By Tracy Narins Welchoff, Ph.D.
Having someone you care about struggling with an eating disorder is understandably upsetting. It can also be confusing, leaving you feeling like everything you say or do is somehow “wrong”. Although this is certainly not the case, the constant, high level of anxiety that comes with an eating disorder can make for some tricky situations. Although it would be impossible to provide a complete list of ways to be supportive, here is a place to start.
By Tracy Welchoff, Ph.D.
Eating and substance abuse disorders are a common combination that we see too often in our work. The co-morbidity has been heavily researched, and the same evidence-based counseling practices- Cognitive-Behavioral Therapy, Dialectical Behavior Therapy, and Motivational Interviewing- have proven to help both disorders. One of the many commonalities between EDs and substance abuse disorders is how often they are misunderstood. We hear questions like “why can’t they just stop using?” just as others ask, “why can’t they just eat?” There are many reasons why these diagnoses often co-occur. Overlapping characteristics include high impulsivity, low self-esteem, history of trauma, tendency to isolate, and the desire to be outside of oneself and escape reality; consequences include poor physical health, depression, shame, and guilt. Individuals with either of or both of these diagnoses can experience stigma that may be greater than other mental health diagnoses due to the general perception of both disorders as “self-inflicted”. When attempting with a patient to compare their eating or substance abuse disorder to another disease like cancer or diabetes, I often hear the same response- “but this is my fault. I chose to [insert symptom here]. It was my decision.” Convincing them otherwise tends to be challenging, as individuals with these disorders are normally comfortable with self-blame and resistant to any suggestion to the contrary.
According to research done by National Institute on Drug Abuse (NIDA), 6 out of 10 substance abusers also meet criteria for another mental health disorder. This could be because drug abuse can cause mental illness, mental illness can lead to drug abuse, or drug abuse and mental illness are both caused by common risk factors, such as genetic vulnerabilities and environmental triggers. Drug abuse and eating disorders also trigger the same “reward centers” in the brain to keep the behaviors going. Endorphins are released as rapidly in a binge/purge cycle as in use of an opiate, and it takes time-usually weeks, months, or even years- without the unhealthy behavior for endorphins to be released normally again (as a result of another pleasurable behavior). This explains the depression and anxiety our patients may experience without symptoms and their complaints that no other coping skills produce the same calming result. No wonder it’s so difficult to give up symptoms! It also explains why our dually-diagnosed patients may relapse into substance abuse while recovering from their ED (or vice versa).
At Narins EDC, it’s often difficult for participants to talk about their substance use. In chemical dependency treatment program, it can be challenging to talk about eating disorder behavior. Ironically, even those suffering with these co-occurring disorders stigmatize other mental health disorders. Hopefully, providing education and understanding about the risk factors of both disorders and their co-occurrence can encourage the openness needed to address both head-on.
By Tracy Narins Welchoff, Ph.D.
Undoubtedly the most commonly asked question of friends and family members, it is understandable that loved ones want to know why their loved one is suffering from this scary, confusing, complicated illness. Is it the parents’ fault? (Nope.) Is it vanity or a desperate attempt at getting attention? (nope and nope.) Is it a choice? Is it a behavior problem? (Still nope.) In fact, there is no simple answer to this important question. Eating disorders are complex and affect people of all ages, ethnicities, socioeconomic groups, genders, and education levels. They impact loving, supportive well-functioning families as well as families with significant dysfunction. Eating disorders also occur in people of all shapes and sizes. External appearance should never be used as an indication of someone’s potential to develop an eating disorder, nor is it an indicator of its seriousness.
Risk factors involve a range of biological, psychological, and sociocultural issues. These factors may interact differently in different people, so two people with the same eating disorder can have very diverse perspectives, experiences, and symptoms. Although not an exclusive list, the following can be considered in trying to understand the myriad of contributory factors to the development and maintenance of an eating disorder.
Genetic factors work in combination with environmental, psychological, and other biological effects to increase risk. An individual’s genetic predisposition might influence how one responds to the environment as well as what environments an individual might seek out. Eating disorders are not a choice. They are serious psychiatric illnesses accompanied by a high medical risk. It is important to know, however, that eating disorders are treatable and do not automatically last a lifetime. Early, aggressive treatment is widely considered the best approach as this minimizes lasting physical problems as well as psychosocial and developmental disruption. Recovery is possible and always worth fighting for. Please reach out to the staff at Narins EDC if you have questions or concerns.
by Tracy Narins Welchoff, Ph.D.
