Thursday, January 3, 2019

Rapid Refeeding and Anxiety among AN Patients

Swift weight gain did not increase anxiety or depression.
Traditionally, refeeding patients with anorexia nervosa (AN) has been cautiously done, mainly to avoid the refeeding syndrome. Metabolic disturbances from the refeeding syndrome can include abnormalities of glucose metabolism, low serum phosphate, potassium, and magnesium levels, deficiencies in thiamine, and sodium and fluid retention. If not treated, patients can face more serious complications, including delirium and seizures, cardiac arrhythmias and sudden death.
However, results of more recent studies have pointed out that the previous caloric prescription of approximately 1,200 kcal/day, increased by 200 kcal/day, may not be adequate for this patient population. [See also Small Feedings and Current Nutrition Practices in Anorexia Nervosa, elsewhere  in this issue.] Dr. Sarah Kezelman and associates at the University of Sydney and Westmead Hospital, Sydney Australia, and the Neuropsychiatric Institute, Fargo, ND, point out that rigorous monitoring and additional nutritional supplements can avoid the refeeding syndrome. In addition, these measures can shorten inpatient stays for patients with AN (Front Psychol.2018; 9:1097).
But, are there possible psychological repercussions from rapid refeeding and subsequent weight gain? Noting the lack of research into this area, Dr. Kezelman and colleagues designed a study to understand anxiety symptoms and other psychological experiences among AN patients during the acute states of nutritional rehabilitation. The study was conducted among 31 female adolescents who presented at a special adolescent medical unit in Sydney, where young, medically unstable patients with malnutrition are admitted to the unit to for nutritional rehabilitation. The mean body mass index (kg/m2) for the group was 16.3 at admission.
On admission, patients are begun on continuous nasogastric feeding, at 2,400 kcal/day for the first 24 hours. Under careful monitoring, patients are started on phosphate and multivitamin supplementation. Once they are medically stable, they receive nasogastric feeding overnight only, and this is reduced as oral feeding increases. Each patient then progresses through a meal plan that increases by 5 steps, beginning at 1800 kcal/day, and leading to maximal oral intake of  3,800 kcal/day. As the authors explain, each refeeding plan is individually designed according to the patient’s medical needs. The plan is reviewed three times a week, and all meals are supervised by trained nursing staff.
Sizeable changes in weight did not affect depression or anxiety
The authors could find no evince of a relationship between weight and anxiety and significant changes in weight. These findings were consistent with conclusions from an earlier study by the author and her colleagues (J Eat Disord. 2015; 3:7).  The authors also noted that although two-thirds of the young patients were receiving an antipsychotic mediation, this did not interact with the observed reductions in anxiety. Their findings “may challenge the increasingly routine administration of antipsychotic medications within this population,” according to the authors.  They call for future search with a longer follow-up, to further investigate this finding.

Olanzepine and Weight Gain in Teens with AN

Side effects did occur in one-third of the young patients.
A group at the University of Ottawa, Canada, recently tested the efficacy and safety of olanzapine treatment for low-weight adolescents 11 to 17 years of age  with anorexia nervosa (AN). In their non-randomized open-label trial conducted between 2010 and 2014, those receiving olanzepine had a higher rate of weight gain than did the comparison group. Although there were no serious adverse effects reported, one-third of the teens did discontinue the drug because of side effects (J CanadChild Adolesc Psychiatry. 2018; 27:197).The study is the largest trial to date to test the use of olanzapine for AN in adolescents.
Olanzepine, a second-generation antipsychotic (SGA), is believed to enhance the reactivity of the anterior cingulate cortex and the salience network (SN) in response to the reward value of food in persons with AN. Some of the drug’s useful qualities for patients with AN include reducing anxiety and agitation and concerns about body shape and weight.  Thus, when used among adults, teens and children with AN olanzapine has increased weight gain, reduced levels of agitation, decreased obsessionality, improved sleep and general function, as well as overall improved compliance with treatment (Int J Eat Disord.2000; 27:363; Eur J Child & AdolescPsychiatry. 2001; 10:151).
Dr. Wendy Spettigue and her colleagues noted that although the drug was generally well tolerated by the subjects, and adverse effects were not serous, there was an increased likelihood of high triglyceride, total cholesterol, prolactin, and ALT/AST levels with olanzapine. The increase in abnormal lab values suggest that adolescents being treated with olanzapine be closely monitored, with emphasis on liver function tests and prolactin levels.

