“Is it Vegetarianism or Disordered Eating?”

By Malak Saddy RDN, LD

The role that vegetarianism can play in one’s eating disorder can frequently be multifaceted and complex. As eating disorder providers, we know that dieting or the elimination of food groups can increase the risks of developing an eating disorder or hinder one’s recovery. Not all vegetarians have eating disorders, but for those who do, it can strongly enable their distorted thoughts and behaviors. Time and again, I have clients who come in expressing a desire to transition to a vegetarian lifestyle or some who already have adopted this lifestyle. My instinctive thought is not to engage in a power struggle but to engage in curiosity. It can be a slippery slope navigating what came first, the eating disorder or the vegetarianism.

There is limited research about the correlation between eating disorders and vegetarianism, but it most certainly has a synchrony in many cases.  In this article, I will illuminate what I have discerned and what I’ve witnessed while working as a dietitian specializing with those with eating disorders.

Vegetarianism, by definition, is the practice of abstaining from the consumption of meat (red meat, poultry, seafood, and the flesh of any other animal) and may also include abstention from by-products of animal slaughter. Vegetarianism may be adopted for various reasons. It can be related to the person’s health values, religious beliefs, ethical concerns for animals, or the objection to the practice of factory farming animals and growth hormones. With a plethora of food and health documentaries, finding a reason to immerse oneself in this style of living is much more accessible and straightforward to hit upon and carry out. Unfortunately, with so many of our vulnerable clients, their distortions become normalized within our “thin-ideal” society. Teenagers especially, are at a higher risk of having body image issues and becoming vegetarians for the wrong reasons. Their desire to separate from their parents while asserting themselves and expressing their individuality can be manifested by following a vegetarian lifestyle. Choosing to become vegetarian, as a teenager can be the first “informed adult decision” they make. Having this label can set them apart from their parents’ generation, while still coexisting with them. A perfect cover up for eating disorders.

A study published in the Journal of Academy of Nutrition and Dietetics found that women suffering from an eating disorder are four times more likely to be vegetarian than women without eating disorders and more that 52% of women with a history of eating disorders had been vegetarians at some point in their lives. Another study found that 61% of ED individuals who had been vegetarians believe there was a correlation between their choice of vegetarianism and their eating disorder.

An honest conversation and exploration of the motives behind eliminating animal products from one’s diet is a fundamental aspect in recovery. It is of course important to remove the competition from the conversation. Continued support and education are necessary in guiding these clients. As clinicians, we must challenge the mindset of having the label of “a vegetarian” and encourage these clients to perhaps take a break or pause from it, until they are fully recovered. We must educate them about the nutrients they are missing from a vegetarian diet and the benefits of eating animal products while in recovery.  In my opinion, a vegetarian diet or lifestyle can be practiced if one desires, but after recovery.

Authentic health can be defined as one’s optimal wellbeing, a product of the synthesis of honoring your personal values, cognitions, and emotions surrounding food, while integrating balanced nutrition to meet dietary guidelines. When there is cognitive dysregulation, such as that within the context of an eating disorder, clients cannot accurately discern hunger and satiety cues or emotions, and the delicate balance of authentic health maintenance becomes difficult, if not impossible.

Eating Disorder Warning Signs in Elite Athletes

By Kristin Kaye

2002 United States Rhythmic Gymnastics Junior National Champion, 2009 United States Rhythmic Gymnastics World Championships Group Team Member

When I struggled with Anorexia Nervosa as an elite rhythmic gymnast over 15 years ago, my parents, coaches, teammates, and friends did not know what signs to look for when identifying my eating disorder. It was evident that something was changing in me for the worse; however, little knowledge about eating disorders left it difficult for these important people in my life to know what to do. Over time, my life was transformed in such a radical way through full recovery that it became my passion to help others understand the warning signs of eating disorders so those who are struggling can best be supported with the resources they need as early as possible. It is my hope that the following discussion on many of the major eating disorder warning signs in elite athletes, coupled with personal stories from my own struggle, will aid in a better understanding of how to identify these issues.

Elite athletes come in all different shapes and sizes. A national champion in rhythmic gymnastics may look strikingly different than a national champion in weightlifting at first glance, yet both athletes are at the top of their sport and share a similar desire to succeed and perform to their greatest potential. Both athletes may also be struggling with an eating disorder. Though male elite athletes are not exempt from developing eating disorders, female athletes in certain sports, such as gymnastics, diving, and figure skating, evidenced a higher risk for full-blown eating disorders (1). These aesthetic sports all share a similar element of pressure to look a particular way when executing a physical move, which often leads to a greater focus on one’s appearance. Sports that have weight classes, such as rowing or wrestling, also show a greater likelihood of athletes with eating disorders as some athletes find themselves harmfully trying to control their weight due to often strict regulations for “making weight” before a competition. Cycling is an example of a sport where low body-mass is seen as an advantage to performance, and therefore, also suggests an increased risk for eating disorders (2). Athletes from any sport, though, may be affected by an eating disorder or disordered eating due in part to their environment, which is why supporters, especially coaches, have an important role in creating an atmosphere that is one of understanding and support rather than one of harsh criticism and a win-at-all-cost attitude.

