Eat what you like and be healthy! Ellyn Satter

Eat what you like and be healthy!

January 2016  -  Family Meals Focus #103   

Ellyn Satter, Registered Dietitian and Family Therapist

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Before the publication of the 2015–2020 Dietary Guidelines for Americans sends you packing for still another guilt trip, consider becoming eating competent. You can enjoy your eating and feel good about it at the same time as you work toward the Dietary Guidelines outcomes of achieving and maintaining good health and reducing the risk of chronic disease.

The new Dietary Guidelines for Americans tell us to eat a variety of fruits, vegetables, grains, protein foods and less sugar, salt, saturated fat. This list is more moderate than before in emphasizing variety rather than stipulating serving numbers. However, there are still enough “eat this—don’t eat that” directives to leave us feeling criticized about what we eat as well as pulled in opposite directions with respect to our “shoulds” and “wants.” One of these five-year-cycles, the Dietary Guidelines committee will get around to considering the remarkable evidence supporting the Satter Eating Competence Model (ecSatter) and including ecSatter in the Dietary Guidelines. Until then, you are entitled to know that ecSatter provides the way for you to pull your shoulds and wants together and achieve nutrition and health goals. Eating competent people have nutritious diets, are active, sleep well, have better medical and lab tests, and do better with respect to feeding their children.

To become eating competent, discover the joy of eating. Eat as much as you want of foods you enjoy. Provide yourself with structure and pay attention while you eat. Be kind, patient, and persistent with yourself and your family, and you will accomplish much gain with little pain.  

• Emphasize the positive and trust the process: Have family meals made up of foods you enjoy. You will gradually get bored with the same-old and seek additional foods to enjoy. 
• Use fat, sugar, and salt to make your meals and snacks tasty and rewarding. You will eat a variety of fruits, vegetables, grains, and protein foods because you enjoy them, not because you have to. You will also eat less sugar, salt, and fat.
• Use a variety of fats: Butter and cream, olive or canola oil, corn or soybean oil.
• Have planned, sit-down meals and snacks between times. Drink your soda, tea, or coffee then rather than carrying it around between times. You will consume less sugar and be kind to your teeth.
• Let your body weigh what it wants to weigh. Evidence shows that weight stability supports health; Weight yo-yoing doesn’t.
• Emphasize sustainability. Enjoyment and food-seeking are sustainable. Avoidance and restriction are not.

Earlier commentaries:

• Dietary Guidelines 2010 and Eating Competence
• MyPlate 

For more about the Satter Eating Competence Model and how to apply it, “read Part 1, How to eat,” in Ellyn Satter’s Secrets of Feeding a Healthy Family. 

- See more at: http://ellynsatterinstitute.org/fmf/fmf-103-diet-guide-2016.php#sthash.bxPyLZjU.dpuf

Eating Competence from Ellyn Satter

February 2016 – Family Meals Focus #104 - A Taste of Eating Competence

Keira Oseroff, MSW, LCSW & Jennifer Harris, RDN, LD, CEDRD

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Keira Oseroff and Jennifer Harris are ESI faculty members who are expert in the treatment of eating disorders. They depend clinically on the Satter Eating Competence Model and the Satter Feeding Dynamics Model for symptom management of distorted eating/feeding attitudes and behaviors. This article was originally published in the Eating Disorders Catalogue. 

An all-too-typical first meeting with a new client struggling with disordered eating and with her relationship with food goes something like this: “I have issues and I’m so hoping you can help me. I’ve been trying to lose weight on and off for as long as I can remember, and I just can’t seem to get anywhere anymore. I used to be able to at least lose weight and maintain it for a while, but now, I can’t even put together one day of good eating. I try to stay positive, thinking, Tomorrow is a new day. I’ll do better tomorrow…tomorrow never comes.”  Despite the feminine pronoun, men fall victim to this process, as well, though the underlying issues fueling it may be different. 

What are the choices for the client? 

In essence, this client wants desperately for something to change, but has no idea what that would look like. The only option this individual knows is to return to the cycle of deprivation followed by a loss of control, what is commonly referred to as yo-yo dieting. After exploring the client’s history of eating and weight, we can safely label her a Dieting Casualty—a term coined by Ellyn Satter, MS, RD, LCSW, BCD, a well-recognized authority on nutrition, eating and feeding, used to describe someone who has been on the dieting roller coaster, characterized by highs and lows of restraint and disinhibition. No longer able to sustain caloric restriction, or to trust her internal compass for hunger and fullness, her eating is chaotic and her weight unstable. Yet still, food remains the focus of attention as if the answer can be found there.

 Messages are everywhere that reinforce the diet/binge cycle. That roller coaster does the opposite of building trust in our abilities to eat competently, and it erodes self-efficacy—our belief in our own ability to navigate our way through the world. Just look at magazine covers in the checkout line—pictures of decadent food next to headlines of how to lose weight are commonplace.

Becoming Eating Competent is critical

Understanding how one arrives at Eating Competence, Satter’s term used to describe normal eating, is a personal journey. For some, it’s a logical progression that occurs without much difficulty. For others, it is more challenging, and the reasons for that are varied. When people find themselves struggling with food, it is best for them to work with a professional trained to help identify the factors that have eroded their ability to be Competent Eaters.

Eating competence is about normal eating

Eating competence provides a framework for understanding what normal eating is for each of us. Eating competence is not about controlling our weight; it is about learning to trust our ability to take care of ourselves with food. Interestingly, the focus remains with “how” we feed ourselves, and the “what” follows more naturally within this trust-based model. Eating competence comprises four distinct areas. 

• Positive Attitudes and Beliefs about food and about eating. Competent eaters are relaxed about food and eating. They look forward to eating and enjoy their food. They aren’t anxious about it, they aren’t preoccupied by it, and they don’t obsess after they have eaten it. They eat and then they move on. 
• Food Acceptance Skills. Competent eaters like a variety of food and enjoy trying new foods and learning to like them…or not. They can “make do” in situations that call for it, eating food they don’t much care for because not every meal has to be the most exciting.
• Internal Regulation Skills. Competent eaters tune in to their bodies when they eat. They know when they are hungry and when they are not. They trust those hunger and fullness cues enough to decide to keep eating or to stop because they are truly satisfied.
• Context Management. Competent eaters plan for feeding themselves. They are reliable and can depend on themselves to have regular meals and snacks in between if they want/need them.

Developing eating competence is a process

The areas of competency are not something one masters in isolation. Further understanding of the process is offered by Satter’s Hierarchy of Food Needs. This hierarchy is a review of eating progression that leads to eating competence. From that framework, the four competencies can be achieved. Think of it as a parallel to Maslow’s Hierarchy of Needs. Before moving up in the hierarchy, one must master the skills within each tier, beginning at the base. To bring ourselves along in that process of building greater trust and competency, we must first understand where we are from within each of the four areas.