Small Feedings and Current Nutrition Practices in Anorexia Nervosa

by Meghan Foley, RD, Carrie Schimmelpfennig, RD, MS, and Philip S. Mehler, MD, FACP, FAED, CEDS,Eating Recovery Center and University of Colorado, Denver
During this decade there has been a general change in the manner with which nutritional rehabilitation is prescribed for patients with anorexia nervosa (AN).
In the past, daily caloric prescriptions for initial weight restoration were in the 5- to 10-kcal/kg range.  However, more recent research has shown that higher dietary prescriptions are associated with a reduced length of in-hospital stay, and with no increased risk of electrolyte disturbances or other adverse reactions.  In fact, the risk of refeeding hypophosphatemia has been demonstrated to increase with the severity of nadir weight rather than with the amount of calories delivered. Thus, the lower the initial percentage of ideal body weight (IBW), the greater need for vigilance in checking serum phosphate levels.
Taking a more aggressive approach to refeeding
A weekly inpatient-residential weight gain goal of 1.5 kg to 1.8 kg is being accomplished through a more aggressive approach to refeeding.  Initial meal plans now start at 1400 to 1800 kcal/day, with increases of 300 to 400 kcal/day every 3 to 4 days, until a consistent weight gain of 0.2 to 0.25 kg/day is noted. No maximum calorie levels are applied, as dietary prescriptions are individualized to support ongoing weight gain toward ideal body weight. Also, the ideal macronutrient source of energy (calories) is still not entirely proven for this type of severe malnutrition, but a typical composition is 40% carbohydrate, 40% protein, and 20% energy from fat.
Many dietitians agree that it is helpful to allow patients to choose the form their calories come in while encouraging solid and broad varieties of food for the majority of meals when medically appropriate, but with a lower threshold to revert to liquid supplements and enteral feeds via a nasogastric (NG) tube if oral intake is inadequate.  This is because of a new focus in treating AN, avoidance of “underfeeding.” An ill-defined, passive “wait and see approach” to refeeding AN patients is no longer acceptable.
Comorbidities can affect the nutrition prescribed
Comorbidities such as superior mesenteric artery syndrome (SMA), found with increased frequency as the percentage IBW is lower, and dysphagia, can affect the refeeding regimen or diet prescription, but not the starting calorie prescription.  The severity of SMA determines how a patient’s nourishment is administered. The utilization of the gut is always preferred; if a patient has complete SMA, diagnosed by abdominal CT scan, the recommendation would be to refeed with 100% liquid formula administered via an NG or perhaps a nasojejunal (NJ) tube, placed distal to the obstruction. If the patient has partial SMA, the diet is typically formulated as a pureed or soft diet. Normally, the diet can then be advanced slowly after only a 5- to 10-lb weight gain, as the SMA obstruction resolves.
Dysphagia can also occur in more severely malnourished patients with AN due to pharyngeal muscle atrophy, which places these patients at risk for aspirating liquids and solids.  If aspiration is confirmed by a speech language pathologist, consistent modifications in food and/or formulas should be made until weight restoration normalizes swallowing function.   It is important to note that with both of these medical complications of AN as well as with others such as gastroparesis, diarrhea, and diabetes, increased intensity of nutrition education and counseling by an informed registered dietitian (RD), are imperative to promote patient compliance as enteral feedings, supplements, or modified textures may create an extra challenge to patient compliance.
The benefits of nutrition intervention
According to Ozier and Henry, “It is the position of the American Dietetic Association (now the Academy of Nutrition and Dietetics) that nutrition intervention, including nutrition counseling by a registered dietitian, is an essential component of the team treatment of patients with AN, bulimia nervosa, and other eating disorders during assessment and treatment across the continuum of care” (Ozier and Henry, 2011).
Registered dietitians act as an integral member of the team in the treatment of eating disorders at all levels of care.  A dietitian who specializes in the treatment of eating disorders assists the multidisciplinary team, as well as the patient, in many ways, first by assessing calorie requirements based on typical metabolic needs and weight gain goals for AN patients. Next, dietitians use medical nutrition therapy to treat a patient’s medical complications from malnutrition and weight loss, such as gastroparesis, SMA syndrome, or malabsorption. Finally, when necessary, the dietitian can prescribe enteral and parenteral nutrition support.
The dietitian can also help decipher a patient’s readiness for change by using motivational interviewing.  In addition, the dietitian can help the patient try new types of foods, whether by adding a macronutrient the patient is fearful of or adding a specific food, such as a dessert, into the patient’s diet.  The latter is especially relevant for those with Avoidant Restrictive Food Intake Disorder (ARFID). Dietitians can also assist patients in weaning off of enteral nutrition support while increasing oral nutrition and by challenging patients to make healthy, productive choices towards recovery by setting boundaries around mealtime behaviors, food flexibility and meal completion expectations to ensure adequate nutrient intake and weight gain trajectory.
It is also vital that the dietitian builds a productive rapport with his/her patient by working in an open and honest way, guiding a patient’s choices away from what their eating disorder wants and individualizing their care as much as possible to build a foundation of trust and respect.  Dietitians are often viewed as an “enemy” or an “ally” to a patient as they upset the eating disorder by challenging a patient to interrupt behaviors while they assist in nourishing the patient, which helps him or her feel stronger and healthier.
Reminding a patient about the positive effects of renourishment, such as sharper cognitive skills, improvement in their physical condition, and being able to more successfully engage with loved ones, can help a patient to feel motivated, continue to make progress in treatment, and begin to place trust in their treatment team to achieve a sustained and full recovery.