Many individuals who become elite athletes begin their sports at an early age and find themselves in the midst of various physical and mental changes associated with adolescence as they approach the height of their athletic careers. During these formative years, while athletes are spending long hours physically training, they are also mentally beginning to develop their personal views on body image and a sense of identity, or belonging. Constant self-criticism, low self-esteem, and poor and/or distorted body image are frequently displayed in those elite athletes with eating disorders. Key warning signs may also emerge when an athlete’s sole identity rests on their sport, and they become emotionally distraught when making errors, having a poor competition, or suffering from injury that prevents them from participating in the sport that gives them purpose. When one becomes so focused on being the “perfect” athlete, it is important to recognize that punishment may begin to cultivate in the form of an eating disorder as a result of perceived failure that keeps the athlete farther from reaching this unattainable level of perfection they desire. Though the individual must ultimately see him or herself as more than just an athlete, it is important for coaches, parents, friends, and other supporters to foster an environment that encourages the athlete to develop as a whole being – body, mind, and soul. Learning personal acceptance in the midst of these challenging and influential years is pivotal in nurturing a young athlete’s outlook on their identity, body image, and self-esteem, and may ultimately help to prevent the onset of an eating disorder.

Perhaps the most obvious warning sign in individuals and athletes alike who are struggling with anorexia is extreme weight loss. Weight fluctuations may be much more difficult to detect in other types of eating disorders, including Bulimia Nervosa. Especially observable in the athletic environment during training and competitions, exhaustion, prolonged fatigue, and decreased concentrationprovide warning signs, as well (3). Relating this to my experience, though once known as a persistently hard worker, I no longer had energy to get through my gymnastics routines at practice. It was physically apparent to my parents and parents of other gymnasts in the audience at competitions that I looked weak, which naturally resulted in poorer performances.

It is no secret that elite athletes spend a lot of time physically training. This is often required to reach a certain level, and when in a proper mindset, following a balanced training plan, and providing oneself with the nutrition that is needed, this is often not an issue. It may become a concern, however, when an athlete does not allow him or herself to take a rest daywhen their body needs a break, whether physically or mentally. For supporters of the athlete, it is important to be on alert for comments that suggest the athlete feels they do not deserve time off or that if they were to take time off, this rest period will automatically lead to weight gain.

Along this note is another warning sign that shows up when an athlete has already completed a hard training session and then feels compelled to exercise even more without sensing an ability to control the session. Therefore, it is important to be able to differentiate between long training hours or multiple training sessions a day that are required for a sport with that of compulsive exercisingbecause of more deeply-rooted body image issues. In my case, the mentality of the exercise that I required of myself after a long day of training was not to enhance myself as a gymnast. I was not thinking about how this exercise could help improve my performance as an athlete, but rather, it was a direct attempt to rid myself of negative feelings. This exercise became a compulsive behavior beyond training, often after meals and done in secret, so no one could observe how I was punishing myself for the shame I felt about how I looked. If I was not allowed to do this exercise or was interrupted during this time, I often became agitated and short-tempered, which was a strikingly different attitude in comparison to my usual personality during a regular gymnastics practice.

Additionally, it is not uncommon for athletes to be highly focused on nutrition, as this can be an essential component to enhanced physical performance (1). Though eating disorders are about much more than just food, there are certain warning signs to look for around food behaviors in elite athletes. Although unnoticed at the time, as I have looked back on my gymnastics career over the years, it is clear to see that there were some very apparent warning signs that I was not developing a healthy relationship with food. For example, even before I had reached elite status, I was fearful to eat around my coaches. Unfortunately, the lack of education around proper nutrition for optimal performance in sports like gymnastics can result in food being presented in a negative way. Rather than being seen as a source of energy that can enhance training and recovery, many times food becomes exclusively linked to one’s body weight, which in aesthetic sports, sometimes can dishearteningly be used by coaches as a reason against why an athlete cannot perform an element to the ideal standard. In young athletes especially, these mixed messages about food as related to personal judgment rather than fuel the body requires can lead to disordered eating behaviors, such as hiding orrestricting food for fear of consequences to their athletic performance. Coupled with issues such as identity and body image, these behaviors may develop into a full-blown eating disorder.

Hydration for an athlete can be crucial to enhanced performance and recovery, and water intake, whether restrictive or excessive,may also indicate eating disorder behaviors. Furthermore, when the body begins breaking down due to improper nutritional intake, an athlete may become more prone toinjuriessuch as bone fractures or muscle strains (3). Another common symptom of anorexia is low heart rate, which for athletes can sometimes be misinterpreted in terms of fitness levels rather than a reason for cardiac concern (4). In addition, for female elite athletes, irregular menstrual cyclesmay be a warning sign of further eating disorder complications, such as the Female Athlete Triad, which consists of energy deficiency, amenorrhea, and osteoporosis (5).