Identify your level of eating competence

To get started in identifying your level of eating competence, use Satter’s assessment tool, ecSI 2.0. From there, you can use the Hierarchy of Food Needs to bring yourself along, or work with a qualified professional to begin identifying what steps to take to achieve greater competence with eating. The Satter Eating Competence Model offers a path to emotional and physical wellness. You can learn more about the Satter Eating Competence Model by visiting ellynsatterinstitute.org.

- See more at: http://ellynsatterinstitute.org/fmf/fmf-104-taste-eat-comp.php#sthash.eFiKIz0N.dpuf

QUESTIONS & ANSWERS: Music Therapy for Patients with Anorexia Nervosa

Reprinted from Eating Disorders Review
January/February Volume 27, Number 1
©2016 IAEDP

Q. One of my anorexia nervosa patients, who experiences great anxiety before and after meals, has asked me about music therapy. Is this therapy worthwhile? (T.Z., Birmingham, AL)

A. Anxiety and physical discomfort are typically high, especially early in AN treatment. Music therapy could provide distraction from negative thoughts and feelings, and diminish stress.

Results of a recent pilot study underscore the potentially helpful aspects of this therapy. Drs. Jennifer Bibb, David Castle, and Richard Newton designed a program to test the effectiveness of music therapy versus standard post-meal support in an inpatient eating disorder unit in Victoria, Australia (J Eat Disord. 2015.3:50). 

The participants were 18 inpatients with severe AN who attended a program of two 1-hour music therapy group sessions held following lunch each week. During each session, patients were encouraged to sing and to listen to songs, and to talk about and share music with other. Some patients wrote songs together. The registered music therapist who led the session also took an unconditionally positive approach instead of an instructional or directive one. Members of the group were encouraged to listen to each other and to discuss song lyrics and their own music tastes. During the remaining 3 days of the work week, the participants received standard structured post-meal support therapy, involving a 1-hour group session. During these sessions patients were encouraged to discuss their feelings, and were encouraged to focus on achieving the goals of admission and to participate in group activities such as playing games or art activities. The authors used the Subjective Units of Distress Scale before and after each condition to measure the participants’ responses to the intervention and control sessions.

The results showed that SUDS scores were lower following music therapy than was meal support (5.6 vs. 7.1). Three cautions: first, the study was non-randomized. Second, further work is needed to confirm these preliminary findings. Third, many would consider meals in AN treatment to provide nutrition—but also exposure therapy. For the latter, things that distract or divert attention might diminish distress, but may also dilute the value of the exposure. This last concern must be balanced against the possibility that therapeutic modalities such as music therapy might provide enough relief of distress to allow some patients to persist in treatment when they might otherwise not do so.

Sense of Smell and Its Role in Abnormal Eating Behavior

Olfaction and ghrelin may moderate emotional eating.

Reprinted from Eating Disorders Review
January/February Volume 27, Number 1
©2016 IAEDP

It seemed a fairly straightforward research project: analyzing the effect of olfactory capacity upon abnormal eating behavior. However, after a thorough literature review, Dr. Mohammed A. Islam, of the Hospital of Bellvitage-IDIBELL, Barcelona, and colleagues at other institutions in Spain and the United Kingdom found the answers were not so clear-cut (Front Psychol. 2015. Doi:10.3389/psyg.2015.01431). 

Olfactory capacity has been widely studied in a number of psychiatric disorders, including schizophrenia, depression, and dementia. Researchers have learned that the brain’s reward system is actively involved in eating behavior and reactions to olfactory stimuli. The few studies that have investigated a connection between olfactory capacity and eating disorders have reached conflicting conclusions, perhaps due to lack of sample size and available assessment procedures.

Dr. Islam and colleagues identified 1352 studies of olfaction and disordered eating after searching all electronic databases, including Medline, PubMed, and PsycINFO. Most research centered on patients with anorexia nervosa (AN). After all study criteria were met, only 14 studies remained in the evaluation. 

Results of individual studies varied so widely that the authors could not draw firm conclusions. For example, several studies suggested that patients with AN had a poorer sense of smell; however, a recent study (described later in this article), reached a different conclusion. An analysis of 5 studies of patients with BN, the authors found no differences between patients and the general population. 

A second study of taste and olfactory function

A second recent study from the same institution led by one of the co-authors of the review, evaluated smell and taste dysfunction among females with AN and a group of obese females (Endocrine. 2015 July [Epub ahead of print]). The goal was to explore the interactions between smell/taste capacity, gastric hormones, eating behavior, and BMI. The study group included 239 females, with 64 AN patients and 80 age-matched healthy controls, and 59 obese women and 36 healthy weight, age-matched controls.

Dr. F. Fernández-Aranda and co-workers used the Eating Disorders Inventory-2, the Symptom Checklist 90-revised, and the Dutch Eating Behavior Questionnaire, and also analyzed samples of peptides (ghrelin, peptide YY, and cholecystokinin) taken from the gastrointestinal tract of each participant. The sense of smell was assessed using “Sniffin’ Sticks,” which measure threshold, discrimination, and identification of smells.

Obese subjects and those with AN had distinctly different olfactory profiles and circulating ghrelin levels compared to controls. The researchers found that olfaction was clearly impaired in the obese participants but was increased in those with AN. Taste capacity did not vary between the study groups. Ghrelin levels were significantly decreased in obese subjects and were related to impairment of smell. These results may help to clarify this confusing literature, as they provide data using a well-validated methodology in an adequately sized sample.

Restriction and the Brain in Anorexia Nervosa

The frontal cortex provided some intriguing clues in a recent study.

Reprinted from Eating Disorders Review
January/February Volume 27, Number 1
©2016 IAEDP

It remains puzzling why restrictive eating is so robust among patients with anorexia nervosa (AN), and a better understanding of why this happens may be critical to developing more effective treatment. In a recent study (Nature Neuroscience. 2015. 18: 1571), two groups, individuals with AN and healthy controls, completed a food-choice task in which they reported their preferences among a variety of different higher- and lower-fat and higher- and lower-calorie foods, They also rated the foods for desirability and healthfulness. Using functional magnetic resonance imaging (fMRI), brain activation patterns during food choices were studied. The next day, participants ate an actual test meal at a buffet lunch. 

AN patients preferred low-fat foods

Not surprisingly, people with AN were less likely to choose high-fat meals. Interestingly, the frequency of choosing high-fat meals was related to intake during the buffet lunch. Greater amounts of high-fat foods were chosen when lunch intake was greater. fMRI scans showed that the dorsal striatum was activated when foods were being chosen, as was a portion of the frontal cortex (the ventromedial prefrontal cortex, or VMPFC). The dorsal striatum activation was greater in people with AN, but there were no differences in VMPFC activation between AN patients and controls. A measure of the strength of connection between those two regions showed that there was greater connectivity in people with AN when they were choosing low-fat foods as opposed to high-fat foods. Furthermore, longer differences in connectivity between low- and high-fat choices predicted lower amounts of food intake during the test meal. 

These results may help bring better understanding of the neural basis of changes in mechanisms that may explain restrictive eating in AN.