A luxurious bubble bath, scented candles, soft music, a perfect cup of tea… sounds wonderful, doesn’t it? Although fabulous when you can engage in this kind of self-care, this is only the tip of the iceberg when it comes to treating yourself in ways that lead to a happier, healthier, more productive and meaningful life. Although the above scenario (or your personal version of relaxing) is where the mind often goes when considering self-care, there are actually many different, and equally important, ways to take control of your well-being. When life is overwhelming, it can help tremendously to slow down and ask yourself what kind of self-care you have been neglecting. Here is a quick rundown of the different categories of self-care that you might consider:
But it feels so selfish!
Getting past this feeling is so important… allowing yourself to regularly engage in activities that promote wellness can boost your mood, support good health, enhance productivity, and put you in the best possible position to contribute to the wellness of others. You are worth it!
by Tracy Narins Welchoff, Ph.D.
Family Based Therapy (FBT) is an approach to treating eating disorders that recognizes the powerful influence that families can have on their loved-one’s recovery. Thankfully, the outdated notion that parents cause eating disorders no longer dominates the treatment community. Rather, the family is appreciated as a tremendous support and agent of change. Although FBT is typically used with children and adolescents, the principles of FBT can be adapted to benefit adults as well. Family Based Therapy is based on the following principles:
By Hannah Bock, Recovery Warrior and fabulous guest blogger
I was sitting in my dietitian’s office, listening to her telling me for the thousandth (at least) time that something had to change. I’d been in active recovery for about 11 years, and in that time I could reach a point of stability in recovery, but I could never actually call myself “Recovered”. What was I missing? What was I doing wrong?
The realization hit me like a ton of bricks: I had to cut out exercise.
I’d been struggling with compulsive exercise for years, almost the entire duration of my illness. During that time, I would eat any meal plan that I was given, do all of the journaling and self-care prescribed to me, and participate actively in individual and group therapy sessions. The one thing that I was unwilling to let go of? Exercise.
I always had a reason to continue to hit the gym. Despite repeated suggestions from my treatment team to quit, I couldn’t stop. Working out was my drug of choice. It made me feel great about myself, it was a way for me to relieve stress, and I loved my identity as “The Healthy Girl”. I never felt like I was going to the gym too much, and I never felt like exercise was negatively impacting my life. After all, how could something that society says is so good for you possibly be bad for me?
First, I had to understand and accept the difference between over exercise and compulsive exercise. According to my justification, I wasn’t spending hours and hours every day at the gym, so I was fine, right? Wrong. Although the time I was spending exercising wasn’t considered extreme, it was still disrupting my daily life. Accept an invitation to go out with co-workers in the evening? Sorry, I have to work out. Birthday dinner with my fiancé? Have to make sure I get my run in that morning. Spend the day at my friend’s house because she just had a baby and can’t really go anywhere? Maybe for a while, but then I have to make sure I can get to my 4:00 class at the gym.
My compulsive workout schedule didn’t stop at dictating my social calendar. It constructed my food rules, too. What I consumed in a day depended completely on whether or not I had “earned” it at the gym. My workouts even dictated which outfits I was allowed to wear in a day. I did not trust my body to tell me that it was hungry or full. I did not trust that my body was fine in whichever outfit I chose that day. Exercise was the control that I thought I needed over my body.
After I made the realization that I was indeed exercising compulsively, I did something that was terrifying and seemingly impossible. I made the decision to try something that I had never tried in recovery before. With the support of my therapist, dietician, and fiancé, I surrendered all of my sneakers and my gym tag. I gave up my workouts indefinitely.
The First Week
The first week was loud. The eating disorder voice in my head was relentless. Strains of “Why would you do this? You’re going to get so fat! You’re going to get so out of shape! You’re not even going to be able to walk up a flight of stairs! What are people going to think? The healthy girl, the runner? Can you even call yourself those things now that you’ve just given up?” were constantly scrolling through my head, making it very difficult to focus on anything else. I am incredibly fortunate to have a strong support system. As I voiced my thoughts, I always had someone there to help me debunk my ED’s hurtful accusations and reshape my thoughts. The first week was by far the hardest, but with help from my amazing supports (and a lot of crying, arguing, and attempted bargaining), I got through it.
One Month In
After about 4 weeks of discovering new ways to cope with stress (some of which worked, some of which did not), I had a pivotal light bulb moment: Nothing bad had happened to me. I still fit in my clothes. I still got up and down stairs just fine. No one made comments about my break from the gym. I had an appointment with my dietician, and although I was expecting tremendous weight gain, she assured me that was not the case and that my weight was the same. The same! It was in that moment that I had my third major realization: Maybe I could trust my body.