Most athletes go through periods of training that are mentally challenging. It is not always fun for a rower to wake up at dawn to row on a chilly November morning; however, many times short- and long-term goals can keep athletes moving forward through these brief phases of wavering motivation. Though interests can change over time, when an elite athlete no longer finds enjoyment from participating in their sport, this may be yet another warning sign of an eating disorder, especially when an athlete does not acknowledge their unhappiness and continues going through the motions of training so as not to disappoint themselves, their coaches, or their families. Moreover, when an athlete begins to show signs of isolation from teammates, family, and friends during meals or declines to participate in social and team bonding activities, this may also be an indication of deeper issues.

On a final note, quite often various qualities that are praised in the athletic world are similar to the characteristics that are seen in those struggling with an eating disorder, but can also be used to aid in recovery when it is understood how to use these traits in a positive way. There is no doubt my determination, discipline, and the perfectionist tendencies that I used to reach success in my gymnastics career also helped in my journey of recovery from anorexia. Ultimately, when I learned recovery did not mean changing who I was, but rather enhancing who I already am by learning about what my body individually requires nutritionally and how to constructively cope with life’s challenges, I overcame my eating disorder. I am grateful to be able to share that after three years completely away from gymnastics due to treatment, I returned to the sport I truly loved with the support of my family and coaches, and two years later achieved the goal I had set as a young gymnast to one day represent the United States at the World Championships.

Gastrointestinal Issues Which Impede Successful Weight Restoration in Anorexia Nervosa and ARFID

By Philip S. Mehler, MD, FACP, FAED, CEDS

Nutritional rehabilitation and weight restoration are primary goals of the overall treatment for patients with anorexia nervosa (AN) and Avoidant/Restrictive Food Intake Disorder (ARFID). Therefore, medical conditions which interfere with this goal must be considered and successfully treated if a favorable outcome is to be achieved. Three such common gastrointestinal complications, which develop as a result of the marked weight loss of AN and ARFID, are gastroparesis, superior mesenteric artery (SMA) syndrome, and diarrhea. They will be reviewed in order to enable clinicians, caring for these patients, to definitively address these potential impediments to successful weight restoration.

Gastroparesis

Gastroparesis refers to delayed emptying of the stomach due to impairment of the antral portion of the stomach’s normal contractions. This in turn, causes reduced grinding of the food and an overall slowing of the normal rate of the egress of food from the stomach. Therefore, as the food eaten during the course of a day abnormally accumulates in the stomach, the patient with gastroparesis experiences predictable feelings of fullness, nausea, bloating and early satiety during meals along with non-descript mild left upper quadrant abdominal discomfort which may impede refeeding.  While weight restoration will almost always resolve this problem, medications can be temporarily utilized to hasten gastric emptying. Some commonly used medications to treat gastroparesis are metoclopramide and azithromycin. Metoclopramide has the additional benefit of being an antiemetic but is associated rarely with the development of tardive dyskinesia. Azithromycin can prolong the QTc interval on the EKG. Therefore, before starting it and a few days later, it is recommended to repeat the EKG to ensure a normal QTc interval. A nuclear medicine gastric emptying study, which is the gold standard for the diagnosis of gastroparesis, can be obtained to confirm the diagnosis of gastroparesis, but is not often needed given how common this complaint is in patients with AN and ARFID, with moderate or greater degrees of weight loss.

A second gastrointestinal issue which develops in patients with AN and ARFID and can impede refeeding is known as the superior mesenteric artery (SMA) syndrome. This develops as a direct result of the weight loss which accompanies AN and ARFID. SMA syndrome causes compression of the third portion of the duodenum. The compression occurs with weight loss because normally there is a fat pad which cushions the SMA and presents its lateral movement in the abdominal cavity.  When there is significant weight loss, there is atrophy of the fat pad; this in turn allows for medial migration of the SMA, which in turn now constricts the lumen of the duodenum and blocks the passage of food through the small intestine on its normal path to the large intestine.  As food then backs up from this point of obstruction, the patient experiences crampy upper abdominal pains, bloating, nausea and even vomiting of undigested food within approximately fifteen minutes of initiating their eating.

SMA syndrome should be suspected when a patient with anorexia nervosa, of moderately severe weight loss or greater, complains of the aforementioned symptoms during the early stages of their refeeding program.  One can presumptively make the diagnosis in the proper clinical setting, but it might be best to definitively prove its presence by obtaining a CT scan of the abdomen with oral and intravenous contrast, and specifically requesting that the radiologist carefully look at the angle size between the SMA and the aorta.  Normally, the SMA forms an approximately 45°angle (range 38°-65°) as it branches off the aorta.  When the angle decreases to less than 25°, due to loss of the fat pad and the third portion of the duodenum is compressed, SMA syndrome symptoms ensue.

Treatment for SMA syndrome is a temporary change in the patients diet toward softer and more liquid calories.  Surgical intervention is rarely, if ever, indicated.  The treatment also includes close collaboration with a registered dietician to amend the dietary plan.  Specifically, this involves dividing the dairy caloric prescription into smaller more frequent meals in addition to the softer foods or it may involve changing to an entirely oral liquid diet.  Passage of a nasogastric (NG) tube may at times be necessary, or even less commonly, insertion of a nasojejunal (NJ) tube past the point of obstruction.  Generally with just 5-10 pounds of weight gain, the fat pad is reconstituted and the SMA is again pushed back to its more lateral normal position, removing the compression on the duodenum.