Another Measure of Personality in Eating Disorders

Results from the Five Factor Model may enhance treatment and improve outcome.

Reprinted from Eating Disorders Review
January/February Volume 27, Number 1
©2016 IAEDP

Perfectionism, impulsivity, neuroticism, and sensation-seeking are all thought to be elements underlying eating disorders. A group at the Karolinska Institute, Stockholm, report that identifying and focusing on eating disorders patients’ personality traits may enhance treatment, address underlying problems, and improve outcome. 

Dr. Johanna Levallius and her colleagues used the Five-Factor Model (FFM) of personality to assess personality traits among 208 non-anorexic eating disorders patients and 94 age-matched controls (J Eat Disord. 2015. 3:3). The FFM delineates five broad traits--extraversion, neuroticism, agreeableness, conscientiousness, and openness to experience--that encompass most differences in personality across individuals. Relatively few studies have examined FFM dimensions in eating disorders patients, according to the authors, and the results of those studies have generally shown high neuroticism, low extraversion, low agreeableness, and low conscientiousness.

The 208 female patients in the study were outpatients who had been treated for bulimia nervosa or eating disorders not otherwise specified (EDNOS) between 2010 and 2013 at the Stockholm Centre for Eating Disorders. Participants had mean scores corresponding to the 95th percentile on the Eating Disorder Examination. The 94 female controls were either university students in various courses or employees from various companies in Stockholm. Patients and controls completed a series of other tests including the Clinical Impairment Assessment and the Structured Eating Disorders Interview. 

Patient profile: less joy, warmth, or love

Overall, the patients with eating disorders differed significantly from controls in that they had higher pervasive negative affectivity vulnerability and less joy, warmth, and love. Patients also reported a tendency to self-doubt, were self-effacing, and lacked trust in others. They also tended to avoid social gatherings and seemed to be less open to exploring new areas, emotions, ideas, or activities. They reported a tendency to procrastination and had impulsivity.

Dr. Levallius and her team suggest the results of their study provide new information on the relationship between eating disorders and the most common personality trait model used today. Personality explained 9% to 25% of the variance in general psychopathology and eating disorder pathology. Patients differed markedly from controls in regards to personality, and certain facets of the patients’ personalities, especially trust, achievement striving, and some areas of neuroticism may be important for better understanding eating disorders. They suggest that future research target the interplay between personality traits and eating disorders.

Online Training for Eating Disorders Professionals

100% of participants felt such training was worthwhile.

Reprinted from Eating Disorders Review
January/February Volume 27, Number 1
©2016 IAEDP

The Australian medical system poses challenges for people seeking eating disorders treatment and for professionals as well. First, most eating disorders treatment is provided by clinicians in general practice, in community clinics or hospitals. And, since most care is only available in urban areas, many patients live far from specialized care. Another element in care for people with EDs is dealing with the lack of empathy and stereotypical images of patients and their families. Such stigma poses a serious barrier to patients seeking and receiving effective treatment. 

Dr. Rachel S. Brownlow and colleagues at the University of Sydney and the University’s Centre for Eating and Dieting Disorders (CEDD) recently had an idea: Why not use the Internet to provide training for healthcare professionals treating people with eating disorders (J Eat Disord. 2015. 3:37)? After all, there is growing evidence that internet-based medical education works well in other areas (J Contin Educ Health Prof. 2004.24:20; Int J Eat Disord. 2013.46:508; JAMA.2005. 294:1043) and has been well accepted by clinicians. 

Finding professionals for the study

The authors recruited participants online, via websites and a list serve. Health professionals from Australia and other countries, including Indonesia and the US, provided informed consent to participate in the study and were given 6 months to complete the online training. During the 6-month period from July 2012 to October 2013, 187 health professionals completed the online training program.

The online program was composed of 5 modules: understanding eating disorders, diagnosis, preparing patients for treatment, treatment, and management. Each 3.5-hr module used text-based psychoeducation, role-playing, interactive exercises and tests, as well as videos of patients with eating disorders and their families. Each of the modules also contained a core curriculum and an in-practice section.

All participants had to complete a pre-training questionnaire and post-training evaluation once they completed the modules. They were also asked a series of 10 questions that explored their ability to assess and treat people with eating disorders; questions also examined the professionals’ attitudes and beliefs about people with an eating disorder. The mean age range of participants was 31 to 40 years of age and most (91.4%) were female. 

The 187 participants completed the entire program and all pre- and post-program questionnaires. Psychologists made up 34.6% of study participants; 22.7% were nurses; 19.5% were dietitians; and 9.2% were social workers. More than half were employed in community health or mental health centers (40.2%), and 62.3% practiced in a metropolitan area. The remaining 36.8% worked in a rural or regional health care center. Nearly half of the participants reported that they didn’t have the necessary skills to great eating disorders patients; another 34% said there were not enough resources obviable to help them adequately treat these tents. Only 2.7% indicated that they did not like treating people with eating disorders because treatment was too time-consuming.

Training changed misconceptions and increased confidence

Overall, the online training program worked very well, according to the authors. Knowledge and skill levels improved, and after completing the online training program, participants also held significantly less stigmatizing beliefs toward the eating disorders and felt more confident in treating eating disorders patients. This applied to all subtypes of eating disorders. Overall, the program earned positive self-report reviews, and 96.2% of respondents indicated that their current clinical practice had improved as a result of finishing the online learning program. The results showed that 98.4% of the respondents felt the online program had met their expectations; 99.5% indicated that the program was relevant or highly relevant to their practice; and 95.8% reported that the program met their needs. All said they would recommend the online learning program to other health professionals.

Reading Memoirs as Part of Therapy: Helpful or Not?

Timing was the key in one Australian study.

Reprinted from Eating Disorders Review
January/February Volume 27, Number 1
©2016 IAEDP

The use of memoirs of individuals struggling to overcome an eating disorder as part of therapy has both fans and opponents. Does the shared information, including negative aspects of the disorders, help or harm an individual’s efforts to recover? In one early study, 75% of anorexia nervosa (AN) patients mentioned feeling hopeless, and felt that life without their AN might be impossible (Commun Monogr. 1992. 59:330-338). In another study, patients with bulimia nervosa (BN) were most likely to seek treatment after receiving messages emphasizing both the health consequences and the effectiveness of treatment (J Behav Med. 2000. 23:37).

The positive effect was greater during recovery

Correct timing makes all the difference in the use of memoirs as part of eating disorders therapy, according to two psychologists at Macquarie University, Sydney, Australia (J Nerv Ment Dis. 2015. 203:591). 

The researchers conducted their study using an anonymous online questionnaire. Participants were recruited through an ad on a web page of a Sydney-based ED organization. The 24 women were between 16 and 47 years of age; 11 had AN only, 5 had BN only, and 8 had multiple ED diagnoses. Participants were asked a series of questions about the effect of reading eating disorders memoirs, including the influence the memoirs had upon their own course of the disorder.