Needed: More Vitamin ‘N’

By Sandra Wartski, PsyD, CEDS
Eating Disorder (ED) recovery work includes much focus on food inclusion, meal regularity, and nutritional balance. However, there is often little emphasis on adding more Vitamin N (for Nature).
Numerous studies have shown the incredible physical and psychological benefits of spending more time in Nature, and this may be an intervention that more clinicians need to consider as part of the eating disorders treatment plan.  The notions of slowing down and mindfulness are commonplace for therapists teaching clients about food, mood, and body. Taking in more Nature can have exponential benefits as well.
Richard Louv coined the term, “Vitamin N” in his landmark book, Last Child in the Woods(in which he also creatively references Nature Deficit Disorder and “Leave No Child Inside”) and adds more in his latest book, The Nature Principle.  Louv has been actively promoting the concept of teaching today’s children about nature, particularly in our current technologically-focused society overrun by electronic devices.  One of his well-known quotes is “The child in nature is an endangered species, and the health of children and the health of the Earth are inseparable.”
The  “Nature movement” has grown exponentially, and many other authors have explored and reviewed various aspects of the benefits of nature, including the seminal work of Florence Williams’ The Nature Fix, Amos Clifford’s Forest Bathing, and Eva Selhub and Alan Logan’s Your Brain on Nature.  Although the periodic reference by some of the authors to assisting the “obesity epidemic” is likely to bring up disgruntlement or disagreement among ED clinicians, the science behind the benefits of nature remains awe-inspiring.
The Value of Time Spent in Nature
The value of time spent in Nature is indisputable, and some of the quantifiable benefits are fascinating. Many great thinkers and inventors (Aristotle, Darwin, Beethoven, Einstein, and Roosevelt) have noted that they were inspired by Nature. Now, neuroscientists and social psychologists are going back into Nature as well.  Scientists have documented that individuals who spend more time in Nature are happier, calmer, less anxious, learn better, have improved memories, pay attention better, get sick less often, have more social skills, and in general are nicer individuals.
Many studies also consistently show the many physiological benefits of those who spend time in natural environments. Some of these benefits are decreased sympathetic nervous system symptoms (heart rate, blood pressure, sweat glands and decreased cortisol [stress hormone], and increased performance on memory and creativity tests.
Some of these positive effects have even been duplicated by simple things – like putting more green plants or Nature photos in the lab or the office where they do their testing. Others plan testing subjects before and after a walk on an urban street compared to a walk in the woods.  Some subjects are subjected to temporarily stressful events, like watching a video of a gruesome woodworking accident, and then view a Nature or urban video. Individuals who viewed Nature photos following a stressful video returned to baseline considerably faster than those viewed non-nature videos. Hospital patients with “green” views apparently have been found to have shorter postoperative stays, require fewer painkillers, and have slightly fewer complications compared to those who have no such views.  This type of research is clearly complicated, and involves many confounding factors, but the initial findings are quite impressive.
The World Takes Notice
Research on this topic is spreading worldwide.  In the United Kingdom, a Mappiness App with a reported 3 million subjects tracked mood randomly throughout the day and found strong evidence of joy correlated with being outside.  Japan started a practice of “forest bathing” (hiking in the forest for a weekend) and found many healing effects, including increased immune system health and decreased inflammation. In the Netherlands and Canada, researchers found a lower incidence of various diseases—including depression, anxiety, and migraines—in people who lived closer to green spaces.
Effects on the Brain
The neuroscience behind being out in Nature suggests a number of important brain functions are affected.  For instance, subjects tested after spending time in urban settings were found to have more blood flow to the amygdala (known as the alarm system of the body, where fear and anxiety are processed), while subjects spending time in natural settings were found to have more blood flow to the anterior cingulate and insula (areas of the brain associated with empathy and altruism).  Those spending time outside were found to have higher alpha waves (with accompanying increased levels of serotonin and greater relaxation), as well as less blood flow to the lower area of the prefrontal cortex (and therefore suspected to have decreased levels of depressive rumination).
Research Looks at the Positive Effects
There has been a fair amount of research into why Nature has such a positive effect on so many areas of the body, and this realm of research seems to include a bit more controversy among scientists.  There are some who say that the positive relaxation effects of being outside relate primarily to increased body movement, which is more likely to occur if an individual is outside. Others suggest that bodies relax in more natural surrounding because this is where humans evolved.  Time spent in Nature also tends to touch upon all of our senses, and so there are hypotheses about how a recalibration of our senses with natural input is key.  Some theories focus on the visual senses, including the fact that more fractal shapes may trigger neurochemicals in our visual cortex,which assists in relaxation.  Others focus on the smells present in outdoor space; here, airborne chemicals raise white blood cell counts, which are helpful in fighting infection. We might not know exactly why Nature can be both tranquilizing and re-energizing, but the evidence continues to support that there are certainly multiple benefits.
A ‘Nature Pyramid’
How much nature time is beneficial also remains unknown, but Tanya Denckla-Cobb and Tim Beatley from the University of Virginia have developed a “Nature Pyramid,” which outlines ideas on getting adequate servings and variety of Nature in the course of a year.   Like the Food Pyramid, there are elements in Nature that should be consumed more frequently and in greater quantities, and those that might be consumed less frequently.   Denckla-Cobb and Beatley, along with others, argue that exposure to Nature is a necessary part of human life.  As ED clinicians, we are quite familiar with the prospect of helping clients learn that attention to all foods in various quantities throughout the day is what allows for healthy brain and body functioning.   The Nature Pyramid is not intended as a strict guideline, but more as a conversation-starter about getting doses of outside time at regular intervals. 
Regular Infusions of Nature Could Help Almost Everyone
Regular infusions of Vitamin N could help most anyone living in our fast-paced, plugged-in, social-comparison digital age, particularly those struggling with serious mental health issues like EDs, who might derive even greater benefit. There is good sense and science behind including time in Nature as part of the wellness plan, especially given the many improvements in mood, mindfulness, mental capacity, medical recovery, creativity, and overall better functioning that are reported after contact with Nature. This recommendation might not only be more readily accepted by our clients but could have long-lasting impact as well.
Ideas for how we might use nature in our ED treatment plans abound, ranging from simply recommending time outdoors to using active 5-senses-centering in the woods.  Being in Nature allows time and space for slowing down, and for distraction, metaphor hunts, and taking in a big-picture perspective.  Outside there are no mirrors, no scales, and no electrical outlets. There is less need for a certain “look” before spending time outside, and instead a greater focus on being functional and comfortable, notions quite similar to those being emphasized in ED treatment in terms of aiming for feeling good rather than over-focusing  on looking good.
There are, of course, caveats for our ED clients, such as not allowing the Nature prescription to become an excuse for over-exercise or for isolation. However, as is the core of so much of ED work, using moderation and an individualized approach is key.   Attending to Nature could not, naturally, be a substitute for the primary steps of ED treatment, but it might allow an add-in of a “vitamin” often overlooked in our usual approach to addressing the brain and the body in recovery.
So, as has become the new motto in Nature proponents’ blogs, let’s promote trading screen time for green time! 