An additional gastrointestinal factor which can impede and frustrate the refeeding plan, for patients with AN and ARFID, is the advent of diarrhea during the early stages of refeeding. Certainly in this day and age, first and foremost, an infectious etiology must be excluded. Parasites, such as Giardia, are the most common infectious agents causing diarrhea of 1 week or less and must also be excluded. Parasitic diarrhea is much less common in industrialized countries. C. difficile causes recurrent diarrhea among patients taking antibiotics in health care settings and must always be considered, especially with its increasing virulence worldwide.

Once infectious causes have been thoughtfully ruled out, other noninfectious pathologies to consider include celiac disease, irritable bowel syndrome and other forms of functional bowel disease. The evaluation for persistent diarrhea early on in the refeeding period includes a complete history and physical examination and diagnostic testing for infectious and noninfectious etiologies responsible for the patients’ symptoms. But, in the end a common additional cause to consider, which is really a diagnosis of exclusion, is a malabsorption state which accompanies marked weight loss in patients with A.N. Basically, it is directly caused by the weight loss and subsequent loss of small intestinal absorptive surface. Therefore, in essence, a new state of short-gut syndrome ensues due to the reduced intestinal absorptive area from villous atrophy, wherein calories are normally absorbed. There is actually one blood test which can be done to confirm the diagnosis, called a diamine oxidase level; it will be abnormally low in patients with AN, if the diarrhea is due to malabsorption. The treatment for this malabsorption state, which ultimately will correct itself with weight gain and nutritional rehabilitation, is to alter the diet so that the reduced absorptive area does not adversely impact weight restoration. Once again, this requires a close working relationship with an informed registered dietician to add more complex carbohydrates, to increase the protein content of the diet to reduce the amount of liquid ingested during the meal and to substitute six smaller meals instead of the traditional larger breakfast, lunch and dinner meals.

Living a Recovery Oriented Life

By Beth Persac, LMFT

“You need to see a treatment team weekly for a year,” is often met with wide-eyed astonishment and/or disbelief. After being inpatient, people are so ready to get back to the “real world” and leave their eating disorder behind. As an inpatient therapist, it’s my job to help them understand that they need to fit their life into their recovery and not their recovery into their life. Recovery has to come first. How do you make this happen?

Most patients say maintaining recovery is really simple and yet the hardest thing they have ever done. Attending appointments is simple; talking about issues and concerns is really hard. Following a structured meal plan is a simple concept but a difficult reality.  Contacting a friend is easy enough, being brutally honest about your struggles is really hard. Make the commitment to keep moving toward recovery no matter what. Keep taking steps toward recovery every day.

Before someone leaves inpatient, ask them to take a moment to assess how they feel physically, spiritually, mentally and emotionally and have them write down their answers. Next, have them compare these feelings to how they felt just prior to entering treatment. Keeping a written comparison is often a strong motivator for sustaining a recovery oriented life.

Yes, a recovery oriented life – something much different from the elusive recovery that most patients think about. Shifting to recovery as a fluid process and not something you are “in or out of” helps loosen the rigidity and opens up space for mistakes and the ability to learn from those mistakes. A recovery oriented life involves flexibility and not perfectionism for “struggling well” (recognizing your urges, admitting them, speaking them out loud, getting support to resist them). It is also owning up to any behaviors and immediately getting back on track. Again, continuing to take steps toward recovery.

The steps are many and varied – and like any other skill, one must practice. And practice more. Practice breathing, practice sharing your thoughts and feelings, practice resisting urges, practice journaling, practice meditation or mindfulness, practice thought stopping and reframing beliefs. Practice radical acceptance and opposite action. Practice whatever works and practice it over and over. Years ago we had a patient complain about how “cheesy” group activities were until one day she surprisedly admitted: “This cheesy stuff really works.”

Take the risk to allow your loved ones to support you. Before you leave treatment, let them know what you need to be successful in recovery. Explain to them how to approach you when your eating disorder is loud. Give them ammunition to help you fight your eating disorder neurochemistry – to get you out of the unending loop. You will need the help and support of all of your loved ones since the bulk of recovery happens “in the real world”.

As you rely on your loved ones more and more, your relationships will expand and deepen and become so much more rewarding. It’s these rewarding relationships that will provide the most significant buffer between you and your illness. As you experience how rewarding relationships are, you realize more and more how empty your illness truly is. The true rewards in life come from connections to people. This is probably what I hear most from former patients – how much richer their lives are because of their relationships.

These more fulfilling relationships also help you to understand yourself better. The more honest, connected and intimate your relationships are, the more you can appreciate yourself – foibles and all! You become more patient with yourself and your struggles. You are better able to learn from your mistakes and slips. You have more freedom to live a recovery oriented life – and all those skills you practiced so much become second nature. You accept life as it is even if you don’t always like how it is.