The authors found that as individuals described being more motivated to recover and moved toward recovery, their focus shifted away from the food or weight aspects of the memoir, and they more closely emulated the protagonist’s recovery journey. This contrasted with individuals exposed to memoirs before, or during their illness, who experiencing negative consequences that included emulating and triggering disordered behaviors.

The results of this qualitative study emphasize that reading memoirs may be deleterious prior to entering active recovery, but useful as recovery progresses.

Intimate Partner Violence Among Women with Eating Disorders

Two conditions increased the risk in two studies.

Reprinted from Eating Disorders Review
January/February Volume 27, Number 1
©2016 IAEDP

The Centers for Disease Control and Prevention defines intimate partner violence, or IPV, as physical, sexual, or psychological harm by a current or former spouse or partner. IPV currently affects 44% of American women. By contrast, men are far more likely to experience violent acts from strangers or acquaintances than by an intimate partner (World Health Organization. 2002). 

Two recent studies have highlighted the increased risk among women with eating disorders during the perinatal period and among women with poor social support. 

Poor social support increased risk

Lack of social support increases the risk of IPV, according to results of a recent Penn State College of Medicine study (Int J Women’s Health. 2015. 7:919). Dana K. Schirk and colleagues examined the frequency of risk of eating disorders in adult women exposed to intimate partner violence and then assessed the effect of social support on the risk of disordered eating among these women. 

The HARK Questionnaire Have you been humiliated or emotionally abused in other ways by your partner or ex-partner? Have you ever been afraid of your partner or ex-partner? Have you ever been raped or forced to have any kind of sexual activity by your partner or ex-partner? Have you ever been kicked, hit, slapped, or otherwise physically hurt by your partner or ex-partner?

The women, who were from 18 to 64 years of age, completed a screening survey examining health, demographics, and IPV exposure, as measured by the Humiliation-Afraid-Rape-Kick (HARK) screen. This 4-question survey (see table) accurately identifies women who are experiencing IPV. For this study the survey was modified to ask about both IPV exposure in the past 12 months and lifetime exposure. 

After the screening questions were completed, women were invited to leave their contact information if they wished to participate further. To protect the participants, safety and confidentiality steps were put in place, and the women were also given referral information for services for general health, domestic violence, mental health, substance abuse, and eating disorders. Individual social support was measured with the MOS Social Support Survey, which contains 19 questions about emotional informal support, tangible support, and social interactions. Risk of ED was assessed during the Eating Disorders Screen for Primary Care (ESP), a five-question screen.

When the researchers examined the risk of eating disorders among the 302 women with lifetime IPV, 14% were found to be at high risk, 42% at moderate risk, and 44% at low risk. Among women exposed to abuse, low social support was significantly associated with an increased risk of eating disorders, suggesting that social support may help protect women dealing with IPV against developing an eating disorder, if the women take advantage of the support. 

IPV during the perinatal period

Mothers with eating disorders and their children may be especially vulnerable to negative effects from IPV, according to Dr. Radha Kothari and a team in the UK (Int J Eat Disord. 2015. 48:727). In the team’s recent study of women participating in the Avon Longitudinal Study of Parents and Children, three groups were evaluated: women with lifetime histories of eating disorders (n=174), those without pregnancy shape and weight concerns and/or purging behaviors (n=189), and women with no history of eating disorders (n=8723).

Just as they had hypothesized, women with a lifetime history of eating disorders were more likely to have experienced physical IPV during the perinatal period (but not the postnatal) period and more likely to report emotional IPV. Rates of IVP were high: physical violence affected from 9.6% to 14.0% of women, while the incidence of emotional violence was even higher, up to 28%.

YouTube: Striking Back at Pro-ana Communities

A Finnish group used a hi-tech approach to evaluate pro- and anti-pro-ana video viewers.

Reprinted from Eating Disorders Review
January/February Volume 27, Number 1
©2016 IAEDP

Pro-anorexia (pro-ana) online communities have aroused concern because they are readily accessible and promote adoption of an illness with high morbidity and mortality. Moreover, they are very frequently visited: for example, in the EU Kids Online survey, 10% of children 9 to 16 years old had viewed such sites (Livingstone et al, London: LSE, 2011).

But, what about the anti-pro-ana online sites and videos? Are they equally effective? Dr. Atte Oksanen and colleagues at two universities in Finland teamed with the Swiss Federal Institute of Technology (ETH Zurich) in Zurich, Switzerland, to study emotional reactions to pro- and anti-pro-ana online content using a technique called sentiment analysis (J Med Internet Res. 2015. 17:e256)

Pro-ana communities are found on various social media sites, including Facebook, YouTube, Twitter, Instagram, Pinterest, and Flickr. YouTube is a social media mega-star that reaches more than 1 billion viewers, and 300 hours of video are uploaded to it every minute. YouTube is also the most popular social media site that uses publicly available videos and comments; thus, its easy availability and popularity make it a significant source for information about anorexia. Dr. Oksanen and colleagues used one of the features of YouTube, the feedback by viewers of videos to either “like” or “dislike” the video or to post a comment in the comment section below the video. Any registered YouTube user can use this function. The authors selected YouTubebecause users commonly engaged in active discussion by expressing either positive or negative sentiments in their messages, so that, for example, anti-pro-anorexia content may challenge pro-ana content. The researchers asked three research questions concerning the characteristics of the pro-anorexia and anti-anorexia videos and video uploaders: the strength of the positive and negative emotional feedback, and whether uploading time or video length was related to comments.

From October 15 to 29, 2014, the authors retrieved YouTube videos by searching two terms, “pro-ana” and “anti pro-ana.” They also used an automatic web crawler using the YouTube Data Application Programming Interface, a technique used to measure video popularity during political campaigns. Video comments were assessed with the SentiStrength automatic sentiment tool, which uses an algorithm to estimate the sentiment content based on a list of approximately 3,000 sentiment words and grammatical categories. 

Anti-pro-anorexia videos were more popular among viewers

The authors collected a large amount of data, including 133 pro-ana videos and 262 anti-pro-ana videos. These 395 videos drew a total of 12,161 comments from 7,903 commenters. Only 1% of viewers commented on both types of videos. Ninety-two percent of the video uploaders were female and the rest qualified themselves as unknown or “other” genders. The viewers came from 13 different countries; 44% came from the US, but the authors reported that the country of origin had no impact on the comments. The two types of videos had more than 6 million total views, and a positive finding was that the anti-pro-ana videos were more popular than the pro-ana videos.

Unlike an earlier Facebook study in which a pro-anorexia group was found to be more active and better organized than an anti-pro-ana group (Eat Weight Disord. 2013. 18:413), in their study the authors found that pro-anti-ana videos were more popular among viewers, received more video “likes,” and were commented upon more positively. The difference between these two studies may be traced to the type of social media examined. YouTube is a publicly available global platform for distributing video content; with Facebook an individual often sets up the group and thus has more power and means to manage what is said and distributed within that group and how it is structured. The content is also commonly available only to those users who join the “group.” In contrast, YouTube material is available to all users and can spread virally to other YouTube users and other social media. 