98 Days In
After the first month, I started challenging myself in ways that I never thought I would. I started listening to my body. At first, this was very difficult and confusing. If I got hungry, my first reaction was always, “I didn’t do anything today, so how could I possibly be hungry?”. After repeating my ED’s thoughts out loud, I would remind myself that all humans need to eat to survive, and hunger cues are your body’s way of signaling that you need food, just like being thirsty means that you need a drink and being cold means to put on a sweater. They’re all signals that your body sends, and guilt should not be a reaction to hunger (or thirst or cold). I started to honor my hunger with foods that would satiate and satisfy me. I learned in that time that I really like Indian food, that I feel way better when I put dressing on my salads, and that cottage cheese doesn’t really agree with me. I went out with my friends and tried new restaurants. I spent more time with my fiancé because I didn’t have to rush to the gym after work or first thing on a Saturday morning. In short, I felt like I was connecting with people I loved and like I was living the life I truly wanted to be living.
The 99th Day
On the 99th day, it was very nice outside. I drove to work with the windows down, looking at the woods on the side of the road and remembering when I used to go exploring in the woods when I was younger. I wanted to be outside in nature. I happened to have an appointment with my dietitian that day, and I told her that I really thought I was ready to add some movement back into my life. I wanted to connect with nature and feel my body move. I wanted to appreciate what my body could do instead of forcing it to do something it couldn’t. I wanted to honor my limitations (as it turns out, all humans have them) and listen to my body when it asked for exercise. I didn’t want exercise to be a scary thing anymore. Just like I had to learn to listen to my body’s hunger cues, I had to learn to listen to my movement cues, too. My dietitian agreed, and the next day I went on the shortest but most enjoyable jog of my life.
Today I’m still working on my relationship with food and exercise, but it has come a very long way. Fear is not a word I use to associate with going out to a restaurant or skipping a workout. Guilt doesn’t bubble up in me when my friend brags about how far she ran yesterday and I brag about how far I got in my current Netflix obsession. Hunger isn’t a good thing or a bad thing, it just is. Some days I want to move a lot and some days I don’t want to move at all. Some days I’m really hungry and some days, not so much. I’ve learned to hear what my body needs and respond appropriately.
Warriors, this has not been an easy road. I am extremely fortunate to have amazing supports and an outstanding team help me through the tough times. Although I am not fully recovered (and I DO believe in full recovery), I am the most recovered and the happiest I have ever been. Giving up exercise to gain back my life is the best thing that I have ever done for my recovery. It was scary, Warriors, but if you have an inkling of suspicion that giving up exercise might be what you need, you won’t regret it. Remember, nothing bad will happen to you.
By Tracy Narins Welchoff, Ph.D.
It is no secret that our society is obsessed with dieting an losing weight. Magazine covers, billboards, television and radio commercials, and fitness centers popping up on every corner remind us almost constantly that we need to lose weight, even if we don’t. This is not to deny that there is an obesity epidemic that must be addressed. However, dieting is not the answer, and here’s why:
“So what do I do if I am overweight?”
By Sheila Flavin, M.S., R.D.N.
With a myriad of complicated, sometimes conflicting, and often expensive advice available about sports nutrition, it’s no wonder that people are often confused about what to eat and drink before, during, and after exercise. Carbs or protein? Before or after workout? Water or sports drinks? Protein powder? Nutrition bars? Help!
As a dietician, I am often asked for help in sorting through all of this information and helping people decide on the best nutrition/ hydration plan. Some of the most commonly asked questions are as follows:
What should I drink when I exercise?
Ordinary water, of course, is the classic choice. But with store shelves everywhere full of sports drinks, energy drinks, and various flavored and fortified waters, what's an exerciser to do? Experts say it all depends on your taste -- as well as the length and intensity of your workouts.
Here's a look at how the various drinks measure up:
How much water should I drink?
To start out well hydrated, drink about 2 cups of fluid at least 2 hours before you exercise.
Drink about ½ cup of water every 30 minutes during exercise.
How do I know if I am dehydrated?
The best way to determine your hydration level is the color of your urine. The following website provides a great guide. http://www.nehc.med.navy.mil/downloads/healthyliv/nutrition/urinekleurenkaart.pdf
Should I eat extra salty food after exercise?
Sweat contains sodium (salt), and the reason for cramps after exercise is to dehydration and/or low sodium level. However, sports drinks do not have enough sodium in them to replace lost sodium during exercise. Salt content in sweat is variable and everyone is different. You can tell if you are a heavy salt sweater if there is a white residue left when your workout clothes dry out after a workout session. If you sweat stings your eyes or leaves a gritty feeling on your arms or legs, then you are a heavy salt sweater. No need to buy expensive sport supplements; just eat or drink salty food: V-8 juice, chicken broth, pretzels or saltine crackers.
What should I eat?
The simple answer is carbohydrates. Carbs are an athlete’s best friend.
Hopefully this simplifies things and reduces the enormous pressure that people feel to buy fancy, expensive, hyped-up sports specialty products. Your best bet still is, and always will be, regular food and water. Thanks for reading, and happy exercising!
Tracy Narins Welchoff, Ph.D.