So, little by little, step by step your life transforms. Years later you realize you are living a recovery oriented life! Commit to taking steps toward recovery every day – regardless of the size of the step!

BIAS (Body Image Awareness Seminars): A new positive body image program

BIAS (Body Image Awareness Seminars): A new positive body image program

By Aly Bailey, PhD candidate and Kimberley Gammage, PhD

We live in a society where the rates of dieting, eating disorders, cosmetic surgeries, skin-lightening and tanning sales, and other body-altering interventions have reached all-time highs. Dissatisfaction with the body is so rampant in society that researchers call this phenomenon a norm, meaning it is abnormal for people to love their bodies. Positive body image interventions are needed now more than ever but currently they are scarce, and this is especially true for individuals outside the adolescent and university student populations. We recognized this problem and decided to create a positive body image program that would be applicable to a variety of individuals to improve body perceptions and attitudes with people in the community.

This led to the creation of BIAS (Body Image Awareness Seminars), a positive body image program that is unique in three ways: 1) it was created by working with participants, 2) it is applicable to a diversity of people including older adults and people with physical disabilities, and 3) it is grounded in the theory of positive body image. Usually body image programs have been created to specifically reduce negative body image or prevent eating disorders. These programs are important and do show promising results; however, there is a lack of body image programs that specifically target the increase of positive body image. This was in part due to limited knowledge about positive body image. Just over the last 10 years the research on positive body image has mushroomed, demonstrating that it has unique characteristics from negative body image. Interview and survey research with adolescents, young adults, older adults, ethnically and racially diverse individuals, and people with physical disabilities demonstrate consistent findings about the core characteristics of positive body image. Positive body image is understood as overall respect, acceptance, and appreciation for the body, above and beyond appearance. Research has also shown that because negative and positive body image operate separately, that it is possible to be unhappy with your appearance and still experience positive body image. This is because positive body image is not contingent on appearance but rather is a shift in focus to more internal (e.g., personality) and functional (e.g., strength) qualities.

The BIAS program was built to specifically educate and promote the core characteristics of positive body image. This occurred in three phases. The first phase involved recruiting seven stakeholders from the Brock-Niagara Centre for Health and Well-Being to help design the program. These individuals included people with spinal cord injury and multiple sclerosis, older adults, and a breast cancer survivor, all who shared their unique experiences and perceptions on designing a positive body image program. It was during this phase that participants voiced a lack of knowledge about the body image concept. It was found that education about the definition, causes, and influences of body image would be very important for improvements in positive body image to occur. Findings showed that specific positive body image activities and tools that people could implement would be essential to see improvement in people’s body image and overall quality of life. At the end of this phase, a 6-week program with 60-minute seminars was agreed upon by the group to be an appropriate length and a stakeholder came up with the clever name, BIAS.

After a few months of designing the program framework, the preliminary BIAS program was rolled out with the same stakeholders to test its effectiveness. It was agreed that nothing needed to be changed to the content but rather a re-ordering of lessons and activities would improve the flow and progression of materials. It was also decided there should be an online component to improve accessibility of content (please visit exerciseandbodyimagelab.com). Lastly, the seminar length was changed to 90-minutes to ensure enough time for group discussions.

The last phase of BIAS involved implementing it to any member at the Brock-Niagara Centre for Health and Well-Being. During this phase, 24 participants who ranged in age, ability, health, and gender, enrolled in the program. Participants completed body image measures at the start, end, and 6-weeks after the program. In addition, participants completed an interview after the conclusion of the program to share their perceptions and experiences. Body appreciation, intuitive eating, and body satisfaction all improved from the start to conclusion of the BIAS program and these improvements were sustained at the 6-week follow-up. Participants described an improved understanding of the body image concept and shared teachings and the website with friends, family, and acquaintances to help spread positive body image in the Niagara community and beyond.

The BIAS program is one of the first to be created by, and implemented for, a diversity of people including men and women, older adults, and people with various physical disabilities. A BIAS program manual is currently being created to provide a step-by-step guide for future facilitators of BIAS. Researchers, teachers, and allied health professionals are just a few examples of potential future facilitators of BIAS who may recognize the need to promote positive body image at their facilities. We are excited to expand the reach of BIAS in hopes to combat the proliferation of negative body image in society and encourage everyone to experience positive body image.

Orthostatic Hypotension and Tachycardia in Adolescent Patients with Anorexia Nervosa: A Marker of Illness Severity

By Barbara Kessel, DO, University of Colorado Denver, Aurora, CO, and
Philip S. Mehler, MD, Eating Disorders Recovery and University of Colorado, Denver

Adolescents with anorexia nervosa (AN) generally present with similar physiologic changes from starvation as are seen in adults.  One common sign is orthostatic hypotension and tachycardia, which are increasingly detected as the severity of AN increases.