Sick Enough Interview

Jennifer Gaudiani, MD, CEDS, FAED joined us for an interview on her book, Sick Enough: A Guide to the Medical Complications of Eating Disorders, which was just released. What follows are our questions in italics, and Dr. Gaudiani’s thoughtful responses.
In your opening chapter to Sick Enough: A Guide to the Medical Complications of Eating Disorders, you include information on “cave person brain.” What are some of the ways “cave person brain” changes with starvation?
What I call the “cave person brain” is the part of our brain that manages us as a mammal. It runs the aspects of our physiology that for the most part are out of our conscious control: our metabolism, temperature regulation, blood pressure, heart rate, digestion, and hormones. This is the part of our brain that evolved exquisitely to save us from common famine conditions our remote ancestors faced. That is: one of its primary directives is to keep us from dying of malnutrition. Therefore, “starvation”—meaning inadequate caloric intake compared with what the body needs, and arising from an eating disorder, disordered eating, a diet, a “cleanse,” or so-called “clean eating” with avoidance of whole categories of vital nutrition like carbohydrates—will make the cave person brain shift into gear to save you. Every person’s cave person brain response is unique, but some common ways that the brain tries to spare calories include: chilliness, cold hands and feet, slowed heart rate, low energy, slowed digestion, anxiety, rigidity, poor skin and hair quality, defending of the body weight (that is, failure to lose weight despite caloric inadequacy), and reduction or total cessation of sex hormone production. Your cave person brain is just trying to keep you alive until you have access to adequate food again!
You note the significant danger of cardiac arrest. What makes the heart stop in those with eating disorders?
Many studies have tried to answer the question: what is the deadly physiology that occurs just before someone’s heart stops from an eating disorder? For years the focus has been on an EKG finding called the “QTc” interval, which means the distance between two wave forms on an EKG, corrected for heart rate. For sure, individuals on certain psychiatric medications and/or at risk for low potassium levels from purging may develop a prolonged QTc, which can definitely lead to a deadly arrhythmia and cardiac arrest. However, this is not the case in the majority of cases of anorexia nervosa.
My clinical experience has led me to recognize that low blood sugar (hypoglycemia) may well be the deadly precursor to cardiac arrest in anorexia nervosa. When the heart runs out of fuel, it stops. Hypoglycemia in anorexia nervosa can occur when someone isn’t taking in enough calories and carbohydratesand has depleted their glycogen stores in muscles and liver and they cannot break down their muscles fast enough (or don’t have enough muscle mass left) to make new glucose to run the heart and brain. Thus, I consider hypoglycemia to be a vitally important diagnosis to make, whether symptomatic or not. Even if the blood glucose stabilizes during the day, drops in levels during the night can tragically cause loss of life. Correction of hypoglycemia requires urgent intake of easily-absorbed carbohydrates (like apple juice or glucose tabs) in the moment and sustained nutritional rehabilitation over the long term.
Can you please tell us your parable of “The Fortress” that you share with your patients as they work at the difficult process of recovery?
I like to use metaphors and storytelling in my clinical practice. I was an English major in college and remain a true book-lover. I think sometimes talking in these ways help patients accept certain ideas without clashing with their eating disorder defenses. I tell my patients the story of “The Fortress and the Nuclear Wasteland” when they feel the idea of even trying recovery is too intimidating. I invite them to imagine that I’m standing on the wall of a fortress, overlooking a nuclear wasteland. Behind me in the fortress is a beautiful, fragrant, warm garden, which represents a life in which one nourishes and rests adequately. The wasteland represents their eating disorder. I call to them to come join me in the fortress, just try standing with me and walking in the garden. Many of them wander around in the wasteland feeling too frightened to enter the fortress. Many come right up to the gates and then retreat. I encourage them to come into the fortress and see what the difference is like, because often they are only imagining what recovery would be like, what the loss of the eating disorder would be like, and it’s too fearsome. But once they stand in the fortress with me, they can make an informed decision about which setting is better for them.
Part 3 of your book focuses on patients in larger bodies. Please address the harm done when terms like “overweight” and “obese” are used.
I was trained in a medical system where students and residents are taught that high body weight is always a problem to be solved, that it’s an individual’s problem with energy intake and output, and that there’s a simple solution: eat less and move more. I am sorry to say I participated in this kind of thinking for many years, and I must have done harm.
