bloating. Increased gas production occurs for many reasons connected to food production and healing. Many report wild swings between insatiable hunger and profound fullness. Some may experience both ends of the hunger spectrum in a course of an hour. Hunger signals are unpredictable and intense. Even on very high calorie meal plans designed for weight gain, people report hunger. In the famous Ancel Keys Starvation Study, subjects were eating up to 6,000 calories per day and still felt hungry or unsatisfied. 
Eating disorder thoughts and beliefs use the chaos and unpredictability of this phase to lure you back to the disorder. People often spend countless hours worrying about the characteristics of weight gain. Some dive into eating disorder behaviors simply as a way to cope. Even within a 24-hour treatment setting, it is possible to use eating disorder “rules” regarding amounts and types of food to develop a sense of “safety” or in order to slow down the weight gain process. Others create rules to apply to the weight gain experience, choosing high calorie foods to speed the process or favoring desserts that are no longer off-limits. The least eating disordered responses to this phase are to choose foods you like, challenge the fears about particular foods, and always strive to refrain from controlling the process. Way too much brain space can get devoted to the “what ifs” when a fear of uncertainty prevails.  Being open to information from clinicians about the refeeding process can also help one put things into context and simultaneously be reassuring that discomfort is expected. Tolerating the uncertainty thus becomes a critically important recovery tool. 

Phase 3: A light at the end of the tunnel?

Many worry about developing a “refeeding belly.” A clinical definition for a refeeding belly does not exist.   Many often worry that they will look pregnant or have an abdominal circumference above a “normal” or tolerable level. Sometimes it is impossible to avoid abdominal discomfort. Following a normal sized meal, you can often feel a tightening in your pants as the abdomen expands to accommodate food just eaten. With meal plans designed for weight gain, this experience is often increased. Additionally, extra stool or urine is produced from the break down of food and conversion to energy thereby creating more mass in the intestines. 
Research indicates that weight gain will often occur first in the abdomen before it does in the legs and arms. This adaptive process occurs in order for body fat to protect and separate vital organs. Due to initial weight gain in the abdomen, one can have the experience of feeling “disproportionate” because the arms and legs have yet to catch up. In research studies, the difference between the abdominal circumferences of someone who has recently restored weight versus an age/weight/height-matched control can be just a pants size in either direction. One year out from weight restoration there is no statistical difference between the shapes of weight-restored individuals and those who have never had an eating disorder. True presentations of a late-stage-pregnancy looking abdomen are very rare. Factors that reduce the risk of disproportionate abdominal weight gain include: regular periods or shorter duration of amenorrhea (less than 1 year), early intervention, and relapse prevention. 
Toward the end of the weight gain phase individuals on a high calorie meal plan (e.g. >3,500 calories per day), may experience fewer episodes of hunger and feel full before even starting to eat. Again, this is both an adaptive and natural response to overfeeding.  The body in a sense establishes a checkpoint from the hormone systems that regulate appetite and body weight. This often can be even more pronounced in a 24-hour treatment setting where food amounts are consistent and higher calorie than in outpatient treatment. Experiencing a change in appetite can contradict the notion that your body is “broken” and doesn’t know how to maintain an appropriate weight. 
In outpatient settings, weight gain might slow a bit as one approaches a healthy weight. It is important to distinguish that a healthy weight is differently defined (based on several factors) for each individual, and is not simply a BMI of 18.5kg/m2. In fact, more than 85% of women recovering from an eating disorder need to be at a BMI of 20kg/m2 or higher for full body function and normal appetite cues to be present. Individuals who have been discharged from a program at a BMI below 20kg/m2 and told they can maintain that weight, often find that their bodies may have different ideas. This should not be seen as the body “tricking” one into gaining weight. More accurately what is occurring is that one is trying to “trick” the body into maintaining a low weight. 
Nearing the end of weight gain can come as a relief or feel like a loss.  People approaching this stage often report feeling sad (or even angry) that the “food party” is over. Often overlooked is the fact that many people recovering from eating disorders actually enjoy food. At this stage, normal amounts of food may appear small. As one continues with recovery, this normalizes. 
Many people report feeling great relief as they approach or achieve a healthy weight. Rarely is it as bad as they expected it to be. The eating disorder feeds on inflated fears of the unknown. Body image will vary dramatically because this is a major transition point in treatment.  The uncertainty of life is reflected in this unstable body image. Often people report feeling like they should be “done” with treatment at this point, but in many ways the process has only just begun. (Hence the question mark in the title of this section – Light at the end of the tunnel?)  