The results clearly show that the pro-ana community has online opponents, at least within the YouTube community. The anti-pro-ana videos were more popular and produced more positive feedback than did the videos promoting anorexia. Study limitations included the use of only one online community and the fact that all comments analyzed were limited to English. However, the results should be viewed as a source of encouragement in the efforts against pro-ana sites.

UPDATE: Calming Fears of Gaining Excess Weight after Recovery

Reprinted from Eating Disorders Review
January/February Volume 27, Number 1
©2016 IAEDP

Often patients recovering from an eating disorder predict they will become obese over the next decade (“I’m scared I’ll get fat”). Results of a recent follow-up study led by Helen B. Murray and colleagues at Harvard Medical School and Northeastern University, Boston, showed that after 22 years, most former patients had body mass indexes (BMI, kg/m2) in the normal range. The results were reported at the 2015 International Conference on Eating Disorders in Boston, MA. Two cohorts were analyzed: Wave 1, from 1987 to 1991 involved 225 patients followed for 10 years, who had DSM-IV diagnoses of anorexia nervosa and bulimia nervosa. Wave 2 involved 175 of the patients followed from 2011 to 2013. The authors also reported that the rates of change in BMI are faster in the earlier years after recovery, and that short-term changes predict long-term return to normal BMIs. To calm a patient’s fear of excess weight gain after recovery, the authors suggest helping patients focus on long-term results. Learning about normal long- and short-term weight changes will help them have reasonable expectations about their weight.

Improving Coverage for Eating Disorders: A Long, Slow Process

Reprinted from Eating Disorders Review
January/February Volume 27, Number 1
©2016 IAEDP

As Eating Disorders Awareness Week 2016 approaches, a little progress has been made in the effort to improve insurance coverage for patients with eating disorders (see also the May/June 2014 issue of EDR on breaking down barriers to eating disorders treatment).

One bright spot in 2015 was passage of Missouri’s Senate Bill 145, which amended a standing state law by adding a new section relating to the treatment of eating disorders. While other states may have vague laws requiring treatment of eating disorders, Missouri’s is the first state to dictate that treatment for eating disorders must be covered by insurance companies, according to Kerry Dolan, who directs the legal advocacy program of the National Eating Disorders Association.

This action followed a six-year battle to get more comprehensive coverage for eating disorders treatment by recently retired Missouri House Representative Rick Stream. Stream’s daughter Katie died in 1995 after a long battle with bulimia nervosa; her potassium levels were so low that her heart stopped. Citizen advocate Annie Seal worked on the bill for 7 years. 

When Missouri Governor Jay Nixon signed the bill in August last year, Missouri became the first state in the nation to establish specific parameters that insurance companies must follow under the Patient Protection and Affordable Care Act, or ACA. Missouri’s new law is the first in the country to fully define treatment that must be covered according to the “Practice Guideline for the Treatment of Patients with Eating Disorders, adopted by the American Psychiatric Association, which outlines medical and psychological care. It is not a mandate but defines coverage under Missouri’s current mental health parity law. One important portion of the new law is that weight will no longer be used as the sole criterion for approving treatment. It replaces the edict that insurers in the state cover treatment only when an individual reaches 80% of his or her ideal body weight. This percentage has been unhelpful for anorexic patients and more so for those with bulimia nervosa, who can maintain a healthy weight despite being unhealthy.

One Idea: A National Benchmark Plan

Proponents of improved health coverage for patients with eating disorders have endorsed adoption of a national benchmark plan that would address the inequalities currently existing in access to lifesaving treatment for people with eating disorders.

Under the current ACA, 10 states now require coverage for anorexia nervosa and bulimia nervosa on the same basis as other mental healthcare conditions. Eighteen states only require coverage for eating disorder treatment within individual health plans, such as plans for state employees and group health plans. The remaining states have no laws requiring coverage of eating disorders. The ACA also provided three positive steps: (1) people with preexisting conditions can no longer be denied coverage for care. Before this, many insurance companies standardly denied coverage to people with eating disorders, classifying their conditions as preexisting. (2) Patients can remain on their parents’ insurance policies until they reach age 26, which is a real boon since so many cases affect people in their teens and 20s. (3) More people may qualify for Expanded Medicaid (now available in 28 states).

Sarah Hewitt, JD, has proposed that the inequalities in eating disorder coverage can be remedied through the adoption of a national Benchmark system. The Health and Human Services Department declined to define mental health care as an “Essential Health Benefit” (EHB), shifting the burden to the states to set individual benchmarks for care. However, this year they will be required to review this decision, taking into account events and consequences during 2014 and 2015 (Law and Inequality 2013. 31: 411). Attorney Hewitt contends that significantly higher healthcare costs result when insurers delay or refuse coverage to people with eating disorders. 

The case of Danielle Moles illustrates this principle. Long-term care in a residential psychiatric facility was prescribed after Moles was diagnosed with anorexia nervosa. Her eating disorder had progressed, leading to permanent damage to her digestive system, a miscarriage, a stress fracture in one foot and periodic seizures. Her insurer insisted that her treatment was not covered by her policy and only agreed to pay costs after delaying a decision for several years. By the time coverage began, Moles’ condition had significantly worsened. Had coverage began earlier, it was found that her treatment would have cost the insurer roughly $80,000 instead of the $500,000 to $750,000 they eventually paid. The patient estimated that she had spent $150,000 out of packet for her4 care. (Michael Ollove, Parity for Behavioral Health Coverage Delayed by Lack of Federal Rules; http:/www.pewstates.org/projects/stateline/headlines/parity-for-behavioral-health-coverage-delayed-by-lack-of-federal-rules-85899433333) 

Including all DSM-5 Recognized Eating Disorders

One step the Department of Health and Human Services could take would be to include all DSM-5 recognized eating disorders, including ED-NOS, into the category of “mental illness” in the EHB. As Hewitt indicates, such a national benchmark would finally guarantee that sufferers of all types of eating disorders received coverage for the long-term and comprehensive care needed for their recovery.

(Note: At the 2016 iaedp Symposium on Amelia Island, FL, Los Angeles-based attorney and eating disorders advocate Lisa S. Kantor, Esq. will present a preconference training session on “Advocating for Patients in the Current Legal and Regulatory Landscape.” The session is scheduled on February 17, from 9am to 12 noon.)

Masculine Norms and Internalization of Body Ideals on Body Image

Lina Ricciardelli, School of PsychologyDeakin University, Australia

Increasingly during the last 10 years, researchers and clinicians have noted the importance that men place on their body image. While many view this as a new phenomenon, the evidence shows that body ideals for men have been valued throughout the centuries and since ancient times (Ricciardelli & Williams, 2012). The main and current body ideal for men in Western cultures is leanness and muscularity but thinness, attractiveness, youthfulness, and fitness are also valued. On the other hand, Eastern cultures traditionally place less importance on the physical body and a higher value on the pursuit of intelligence, justice, purity and celibacy, integrity, and courage. However, there is some evidence that this is changing as studies have shown that non-European men living in Western countries are more at risk of body image problems, disordered eating, and other related health risks behaviors (Ricciardelli, McCabe, Williams, & Thompson, 2007). These differences may in part reflect the changing status quo and power relations for men and/or the higher level of social isolation of men in minority groups when compared to the dominant cultural group(s). 