I now understand how scientifically incorrect and harmful this nearly-universal perspective is. For one, terms like “overweight” (over who’s weight?) and “obesity” pathologize bodies and imply that larger body size per se is pathologic and a problem to be solved. This is not true. You cannot tell who is healthy and who is unhealthy based on size and shape. Many studies have concluded that individuals with larger bodies who are the most cardiovascularly fit are the ones who live longest (although this is clearly not a universal goal or desired by all), not the thinner individuals who are fit.
In addition, diets don’t work. Thus, while there are clearly some medical problems that emerge in concert with higher body weight and that studies show remit or improve with weight loss, physician-prescribed diets clearly don’t work. This isn’t a matter of lack of individual willpower but rather of the fact that we are mammals being protected by our cave person brains. I would suggest that from doctor’s offices to the multi-billion dieting industry, it is diet culture and an unswerving devotion to a narrowly-construed vision of beauty, health, or desirability that have caused people to have an increasingly unhealthy relationship between their bodies and food.
My solution is to follow a Health At Every Size® (HAES) philosophy and never focus on weight or weigh patients unless I’m following nutritional rehabilitation in someone who was previously at a very low body weight. I help patients find a multidisciplinary team that is also HAES-informed, where we focus on behavioral change that is linked to the patient’s unique goals and values. I have found that diabetes, sleep apnea, fatty liver, high blood pressure, and menstrual irregularity respond beautifully when patients eat adequate, nourishing, delicious foods throughout the day and move according to ability and desire. I have no idea what happens with their weight, but since I don’t center the problem within the individual but rather within the toxic society that surrounds them, it turns out the weight doesn’t matter.
Can you provide some information on the path from orthorexia to malnutrition?
Orthorexia is a term that isn’t officially found in the Diagnostic and Statistical Manual-5”(DSM-5). It refers to an unhealthy obsession with healthy eating. People become rigid adherents to food consumption defined by arbitrary rules thought to emphasize quality, purity, or health, in a way that interferes with their social or medical functioning. The reality is that while delicious, sustainably-grown, fresh foods are wonderful, and ideally, we eat foods that maximize taste and nourishment for our bodies, overly-rigid eating is disordered and puts people at risk for malnutrition and development of an eating disorder. A desire to eat well can become a rejection of all carbs which can result in fatigue, poor athletic performance, low energy, and an increasing mental fixation on getting carbs that can easily result in bingeing with or without purging or can progress to anorexia nervosa.
Please comment on your lead-in, “Males Arrive for Treatment Just as Sick as Females.”
Males with eating disorders form an underrepresented, marginalized population. Even the common abbreviation for eating disorder, “ED,” may cause a male seeking help to be alienated, since that abbreviation to many males first signifies “erectile dysfunction.” A study I helped write from my former hospital program assessed the 10% of total patients who were males who admitted for care. Those patients arrived with just as much medical compromise as the female patients.
Certain advocates within the field are helping practitioners across multiple disciplines to recognize that males with eating disorders may or may not have the same fears and drives as females, and that we must focus our efforts on making eating disorder treatment welcoming and relevant to their diverse needs.
Furthermore, I recognize that gender is not binary and that individuals of all genders are affected by eating disorders. Care in every setting must manifest competencies in and relevant treatment for patients of diverse genders and sexes.
What are appropriate goals for those who refuse treatment and are facing end-of-life issues?
This is such a complicated question, and it took me a whole chapter and a lot of research and years of patient care to try and give it a thoughtful answer. However, I would say in brief that I believe every individual has the ability and should receive full support to fully recover from an eating disorder. That said, there are some people who are older (usually over 30), have recently completed high-quality standard of care multidisciplinary eating disorder treatment, and who continue to be tormented by their eating disorder without a consistent ability to abstain from behaviors. In this unique, circumscribed population of patients, I believe that a slow, thoughtful, nuanced set of conversations over time can take place in which goals other than those of full recovery may be established and supported. Loved ones are invariably a part of these difficult and important conversations. Every person is different, but I always try to relocate my medical efforts around an individual’s stated goals and values.