Although eating disorders are difficult to deal with no matter what the circumstances, athletes deal with some unique pressures that complicate the recovery process. A thletes are vulnerable to developing eating disorders due to intense pressure of performance and competition combined with strenuous physical demands which require specific nutritional requirements to sustain. However, participation in certain types of sports can contribute to the development of eating issues. These include those that emphasize LEAN APPEARANCE such as swimming and diving, figure skating, and gymnastics. Also, risk is greater in sports that emphasize on LEANNESS FOR PERFORMANCE, like cross country running and swimming. Finally, there are those sports that include WEIGHT-CLASSIFICATION, such as boxing, wrestling, and crew.
Athletes require a high level of energy (i.e. calories) to fuel activity. Energy deficits can be due to dieting or purging, but they can also be the result of increased activity without increased caloric intake. Female athletes risk developing Female Athlete Triad, a constellation of symptoms including low energy availability, low bone mineral density (BMD), and menstrual dysfunction. Although BMD usually higher in athletes due to protective effects of high-impact activities, the nutritional deficiencies of an eating disorder are prone can cause low estrogen levels which can lead to bone loss, osteopenia, and osteoporosis. Male athletes with eating disorders are at risk for decreased testosterone levels (without which muscle development cannot occur).
Psychological issues affecting athletes may be similar to non-athletes, such as rigid perfectionism, trauma, fear of growing up, anxiety, depression, family issues, or cultural pressures to be thin. Driven, competitive personalities that lead to success in sports can cause problems if exercise or eating routines become rigid. The “I’m an athlete” excuse often hides compulsive exercise as the athlete is praised for “being so dedicated” and “training so hard”. To determine if exercise is compulsive, get details about exercise patterns to see if they are inflexible and do not change for illness, injury, or important life events. If an athlete cannot deviate from the training plan without anxiety or excessive guilt accompanying a day off, exercise has become compulsive.
When treating an athlete with an eating disorder, several treatment providers may be involved. The more people that are supporting the athlete, the better the chance of recovery. The Treatment Team may include a physician, psychologist, nutritionist, coach, trainer, family members, and of course, the athlete. Treatment starts with recognition of the problem, accurate identification and treatment of psychosocial precipitants, stabilization of medical conditions, and re-establishment of healthy eating patterns. Ideally, the athlete can be treated while continuing to participate in his or her sport, either fully or in a modified capacity. However, it may be necessary to pull the athlete from sports if health is compromised or if sports are used as excuse to avoid recovery behaviors.
If you suspect that an athlete you care about is suffering from an eating disorder, remember the following: Talk privately with the athlete. Focus on health rather than appearance. Convey caring and concern, not criticism. Discuss the need for an evaluation, but also express confidence that the athlete can recover and return to full sport participation. The athlete should be considered “injured” until evaluated. This can help preserve self-esteem and remind the athlete that eating disorders are medical conditions. Emphasizing treatment as a way to improve enjoyment and performance outcome is helpful as well.
Tracy Narins Welchoff, Ph.D.
Things you may notice:
• Preoccupation with food, calories, weight
• Distorted body image (seeing oneself as fat when not overweight)
• Disappearing at mealtimes or only eating alone
• Food rituals (such as cutting food into tiny pieces or making strange food mixtures)
• Sensitivity to cold
• Sleep disturbance/ fatigue
• High caffeine intake
• Sore throat/ chest pain
• Secretive behavior, mood changes
• Compulsive exercise
• Preoccupation with cooking for others but not eating
• Hoarding food
• Avoiding (or severely limiting) entire food groups, such as fats or carbs
• Wearing baggy clothing
Medical Signs of an Eating Disorder:
• Weight loss or dramatic weight fluctuation
• Slow heart rate, low blood pressure, or drop in blood pressure upon standing
• Restlessness/ inability to sit still or chronic low energy
• Irregular or absent menstrual periods
• Decreased bone density
• Severe dehydration
• Dry skin, thinning hair
• Growth or thickening of hair on arms, cheeks, or other unusual areas
• Easy bruising
• Muscle loss
• Dizziness, Light-headedness, fatigue, weakness, or fainting
• Dental problems and/or bad breath
• Scrapes on the knuckles
• Broken facial blood vessels and/or puffy cheeks
• Electrolyte imbalance due to loss of potassium, sodium, and chloride through purging
This list is by no means exhaustive, and eating disorder sufferers generally do not show all of these symptoms. Weight may be average, above, or below average. It is not always possible to tell if someone has an eating disorder just by appearance. A thorough evaluation by a trained professional is necessary to make a diagnosis, assess the severity, and help formulate a treatment plan. The Primary Care Provider is an excellent person to consult, and Dr. Welchoff is always happy to help with consultation, assessment, treatment planning, treatment, and referrals. All inquiries are welcome and will be handled promptly and confidentially.