Orthostatic hypotension can cause syncope, dizziness, weakness, and lightheadedness.  Orthostasis is defined as a drop in systolic blood pressure >20 mmHg with or without a drop in diastolic blood pressure >10 mmHg, or an increase in heart rate >20 beats per minute (bpm) upon standing.  Of note, a very recent study demonstrated that finding an orthostatic drop within the first minute after standing more accurately predicts dizziness and future adverse events than finding it at the long-recommended 3 minutes [Juraschek, 2017].

In one retrospective study of 36 adolescents with AN [Shamim, 2003], time to resolution of orthostasis was defined as the day after which the patient was no longer orthostatic for 48 hours.  In Shamim’s study, 60% of adolescent patients with AN had orthostasis on admission, and this number increased to 85% by the fourth day after admission.  Normalization of pulse changes was achieved at around 3 weeks; on average, patients were 80% of ideal body weight (IBW) at the time of resolution.  Shamim’s study also found that orthostatic pulse changes were more sensitive indicators of hemodynamic instability than were blood pressure changes, and the orthostatic changes took longer to resolve.  Similar results were found in a smaller study by Hill and Maloney, who found that the mean number of days until patients were no longer orthostatic was 27, and orthostatic hypotension was resolved when patients achieved a mean IBW of 79.5%.

A Marker of Instability

It is well established that the cardiovascular response to prolonged starvation is compensatory bradycardia and hypotension, due to the profound parasympathetic predominance at low body weights [Sachs, 2016]. However, tachycardia in patients with AN may be predictive of arrhythmia and risk of sudden death when associated with excessive sympathetic nervous system activity [Krantz, 2004].  An elevated heart rate may indicate a cardiac compensatory mechanism for congestive heart failure, and has been described during refeeding AN patients.  Therefore, closer medical monitoring is recommended when an adolescent patient presents with elevated heart rates and demonstrates orthostatic changes.

A residential or inpatient level of care may be prudent for patients with significant orthostatic changes.  In one study of adolescent males with AN [Siegel, 1995], four of 10 patients presented with relative tachycardia (heart rates of 80 bpm or greater), and three out of four developed life-threatening complications, including severe electrolyte disturbances and congestive heart failure; one patient had cardiopulmonary arrest.

In Tokumura’s study of 40 female adolescents with AN, in which an unfavorable outcome was defined as  <85% of age- and height-specific standard weight, and absent or nearly absent menstruation, tachycardia at rest in the convalescent period was associated with an unfavorable 5-year outcome for patients with child- and adolescent-onset AN. It is suggested that adolescent patients with AN who have higher heart rates at rest are affected by more severe autonomic nervous dysfunction than those are those with bradycardia, thereby having poorer long-term outcomes [Tokumura, 2012].

Thus, one might conclude from the literature that the presence of orthostatic changes may indicate a compensatory mechanism for a patient’s malnutrition, and serves as a marker of more severe illness.  For more refractory of symptomatic patients with AN and orthostatic hypotension, a trial of clonidine, fludrocortisone, midodrine or coenzyme Q10 may be worth considering [Rembold, 2018].

Conquer Picky Eating for Teens and Adults: Activities and Strategies for Selective Eaters Interview

From ED review 10/3/18

Jenny McGlothlin, MS, SLP and Katja Rowell, MD, joined us for an interview on their book, Conquer Picky Eating for Teens and Adults: Activities and Strategies for Selective Eaters. What follows are our questions in italics and their thoughtful responses.

You previously published Helping Your Child with Extreme Picky Eating. Your new book, Conquer Picky Eating for Teens and Adults: Activities and Strategies for Selective Eaters, is a workbook targeted for teens and adults. What has your research shown that led you to develop a tool for this age group?

We’ve been pleased that our first book has helped tens of thousands of families dealing with extreme picky eating. Clinicians working in pediatric feeding clinics, eating disorder programs, and GI clinics also use it. We wrote this new book for teens and adults because many children grow up without having found proper help or support, and continue to struggle.

We were hearing from many teens and their parents who had essentially given up, many having “failed” pediatric feeding therapies (explored in our first book). There is more attention in the media around ARFID, but often the only resource presented is intensive day treatment programs. With our clients, we have seen incredible gains. We think many selective teens and adults, even with ARFID diagnoses, don’t necessarily need intensive treatment.

With the new ARFID diagnosis, there is more research on adolescents but no one therapy has emerged as superior to another (Forman 2014). ARFID appears to have higher treatment dropout rates versus other restrictive eating disorders, and potentially lower rates of weight restoration.

When Katja has done outreach and training on a responsive approach to ARFID for eating disorder treatment professionals,she has heard repeatedly that treating ARFID is challenging and outcomes need improvement. These conversations with eating disorder professionals treating ARFID helped shape the book.

Most teens and adults we have worked with have struggled since early childhood (Nicely 2014, Fisher 2014), and adolescents with ARFID are sicker longer than adolescents with other eating disorders. Most have likely experienced years of coercion or pressure around eating. Therapies that pressure teens and adults with ARFID to eat often backfire. Even subtle prompts and tasks (including exposure exercises) can incite powerful and automatic resistance in a client primed by years of attempts to “get” them to eat. Our book offers a different approach. *

The key points we include in our approach with teens and adults are: autonomy, support and encouragement, anxiety reduction, psychoeducation, exposures at the reader’s pace, relaxation, cognitive reframing and frustration tolerance. The format progresses from exploring and understanding why the reader may have started down the road to selective eating, includes reflective questions, and builds skills with worksheets and exercises.