Three Keys to Recovering from Your Eating Disorder

Three Keys to Recovering from Your Eating Disorder

by Karen R. Koenig, M.Ed., LCSW
Not all eating disorders manifest in the same way, but all of them follow the same milestones on the road to recovery. As a believer in complete recovery, I know that my journey from chronic dieting, binge-eating and bulimia to “normal” eating and a healthy weight took much longer than I anticipated and was far more complex than I ever dreamed. After all, I always had thought that the reason it was called an eating disorder was that it was about dysfunction around food. Little did I know that it was about eating, sure, but equally about the flawed relationship I had with myself and the rest of the world.
At age 71, I’m more than half a lifetime recovered and with over 30 years as a practicing eating psychology therapist I have a solid overview of what makes people get into dysregulated eating—and what can help them get out of it. Most of what I know is contained in my podcasts, books, articles and blogs and I’m always delighted to share my understandings of what attitudes and practices propel and accelerate recovery.
Here are the strategies that worked for me and have helped the people I’ve treated.
  1. Learn new life skills.

Sometimes I think eating disorders are more about a lack of life skills than about food. Life skills are the ways we learn to manage living in this topsy-turvy world. They are adaptive to context and develop over time consciously and unconsciously as we learn and practice them. Unfortunately, most dysregulated eaters, through no fault of their own, did not learn effective life skills in childhood or on their way to adulthood.
Please understand that everyone is learning life skills as an adult because no one acquired all that are needed as children. Some of us end up turning to food because we don’t have the ability to handle life in better ways, while others turn to other unhealthy pastimes and practices.
Life skills involve competencies such as self-soothing and self-regulation; setting and achieving goals; balancing work and play (rather than overdoing one or the other); surrounding yourself with loving relationships; consistently taking excellent care of your body and mind; recognizing, understanding and managing emotions effectively; living intentionally in the present moment (rather than ruminating about the past or anxiously anticipating the future); and using evidence-based practices for problem solving (rather than wishes, hopes or over-thinking).
To overcome my eating problems I had to learn to respect and pay way more attention to my emotions than I ever had, develop successful behaviors to soothe my internal distress rather than run to the cookie jar, value and respect my body and then take care of it well every day, and give up wishful thinking, including fantasizing and dreaming about a life I didn’t have and never would. I learned to do this through therapy and reading self-help books.
  1. Resolve internal conflicts.