Masculine norms and the internalization of body ideals in the media are central sociocultural factors for understanding the importance of body image among men (De Jesus et al., 2015). Masculine norms reflect and reinforce social and cultural expectations for men to conform to particular behaviors and attitudes. In the words of Thompson and Pleck (1986, p. 53) “they prescribe and proscribe what men should feel and do”. Some of the main masculine norms found among men from Western countries such as the US, UK, and Australia, are the pursuit of winning, power over women, and heterosexual self-presentation.  These masculine norms have been found to be related to the internalization of body ideals among men, and typically mirror the content of television and films, where there is an overemphasis on competition and winning, the objectification of women, and an underrepresentation of gay men (De Jesus et al., 2015). Many men internalize these ideals and values, which have then been found to be associated with a higher drive for muscularity and leanness. The drive for muscularity involves a preoccupation with attaining large muscles, whereas the drive for leanness places the focus on attaining a body with well-defined muscles and low fat.

More research is now needed to understand the direction of the above relationships. All the research to date has been cross-sectional so we can not determine whether masculine norms precede or follow internalization of body ideals and body image concerns. Additionally, the majority of studies have been conducted with men who identify as White/European, thus the generalizability of the findings to other ethnic and cultural backgrounds is not possible.

Prevention work is also needed to assist men reject rigid notions of masculinity which highlight the need for power and dominance. The development of broader and healthier notions of masculinity that connect men with other men, family and intimate partners, and that promote rationality, integrity, and free thought, is essential for well-being (de visser & Smith, 2007).

The Attuned Representation of Self (ARMS): 10 Practices for Incorporating Positive Body Image into the Treatment of Eating Disorders

Catherine Cook-Cottone, Ph.D.

Central to each of the Eating Disorders (EDs) is an individual’s relationship to his or her body. That is, the fundamental organizing feature is a disturbance in how the body is experienced, fed, cared for, and accepted. Research has documented a complex etiological course that includes genetic, physiological, familial, and relational influences (Cook-Cottone, 2015a). Central, for many, is the loss of an embodied sense of self (Cook-Cottone, 2015b). Accordingly, along with the other risk factors it is believed that our way of being in today’s culture can lead to risk, and for some disorder. In today’s technological, social media, and image-focused culture, it can be easy to simply ignore, discount, or minimize the importance of the mind and body connection. Through daily implicit an explicit choices, we are all at-risk for travelling down an objectifying pathway upon which an attuned mind and body connection can be lost. Once we are on this path, engagement with the body occurs within the framework of its role in the creation of a manufactured image, edited, and engineered to appear attractive according to current ideals (e.g., thinness, leanness, or with Kardashian/Nicki Minaj curves). Within the unremitting flow of social media “likes”, edits, posts, the casual flips through fashion magazine pages, and hours viewing video screens filled with edited and stylized productions, our sense of who we are as embodied beings fades from awareness. Our individual and perhaps collective consciousness shifts. The body and its corporal needs are split apart from the conceptual image of self so many of us are working to manage. Nevertheless, no matter how far we go down the constructed, idealized image path, the body demands to be fed, exercised, nurtured, and integrated into daily life. In this divide, lies the problem and a big part of the answer. 

The split between actual needs and an idealized, manufactured image can become impossible to effectively negotiate. The Attuned Representational Model of Self (ARMS) provides a model for how to get back to a centered, functional, and embodied experience of the self. It is a road map for awareness and self-care (Cook-Cottone, 2015a, 2015b). Attunement and self-care are viewed as forms of self-love. In essence, the ARMS process reflects the caring for oneself in an active practice of loving-kindness. Notably, this shift toward personal ownership of self-care and body appreciation is not new as an approach to eating disorders. You are encouraged to read Kim Chernin’s influential work on eating disorders detailed in, “The Hungry Self: Women, Eating and Identity,” and “The Woman Who Gave Birth to her Mother: Tales of Transformation in Women’s Lives” (Chernin, 1985; 1998). You will see that finding a positive path to recovery that integrates the whole self and involves active self-care has been a long time coming. 

Attuned Representational of Model of Self (ARMS)

According to the ARMS (see Figure 1), the self is an active construction, a representation of the needs and relational dynamics of the inner and outer aspects of living (Cook-Cottone, 2006, 2015a, 2015b). The inner aspects of self include the physiological (i.e., body), the emotional, (i.e., the feeling), and the cognitive (i.e., thinking) domains. The outer aspects of self include the microsystem (i.e., family and close friends), exosystem (i.e., community), and macrosystem (i.e., culture).  How individuals perceive and experience their bodies involves an ongoing interaction among the aspects of self (Cook-Cottone, 2015b; Wood-Barcalow et al., 2010). The two self-systems (i.e., internal and external) are interconnected by attunement and self-care (Cook-Cottone, 2006). Based on Daniel Siegel’s work in the field of interpersonal neurobiology, attunement is defined as a reciprocal process of mutual influence and co-regulation (Siegel, 1999, 2007). The active construction of the self in shown in the center. (See Figure 1) It is the embodiment of the ongoing behavioral patterns that create and maintain attunement within an individual’s inner and outer lives (Cook-Cottone, 2015a, 2015b). As illustrated by the ARMs, effective functioning of the self goes beyond self as subject or object (Cook-Cottone, 2015b). Healthy, embodied self-regulation occurs when an individual is able to maintain an awareness and maintenance of the needs of the inner aspects of self (i.e., physiological, emotional, and cognitive), while engaging effectively within the context of family, community, and culture (see Cook-Cottone, 2006, 2015a, 2015b; Seligman, 2011). See Cook-Cottone (2006, 2015a; 2015b) for detailed explanations of the internal and external influences that lead to and maintain eating disorders. 