Developmentally, teens yearn for control and independence. We hope to empower teens and adults to tap into their own motivations for addressing their eating challenges. We offer suggestions and information for parents as appropriate. Sadly, some teens don’t have supportive parents, and we wanted a resource they could access as well.

We’ve heard from several eating disorder professionals that they are using the book with clients as part of their treatment. One uses the book hand in hand with the Intuitive Eating Workbook for selective clients. Another shared how she shopped for ingredients with a client in his mid-twenties who then made a homemade pizza and ate most of a slice. Prior to the workbook, he had only eaten one brand of plain cheese pizza for over a decade. His enthusiasm and ownership for the process, via filling in the food preferences list and other exercises helped him feel empowered to choose the next step. This early feedback is encouraging.

You encourage your readers to have patience and to be kind to themselves. Why are these reminders important for this population?

With picky and selective eating, kindness and patience have usually been missing for many teens and adults. There is constant attention and pressure around eating, from parents, teachers, friends and social media! With the attention and pressure there often comes a deep sense of shame and embarrassment.

We want to banish shame and empower individuals. We hope to be a kind and accepting voice in their heads as they read. We include the principle of acceptance from motivational interviewing and ACT (acceptance commitment therapy). As Miller and Rollnick write in Motivational Interviewing,“Paradoxically, this kind of acceptance of people as they are seems to free them for change, whereas insistent nonacceptance (“You’re not okay; you have to be different”) immobilizes the change process.” We have found this to be true with our clients.

“Accept how you eat now” doesn’t mean “give up,” and we explore that nuance. As readers work to change their relationship with food, we also help them explore ways to improve nutrition (chapter 16).

We incorporate technology familiar to teens and adults, suggesting several apps that can help support appetite and wellness with calendar and reminder features. Stress-reducing apps are also recommended. We include real-world examples and have readers brainstorm opportunities in their own lives on how to fit in regular mealtimes and snacks, supporting appetite and sleep as well. We tackle common obstacles such as the time-crunch, or lack of cooking skills as they begin to consider shopping and menu planning. Kindness in this sense includes embracing and caring for themselves regardless of how they eat at the moment. Being “healthy” and thriving is about so much more than food.

In most cases, extreme picky eating is not an emergency. Readers have likely been selective for as long as they can remember. The journey of supporting appetite and increasing variety can take time. They might also see progress in some areas, and experience “setbacks” during times of stress. We normalize this experience. We also provide clear red flags for readers for when the best avenue may be to seek professional help.

Often your exercises are designed to place the eater in control, to be reflective, to be curious. How does understanding one’s experience with picky eating help the individual with change?

This relates back to the last question. Many factors influence the development of a reluctance to eat (2015 Gurze-Salucore interview for more). We essentially say, “It’s not your fault.” So often, selective eaters are told they are being “picky” or stubborn and to just “get over it!“

This understanding leads to acceptance, and often even an appreciation of why they didn’t eat well as children. For many children who had a difficult or painful beginning around food (medical issues, reflux, tongue tie, sensory or oral motor challenges) it was protective and absolutely expected for them to avoid eating. With that acceptance and addressing shame, the reader can shift to curiosity. Curiosity and discovery are recurring themes as well. We were very intentional about the language we used to not add to the sense of pressure, and to present and invite readers to adapt what works for them.

Critically, understanding opens opportunities to support appetite and curiosity around more challenging foods. If readers identify anxiety as a primary stumbling block, they explore the source of the worry and learn tools to identify anxiety in their bodies and to reduce stress and anxiety. If they worry about health, they can explore ways to support health that have nothing to do with food. If their lives are chaotic and not supportive of internal hunger cues, they can work on routines and menu planning. If there are sensory challenges, they can learn ways to have controlled, non-threatening exposures; beginning with paying attention to the language on cooking shows or looking at recipes, and progressing to food explorations.

This is a gradual approach based on what feels best to them at their pace. We offer many different ways to sneak up on different foods, none are better, worse, right or wrong. The reader is in control.

Another area you explore with the reader is anxiety. What are some skills you suggest to help manage anxiety surrounding food?

Addressing anxiety is a theme woven throughout the book. We explore issues from understanding and acceptance as discussed above, to dealing with social isolation, worries about wasting food, health, disappointing family etc. There are many, many worries a client might have. We don’t assume to know what that may be, but help them explore with reflective questions and tuning in to their bodies.

We know that anxiety and ARFID go hand in hand, more so than with other eating disorders. Anxiety also impacts appetite and gastrointestinal function. Step one is to help readers determine the source of the anxiety if they can, and then empower them to address or change how they view things through psychoeducation, acceptance, and embodied techniques such as various breathing exercises, enjoyable movement, singing etc. We offer many suggestions and resources for addressing anxiety, and frequent reminders to check in, as well as when to seek help from a professional.