For the longest time, I had no idea that I had mixed feelings about my body size. Thin was what I thought I wanted, but a lower weight meant uncomfortable self-consciousness, approach-avoidance regarding attention from others, and feeling oddly vulnerable. Unfortunately, I wasn’t aware of how many negative associations low weight had for me, so every time I shed pounds, I gained them back. It wasn’t until I explored my psychic contradictions in therapy that I was able to lose weight and feel comfortable in a smaller body. As I resolved my conflictual feelings and felt more empowered, my eating improved.
I also had conflicts about other issues:
  • What did it mean to be slimmer? Did that make me cold and selfish? Did I now have to be perfect in every way?
  • Did I really want to give up comfort eating 100%? How would I manage to soothe myself without food? Could I actually learn to deal with disappointment, sadness and unhappiness without eating over my feelings?
  • Did I deserve to get what I wanted, that is, a healthy body and freedom from a food obsession? Did that mean I deserved other things I wanted as well such as love?
  • Was I ready to love myself and chart my own path rather than rebel against what others wanted me to do and be? What was my own path?
I realized in therapy that until I resolved these and other conflicts, I was never going to be a “normal” eater at a comfortable, healthy weight. But, slowly, as one after another of these conflicts dissolved, my relationship with food felt more natural and, well, normal. For example, for the longest time, I didn’t know what enough meant in so many arenas of my life. When I learned to trust myself to sense sufficiency, life became much easier.
  1. Develop healthy personality traits.

Growing up, we may not think much about personality traits except when people
say, “She’s so cheerful and patient,” “He’s really good with people,” “She’s such a follower,” or “He seems so angry all the time.” In truth, our temperaments are in part genetic, but much of what we call our personalities develop in response to our childhood environment. If we need to be quiet, passive and nice in order to avoid getting yelled at, that’s what we do. If we need to take care of another family member to survive, we push aside our own needs. If our parents have all-or-nothing thinking, that’s what we adopt. If being perfect gets us praise, we strive for perfection. If Mom was highly distrustful of people, we might become wary of them too. If Dad was a people-pleaser, we might follow in his approval-seeking footsteps. Or we might intentionally choose to be the opposite of our parents and rebel against their norms and values.
Then there’s the role that gender plays in developing personality traits. We all get short-changed by gender pressures, men and women alike. Males feel the burden of needing to have it all together and be hard-driving and aggressive, while females often end up feeling a need to be nice and put others’ needs before their own. I was certainly a product of my generation and am a recovered nice girl. In fact, I’m proud to say that I’m not nearly as nice as I was in my eating disorder days and thank goodness for that. I couldn’t have recovered fully without learning to put myself first along the way. Now I am okay hurting others’ feelings if it happens in the service of self-care and feel less concerned about who likes me or what I do.
So, there you have my three keys to eating disorder recovery. Develop better ways to manage the ups and downs of life, free your mind of old conflicts about who you are and what you deserve, and toss out the personality traits which aren’t serving you while adding the ones that will bring you success. In short, build a better version of yourself from the inside out.

Apple is donating 1,000 watches for a new study to track binge eating and bulimia.

The Eating Disorder Journal
(November 2018, Vol. 19, No.11)

the study is called BEGIN, which stands for Binge Eating Genetics Initiative. Read more here:

Mobile Self-Help Interventions as Augmentation Therapy for Patients with Anorexia Nervosa

The Eating Disorder Journal
(November 2018, Vol. 19, No.11)

It has been suggested that patients with anorexia nervosa (AN) who are resistant to first-line treatment would benefit from second-level interventions targeting specific features, an adaptive form of intervention. Guided self-help programs administered via mobile technology have the dual focus of instigating behavior change and managing anxiety associated with eating disorders in the moment and in users' naturalistic environments. INTRODUCTION: We evaluated the feasibility, acceptability, and preliminary augmentative effects of mobile-based, guided self-help interventions (Recovery vodcasts) after initial unsuccessful first-line treatments for patients with AN. MATERIALS AND METHODS: Patients with AN who were unsuccessful in their treatments were recruited to access Recovery vodcasts as augmentation treatment for 3 weeks in Korea. Acceptability and feasibility of the intervention were evaluated, and qualitative feedback was collected. Preliminary treatment effects of adding the Recovery vodcasts were assessed, including eating disorder pathology, anxiety and depression symptoms, and body mass index. RESULTS: The Recovery vodcasts were acceptable for patients with AN. The patients' psychopathologies of eating disorders improved with augmentation of the vodcasts in their first-line treatments. In addition, there was a tendency toward improvement of affective symptoms. The participants' feedback suggested that the intervention could be improved. CONCLUSIONS: The study demonstrated that the Recovery vodcasts were well accepted by Korean patients with AN. Moreover, augmentation of the Recovery vodcasts could facilitate improvements in psychopathology of eating disorders, anxiety, and mood symptoms for patients with AN. Telemed J E Health. 2018 Oct 16. doi: 10.1089/tmj.2018.0180. [Epub ahead of print]

Self-injurious behaviour in patients with anorexia nervosa: a quantitative study.