Phase 4: Into the great wide open

When an individual is at a healthy weight and has adjusted his/her intake to support maintaining that weight, he/she sometimes prematurely assumes that the physical healing process is over. Research suggests that it can actually take up to 12 months for the body to fully heal from malnutrition. At this point, the majority of work to restore hydration is complete.  Although you have created lean body mass, you may not look “toned” (an eating disorder euphemism for looking “thin” or “good”).  Remember by about one year out, there is no difference in shape between a weight-restored body and someone who has never had an eating disorder. Most people report a “redistribution” of weight within six months, although many report they begin to feel more comfortable within a few weeks. It should be noted that the lean body mass created or repaired makes up essential skeletal muscles for basic movements and not those for athletic performance. Lean body mass also includes increases to organ tissue. 
Because physical restoration isn’t complete, metabolic rate can stay elevated for many months. People often continue to count calories or compare their intake to others but it is never a fair comparison. At this juncture one will need more food than if they were the same weight, height, and age but never had an eating disorder. For example, a 150-pound woman may need 2,700 to 4,000 cal./day to maintain full body function and weight after weight restoration.  You could maintain weight on fewer calories but this would involve starting to sacrifice critical functions like digestion, reproduction, and heart strength, as well as stunting physical and psychological recovery.
Hunger cues still might not make sense. Many people want to quickly jump to intuitive eating and abandon their meal plan. Reaching a healthy weight is not the end of the process. It is important to continue to follow a basic meal plan and work with a team on incorporating information about hunger and fullness cues. You should always add if you are physically hungry, because metabolic rate remains elevated for up to 1 year. You can work on distinguishing physical and psychological hunger but know that one should always err on the side of a little more than a little less. Clinicians advocate for seeing how much food one can eat and maintain weight, not how little one needs. The only “false hungers” people experience tend to be medication related, so talking to prescribing providers becomes important if there are doubts around trusting physical hunger.  
Feeling physically full or overfull at times is not a failure. The weight gain process has provided knowledge about what it takes to genuinely gain weight over time. Having a day of fullness or fullness after a meal does not translate to weight gain. The major goal of this phase of recovery is to reduce the intensity of your response to fullness, perceived weight gain, actual weight gain, and concerns about hunger. Learning to make small adjustments with good intention becomes important when you think you have had too much or too little food. This is always a delicate balance as the eating disorder can often lead one to overcorrect either by restricting or binging, as well as overestimating and underestimating. 
Ultimately having consistent hunger and fullness cues help break the myth that being hungry is associated with weight loss and being full is associated with weight gain.  
Physical experience often continues to be variable. Each day can feel like you are turning away from your identity. Choices can seem counterintuitive, although you intuitively know you have been able to feed yourself at times before in life. You often long to be “normal” and at the same time mourn the loss of a sense of self. Even as others see your body as healthy and your eating pattern as adequate, you will still fight thoughts and urges daily. Even the men in the Ancel Keys’ starvation study took about 6 months after restoring weight and intake to begin to “feel normal” about food. Putting one’s cognitive and emotional experiences into words is a critical starting point for validation from others as well as crucial in preventing a return to a focus on body or behaviors to express distress. 
Recovery happens one small choice at a time. You redefine “good” and “bad” days. You repair one cell at a time. Slowly the thoughts recede because you stop responding to them. There are brief moments of reprieve. You string together longer stretches of hope and freedom from the burden of the eating disorder. Just like no one can tell you the exact day your body recovers, no one knows exactly when your mind recovers. In both arenas, the cues for recovery are subtle and often uncelebrated because they seem to happen in the most uncomfortable ways.