Figure 1: The Attuned Representational Model of Self.
Adapted from Cook-Cottone, 2006, 2015a, 2015b

In the case of eating disorder risk, influences from the internal system (i.e., cognitive, emotional, and physiological) and/or the external system (i.e., family, community, or culture) individual, collectively, and/or cumulatively contribute to misattunement and self-care, which fails to develop or is disrupted (e.g., Marcus & Levine, 2004; Cook-Cottone, 2006, 2015a, 2015b). In deference to external pressures and ideals, those at risk may objectify, invalidate, or see the internal aspects of the authentic, inner self as unacceptable (Cook-Cottone, 2006, 2015a, 2015b; Tylka & Augustus-Horvath, 2011). When missattunement, objectification, and invalidation occur, the authentic, inner self is often abandoned or ignored (Reindl, 2002; Tiggemann & Williams 2012). The disordered representational self is constructed to regain, at least affectedly, the individual’s attunement with his or her external, ecological context (Cook-Cottone, 2006; Cook-Cottone, 2015a, 2015b; Reindl, 2002; Tiggemann & Williams 2012; See Figure 2: The Disordered Representational Self). The internal aspects of self (i.e., thoughts, feelings, and physiological needs) are left without representation through action or voice (Chernin, 1985; Cook-Cottone 2015a). Eating disordered behaviors, thoughts, and motivations take on a critical role in the organization and functioning of the self. The internal aspects of self become attuned to the experience of eating disorder symptoms in a self-perpetuating, self-reinforcing disorder (Cook-Cottone, 2006). As a tangible symbol of the self, the body becomes something to control, change, and bring into alignment with cultural or media ideals. In chronic, clinical cases, the eating disorder becomes the central organizing feature of the individual’s life, his or her identity (e.g., Arnold, 2004; Cook-Cottone, 2006; Cook-Cottone, 2015a, 2015b; Reindl, 2002).

Figure 2: The Disordered Representational Self.Adapted from Cook-Cottone, 2006, 2015a, 2015b

A Solutogenic Approach to Eating Disorders

Taking a salutogenic approach, patients can work on their symptoms, relationships, and coping, as well as strive toward a life that positive psychologists would describe as flourishing (Cook-Cottone, 2015b; Keys, 2007; Seligman, 2011; Tylka, 2012). Full recovery, or flourishing, is viewed as an awareness of, and commitment to, an attuned inner and outer life in which internal needs are met and the external demands are negotiated without compromise to physical or mental health (Cook-Cottone, 2006, 2015a, 2015b; Keys, 2007; Seligman, 2011). For many years, treatment providers have appropriately focused on the physical, cognitive behavioral, and familial aspects of treatment. These approaches often include body image work to reduce body dissatisfaction and distorted body image (see Cash, 2008). From the solutogenic perspective, future directions in ED treatments can build on current treatment models that focus on reducing symptoms and move toward the possibility of creating a positive, healthy, and thriving relationship with the body (Cook-Cottone, 2015b). 

Distinctly, the ARMS approach holds that those struggling with disordered eating can hope for a recovery that is more than a battle to avoid symptoms and tolerate, or ignore, what they perceive as their less-than-perfect bodies (Antonovsky, 1978; Cook-Cottone, 2015b; Frisen & Holmqvist, 2010; Seligman, 2011; Wood-Barclow, Tylka, & Augustus-Horvath, 2010). As an augmentation to traditional therapeutic goals, individuals with EDs can work to nurture a healthy relationship with the body through the development of positive body image and an active practice of self-care (Cook-Cottone 2015b). Further, there is no to need to wait until eating and body-related symptoms have remediated, as safe, positive practices, embracing a positive body image and self-care can begin during any phase of treatment. For more on the framework for a salutogenic approach to flourishing and well-being, see Keys (2007) and Seligman (2011).

What is Positive Body Image? 

According to the experts, positive body image features: inner positivity, body appreciation, body acceptance and love, a broad conceptualization of beauty, and active filtering of information in a body protective manner, and respect for the body (see Avalos, Tylka, & Wood-Barcalow, 2005; Tylka, 2012; Wood-Barcalow et al., 2010). A growing field of research has shown that positive body image is distinct from body dissatisfaction and is uniquely associated with well-being (Avalos et al., 2005; Tylka, 2012; Tylka & Wood-Barcalow, 2015). It is important to acknowledge that to those who are struggling with eating disorders and a strong, negative body image, the idea of a positive body image can seem unrealistically ambitious (Cook-Cottone, 2015b). The gap between what the patient is feeling in the current moment and where the therapist would like them to be can feel too large. Patients need to have an embodied experience of a winnable gap. It is critical to follow a process that allows positive body image to be experienced as accessible and possible. That is, the process must be broken down into small, actionable steps. Further, given the medical risk inherent in eating disorder symptoms, it is important to focus on body image within the context of supporting a patient’s ability to self-regulate, address life-threatening eating disordered behaviors, and increase effectiveness within his or her relationships and environment (Cook-Cottone, 2015b).

Growing toward a healthy embodied self involves active engagement that goes beyond rather than thinking about the body differently (Cook-Cottone, 2015b). As first explicated in the article, “Incorporating Positive Body Image into the Treatment of Eating Disorders:  A Model for Attunement and Mindful Self-Care,” moving a patient toward flourishing is a two-step process (Cook-Cottone, 2015b). Flourishing requires both awareness and action. That is, the flourishing inherent in positive body image necessitates the embodiment of two ways of being: (a) having an awareness of the internal and external aspects of self, and (b) engaging in mindful self-care (Cook-Cottone, 2015b). Mindful self-care behaviors bring awareness and commitment to action and attitude matters. Within the context of mindful self-care, patients attend to the needs of the self with loving-kindness (Cook-Cottone, 2015a). For patients in recovery, this requires a shift from negative, judgmental, over concern with the body toward a stance of loving self-care that honors the inherent need for mind and body connection. In this way, recovery is filled with self-compassion and an appreciation for the living, breathing, functioning physical self (Cook-Cottone, 2006, 2015a, 2015b; Keys, 2007; Tylka, 2012; Tylka, Russell, & Neal, 2015). In the ARMS method, patients are coached to use self-care tools to both protect the self from stress and unhealthy external standards and demands, as well as to assess and choose environmental conditions that enhance well-being and intentionally engage in health promoting behaviors (e.g., intuitive eating, exercise, and yoga; Cook-Cottone et al., 2013; Cook-Cottone, 2015a, 2015b). 

From Eating Disorder to Flourishing: Embodiment of Attunement and Self-Care

It is important to reinforce engagement in sound treatment that includes a team with training and experience treating individuals with eating disorders (i.e., a medical doctor, nutritionist, and mental health professional; Cook-Cottone 2105b) and that the patient is receiving the appropriate level of care (i.e., outpatient, day treatment, or inpatient care). By adding the ARMS approach, there are several practices that can help cultivate an inner and outer attunement that facilitates an appreciation and care for the body, as well as supports the body’s role in the environment (i.e., functions). These self-care tools bolster inner strength and promote resilience (Cook-Cottone, 2015b). The 10 practices are listed here as a short review. For an extended discussion with empirical support for each practice see Cook-Cottone (2015b). 

Practice #1: Body Acceptance

Body acceptance and love involves a comfort with the body exactly as it is (Frisén & Holmqvist, 2010; Tylka, 2012). It involves an attunement of the inner aspects of self (i.e., thought, feelings, and body) via cultivation of a cognitive schema for the body that accepts all shapes, sizes, and unique qualities, as well as an emotional valance of loving-kindness toward the body (Cook-Cottone, 2015b). In this way of viewing the body, it is understood that no one can be perfect and that pursuit of this “illusory ideal” can be physically and mentally harmful (Tylka, 2012, p. 659; Wood-Barcalow et al., 2010). For a wonderful “in treatment” approach use Thomas Cash’s (2008) book, The Body Image Workbook: An Eight-Step Program for Learning to Like Your Looks. The text begins with a set of assessments that can help bring patients to an awareness of their body image challenges. 