The Eating Disorder Journal
(November 2018, Vol. 19, No.11)

Many patients with an eating disorder report difficulties in regulating their emotions and show a high prevalence of self-injurious behaviour. Several studies have stated that both eating disorder and self-injurious behaviour help emotion regulation, and are thus used as coping mechanisms for these patients. We aimed to determine the prevalence of self-injurious behaviour, its characteristics and its emotion-regulation function in patients with anorexia nervosa or an eating disorder not otherwise specified (n = 136). METHODS: A cross-sectional design using a self-report questionnaire. Mann-Whitney U-tests were conducted to compare the background and clinical variables between patients with self-injurious behaviour and patients without this type of behaviour. Changes in emotional state before and after self-injurious behaviour were tested by Wilcoxon signed rank tests. RESULTS: Our results showed a 41% prevalence of self-injurious behaviour in the previous month. Patients who performed self-injurious behaviour had a statistically significant longer treatment history for their eating disorder than those who did not. Whereas 55% of self-injuring patients had a secondary psychiatric diagnosis, only 21% of participants without self-injurious behaviour did. Regarding the impact of self-injurious behaviour, our results showed a significant increase in "feeling relieved" and a significant decrease in "feeling angry at myself", "feeling anxious" and "feeling angry at others". This indicates that self-injurious behaviour can be regarded as an emotion-regulation behaviour. Participants were usually aware of the causes of their self-injurious behaviour acts. CONCLUSIONS: Professionals should systematically assess the occurrence of self-injurious behaviour in eating disorder patients, pay special attention to patients with more severe and comorbid psychopathology, and those with a long treatment history. This assessment should be followed by a functional analysis of the self-injurious behaviour and by effective therapeutic interventions alongside the eating disorder treatment. J Eat Disord. 2018 Oct 3;6:26. doi: 10.1186/s40337-018-0214-2. eCollection 2018.

Clinical Trials: The Anorexia Nervosa Genetics Initiative (ANGI): Overview and methods.

The Eating Disorder Journal
(November 2018, Vol. 19, No.11)

BACKGROUND: Genetic factors contribute to anorexia nervosa (AN); and the first genome-wide significant locus has been identified. We describe methods and procedures for the Anorexia Nervosa Genetics Initiative (ANGI), an international collaboration designed to rapidly recruit 13,000 individuals with AN and ancestrally matched controls. We present sample characteristics and the utility of an online eating disorder diagnostic questionnaire suitable for large-scale genetic and population research. METHODS: ANGI recruited from the United States (US), Australia/New Zealand (ANZ), Sweden (SE), and Denmark (DK). Recruitment was via national registers (SE, DK); treatment centers (US, ANZ, SE, DK); and social and traditional media (US, ANZ, SE). All cases had a lifetime AN diagnosis based on DSM-IV or ICD-10 criteria (excluding amenorrhea). Recruited controls had no lifetime history of disordered eating behaviors. To assess the positive and negative predictive validity of the online eating disorder questionnaire (ED100K-v1), 109 women also completed the Structured Clinical Interview for DSM-IV (SCID), Module H. RESULTS: Blood samples and clinical information were collected from 13,363 individuals with lifetime AN and from controls. Online diagnostic phenotyping was effective and efficient; the validity of the questionnaire was acceptable. CONCLUSIONS: Our multi-pronged recruitment approach was highly effective for rapid recruitment and can be used as a model for efforts by other groups. High online presence of individuals with AN rendered the Internet/social media a remarkably effective recruitment tool in some countries. ANGI has substantially augmented Psychiatric Genomics Consortium AN sample collection. ANGI is a registered clinical trial: clinicaltrials.govNCT01916538 Contemp Clin Trials. 2018 Oct 1;74:61-69. doi: 10.1016/j.cct.2018.09.015. [Epub ahead of print]

A pilot evaluation of a novel First Episode and Rapid Early Intervention service for Eating Disorders (FREED).

The Eating Disorder Journal
(November 2018, Vol. 19, No.11)

This pilot study assesses the impact of FREED (First Episode Rapid Early Intervention for Eating Disorders [ED]), a novel transdiagnostic service for emerging adults with recent ED onset, on clinical outcomes. Data were collected from 56 patients and 19 carers for 12 months following enrolment. FREED patients showed significant improvements in ED and other symptoms across time. Carers also showed psychological improvements. For FREED anorexia nervosa (AN) patients, body mass index (BMI) at initial clinical assessment was similar to that of comparable patients (audit cohort) seen in our service before (16.4 vs 16.1 kg/m2 ). By start of treatment, because of their shorter wait, FREED-AN had gained weight whereas audit patients had lost (16.7 vs 15.8 kg/m2 ). This difference continued throughout treatment, and at 12 months, nearly 60% FREED-AN patients returned to a BMI of 18.5 or greater. FREED shows promise as a service model for emerging adults with EDs. Eur Eat Disord Rev. 2018 Mar;26(2):129-140. doi: 10.1002/erv.2579.