Inadequate sleep and hunger can also worsen anxiety, so we include chapters on getting into a routine and into the habit of offering themselves an opportunity to eat at regular intervals. Eating opportunities always include a preferred food so they know that their hunger will be addressed. For readers who have trouble identifying hunger cues, they work on those skills.

The book offers scripts and ideas on how to talk to family or friends who may tease or pressure around eating, and how to elicit support; maybe even finding a person or two to eat out with or to explore new foods. Readers will identify what supports and what sabotages their appetite, what increases or soothes anxiety.

There is a chapter on eating out, which can be particularly challenging. We offer understanding and support for the times when things don’t go the way the reader would like. For example, if they try an eating exploration and didn’t “like” the food or the way it was prepared, that’s not a “failure” but useful information for next time.

There is a lot around reframing language and expectations to address anxiety. For example, with explorations or exposure around food, changing the language from “I have to eat a bite of this” to “I wonder what will happen if I _________?” can make a huge difference.

“Rehabilitating your relationship with food” is one of the themes in your book. It’s a richly informed phrase. Why did you choose it?

The relationship an individual has with food is built upon years and years of experience and outside influence, much of which has been negative for those who struggle with selective eating or low appetite. Determining where things went wrong, and then gaining a new perspective on eating can be healing and allow for growth. “Rehabilitation” involves restoring what has been damaged — in this case, the relationship — to acceptance, positive experiences (even enjoyment and pleasure), and establishment of a foundation for moving forward.

Addressing these complex issues is about far more than getting in a few bites of vegetables or only addressing the sensory side of the reluctance to eat. This is good news because the transformation that can come from moving towards eating competence is about more than food. We’ve seen overall anxiety decrease, sleep improve, a sense of confidence and mastery develop, as well as improved relationships with family and significant others. The human experience of eating is about more than what we chew and swallow. This notion of “rehabilitating” captures that and blows open the possibilities for readers; eating out with joy, being okay with what they eat even if they never become “foodies,” and caring for their health and wellness in a myriad of ways.

Can you please explain the term, “bridge,” in the context of eating new foods?

Understanding what characteristics of a food makes it pleasurable can help a selective eater explore what other foods might be acceptable through finding similarities or “bridges” to a new experience. This can be in the form of taste, texture, temperature, or food combinations, and also might be by determining how to change a food through preparation techniques to better match a person’s preferences. This can also be called “linking,” “chaining,” or “stretching” to a new food from a familiar one.

What we offer in our “bridging” chapters are many ways to bridge or stretch to different foods. You can bridge to new flavors in drinks, smoothies or popsicles. You can also use “thinking” bridges to realize that a food may be familiar to something you like. A favorite sauce, spice, or sprinkles can bridge.

Readers explore if they tend to be sensory “seekers” or “avoiders,” and gain ideas for how to expand variety. For sensory seekers, hot sauce or crunchy texture may be a bridge. If a reader prefers crunchy and salty foods, they may go from a potato chip to a veggie straw, and may crush freeze-fried sugar snap peas and adapt a “crumbing” technique used by pediatric feeding therapists. We offer lots of ideas to empower the reader to choose and expand the foods they enjoy (or can tolerate if that is where they are.)

The reader experiences food in different ways. They might start with an accepted food and explore smaller or bigger bites, then place the food directly on their tongue or on their molars. If they tend to gag they might pay attention to whenthis happens. We share how one client realized that she preferred larger bites of food than the tiny bites she had been advised to eat in therapy. She felt more aware of the food and didn’t worry it might get “lost” and choke her. For her, a “bridge” opportunity was the size of the bite. We want to help readers question and be curious about their typical patterns and look to replace them with new, more productive ones.

The book incorporates and adapts strategies that come from the pediatric therapy world. One of our goals as we write and lead workshops is to see more collaboration and sharing of ideas between providers for children, adolescents, and adults, working from a lifespan understanding.

Please share your message of hope and success for those who identify as selective eaters.

We were seeing articles that painted such a hopeless picture for teens and adults with selective eating. The idea that this is a ‘disease’ they would struggle with for the rest of their lives, or that every bite of veggie would have to be chased with soda or choked down felt overly pessimistic. We wrote this book partly as a response to this notion.

We believe the majority of teen and adult selective eaters can expect to do better than that. This is a process of discovery and curiosity. Working with teens and adults is inspiring; when they have those “A-Ha” moments and discover they do like apples —thinly sliced and without the peel for now — it’s really joyful.

To the teen and adult we would say: It’s never too late. There is always room for change if you want it. This book can offer a new perspective and roadmap. Viewing your eating differently helps reshape your expectations for yourself and frees you from the anxiety and hopelessness that may have held you back in the past.

*The book is aimed primarily at the ARFID subtypes characterized by low appetite and sensory preferences or who have had negative experiences around food, not necessarily ARFID clients who are acutely losing weight after an aversive event such as choking or vomiting.