Practice #2: Body Appreciation

Body appreciation is the practice of gratitude for the function, health, and aspects of the body (Tylka, 2012: Frisen & Holmqvist, 2010; Wood-Barcalow et al., 2010). Reflecting attunement between the body and its role in the environment, the body is valued for its inherent strengths and its ability to function within the environment rather than its appearance (Frisen & Holmqvist, 2010). This includes thinking about and focusing on the body, and noticing and praising the body for what it is able to do rather than critiquing its appearance (e.g., “My arms are so strong;” Tylka, 2012; Tylka & Augustus-Horvath 2011). At the cognitive and emotional levels, there is an appreciation of all shapes and sizes, ethnicities, skins tones, types and shades of hair, skin art, scars, mobility, disability, and genetic differences (Cook-Cottone, 2015b). 

Practice #3: Self-Compassion

According to Neff (2003), self-compassion is the practice of responding to challenges and personal threats by treating oneself with nonjudgmental understanding and kindness, acknowledging distress, and realizing that pain and struggle are part of the universal human experience. Helping create attunement among the inner aspects of self, self-compassion practice involves a cognitive reframing of challenge and threat as well as an emotional shift toward loving-kindness rather than frustration or fear. Self-compassion has been found to buffer the associations from media-thinness related pressure to disordered eating and thin ideal internalization (see Tylka, Russell, & Neal, 2015). 

Practice #4: Spirituality 

Spirituality can play a substantial role in positive body image. It is theorized that those with positive body image hold a belief that there is a higher power, or an order in the universe, that accepts them unconditionally (Tylka, 2012). Spirituality integrates each of the internal aspects of self (i.e., the thinking, feeling, and physical) through passionately held beliefs and active practices (Cook-Cottone, 2015b). The body is seen as a temple for the spiritual self that must be maintained and cared for in order for an individual’s spiritual life to flourish (Tylka, 2012). 

Practice #5: Addressing Basic Physical Needs

In contrast to making choices based on appearance or unrealistic external ideals or standards, health promoting self-care behaviors support positive body image (Wood-Barcalow et al., 2010). This involves listening to the body’s needs and choosing behaviors based on the needs of the body (Cook-Cottone, 2015b). These practices help to bolster a connection with the inner aspects of self and include addressing basic physical needs (i.e., medical care, nutrition, and hydration), exercise for health and enjoyment, and adaptive methods for stress relief and body care (Cook-Cottone, 2015b).

Practice #6: Intuitive Eating

In early to middle recovery, intuitive eating may be more aspirational as the patient works to adhere to meal plans and reconnect with his or her body (Cook-Cottone, 2015b). Clinically, a meal plan offers the patient safety and security from the possible indecision and ambiguity that can be associated with intuitive eating (Cook-Cottone, 2015b). Intuitive eating can be presented as a possibility once those with EDs are able to detect their hunger and satiety cues (Tribole & Resch, 2012). It is important to know that there, quite possibly, can be a time when eating is enjoyable, connected to the body’s needs and wants, and involves a trust in the body for knowing what it needs. 

Practice #7: Healthy Exercise

Research has emerged that suggests that exercise for health and enjoyment may be associated with positive body image (Frisen & Holmqvist, 2010). For example, adolescents with high levels of body satisfaction tend to view exercise as a natural and important part of life, as joyful, and health promoting (Frisen & Holmqvist, 2010). How one exercises matters. It is important to note individuals with positive body image do not tend to describe exercise as a way to lose weight or control the size or shape of the body and that they slow down or rest when they need to (Wood-Barcalow et al., 2010). Further, having health-related, rather than appearance-focused reasons for exercise may be protective (Homan & Tylka, 2014; O’Hara, Cox, & Amorose, 2014) and help. Calogero and Pedrotty (2004) found that mindful exercise improved outcomes for those with AN. Yogic approaches may be especially beneficial for those with eating disorders (e.g., Carei, Fyfe-Johnson, Beuner, & Brown, 2010; Cook-Cottone, 2015a; Cook-Cottone, Beck, & Kane, 2008; Klein & Cook-Cottone, 2013). 

Practice #8: Appreciating the Function of the Body

Appreciating the body for its functions rather than its appearance can be protective (Cook-Cottone & Phelps, 2003). Physical self-esteem, or feeling good about what your body can accomplish is inversely related to body dissatisfaction, or being dissatisfied with the size and shape of your body (Cook-Cottone & Phelps, 2003). 

Practice #9: Actively Filter Messages

The ability to filter messages from others and the media in a body protective manner may be associated with maintenance of a positive body image (Tylka, 2012; Wood-Barcalow et al., 2010). Those with a positive body image seem to have a cognitive filter that screens information to determine if it is accepted or rejected (Tylka, 2012; Wood-Barcalow et al., 2010). Information that is assessed as negative or harmful to body image is rejected (e.g., weight-related comments; photo-shopped or idealized images of beauty, femininity, and masculinity). According to Tylka (2012), this process includes the affirmation that filtering information in this way creates more time and energy to focus on the important aspects of life. 

Practice #10: Body Positive Friends

Those who have a positive body image secure and maintain relationships with individuals who unconditionally accept their bodies and the bodies of others and do not hold an idealized version of the body as important (Cook-Cottone, 2015b). Specifically, those with a positive body image maintain friendships with others who are accepting of themselves (Wood-Barcalow et al., 2010). Within the context of these relationships, an individual feels valued and loved based on his or her inner qualities such as creativity, personality, and intellect (Tylka, 2012). Further, in body positive relationships, appearance is not frequently mentioned (Frisen & Holmqvist, 2010). If appearance is mentioned, it is related to the creative, interchangeable aspects (e.g., clothes, jewelry, or hairstyle; Tylka, 2012). 

Conclusions

Cultivating mental health goes beyond ameliorating symptoms and asks for more than languishing (Keys, 2007; Seligman, 2011). For those struggling with eating disorders, flourishing and well-being should be considered as possibilities (Cook-Cottone, 2015b). This includes engaging in mind and body attunement and effective, mindful self-care while negotiating environmental demands and supports. The ARMS approach posits that positive body image can play a powerful role in the treatment of eating disorders as patients go beyond traditional therapeutic goals to nurture a healthy relationship with the body and others (Cook-Cottone, 2015b). Through awareness and active practice, patients recovering from eating disorders can potentially experience positive body image along with mental and physical health. They can flourish. 

For more on positive body image and self-care see the full article in Cook-Cottone, (2015b).  Further, see Mindfulness and Yoga for Self-Regulation: A Primer for Mental Health Professionals (Cook-Cottone, 2015a) for a detailed description of the Mindful Self-Care Scale.