​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:

1. Physical: How can you take better care of your body?  Is there something you can do to promote better sleep, nutrition, or activity?  Schedule an overdue doctor’s appointment, get a massage, or remember to put on sunscreen? 
2.  Emotional: Take notice of what emotions you have been experiencing lately… Would it help to express yourself with  journaling, art, poetry, or listening to (or making) music?  Do you need to acknowledge your emotions without all that self-judgement, putting on a cheerful façade, or conversely wallowing?  Is there something you need to express, someone you want to bounce something off of or seek support from?  Learning to mindfully acknowledge emotions without judgment and with the recognition that emotions are temporary might be just what you need.
3.  Social: What have your social connections been like lately?  Do you feel lonely and disconnected, or are you overwhelmed by social obligations?  How are you doing with balancing people-time with time alone to unwind.  Whether an introvert or an extrovert, everyone needs social contact as well as solitude (although in differing amounts).  Do you need to reach out and make plans with a friend, call someone who makes you laugh, text a friend just to say hi, or organize a party?  Do you need to decline some social events and carve out time alone to read, create, relax, or just be alone with your thoughts?  Before reflexively agreeing to. (or cancelling) plans, take a moment to ask yourself what you need for your own well-being.
4.  Practical: Sometimes self-care involves following routines that you know work to keep your life running smoothly.  Do you need to clean out your closet?  Make a to-do list, pull out that neglected planner you bought, or re-negotiate some shared responsibilities?  Start packing lunch the night before?  What is that one thing you can take care of that will help you feel more on top of things?  Just get it done and off your mind.
5.  Spiritual: Are you engaging in activities that nurture your spiritual side?  Whether this includes formal religious practices, a mindfulness or meditation routine, or writing in a gratitude journal, tending to your more spiritual side promote a sense of wellness and perspective.  How you chose to do that can be formal or informal, public or private, routine or spontaneous… what matters is that you regularly check in with yourself to make sure your spiritual self is not being neglected. 
6.  Intellectual:  Are you feeling intellectually stimulated, bored, or neglected?  Sometimes, the daily grind promotes a “going through the motions” feeling that leaves you feeling mentally “dull”.  When was the last time you read a book, did a puzzle, or learned a new skill?  Maybe it’s time to stop living out of habit and get involved in something interesting.
7. Creative:  What kinds of things get your creative juices flowing?  Do you enjoy painting, poetry, or building things?  Maybe you like going to the theater or exploring museums.  How about taking pictures?  (It’s so easy now with such high-quality cameras on phones.)  You can stimulate your creativity with journaling, sketching, or even daydreaming.  Crafts?  Cooking?  The possibilities are endless!

​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!

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:

• Families are not to blame for the eating disorder.
• Families can be a tremendous help in recovery.
• Although sometimes family problems contribute to the development of the eating disorder, more often, family dysfunction is an understandable consequence of having a serious illness in the family.
• Families need (and deserve) support, guidance, education, and compassion as much as the family member with the eating disorder. 
• FBT is both supportive of the family in distress and corrective of problems in the family (without assigning blame).

So… what specifically do parents/ caregivers need to do?

1. Take charge of the food.  This includes grocery shopping, meal planning, food preparation, and meal support.
2. Meal support involves sitting and eating with the family member, watching to make sure all food is eaten, keeping an eye out for eating disorder behaviors, keeping conversation light and cheerful, and providing pleasant distraction and supervision for an hour after meals. 
3. Requests from the family member with the eating disorder can be considered, but parents have final say in providing meals that meet the specifications of the individually determined meal plan.
4. Learn to recognize eating disorder behaviors.  The treatment team can help with this.
5. Learn to provide support and encouragement through the meal by remaining calm and compassionate while also reinforcing boundaries and rules.  Keep conversation calm and pleasant, no talking about issues or stressful topics, and no lecturing or threatening. 
6. Adopt a “staying sick is not an option” attitude with both words and actions. 
7. Recognize signs of emotional distress (anxiety, anger, withdrawal) without making accommodations to reduce or eliminate these feelings.  Communicate that you understand the feelings but that your job is to safeguard your loved one’s health even if it is upsetting. 
8. Support the exercise restrictions given by the team.  Although walking the dog or “just going to the corner for fresh air” may seem harmless, these activities can reinforce the idea that movement is not “exercise” and can be enough to prevent progress with medical recovery.
9. Practice self-compassion in your role of caregiver.  It is very challenging to remain calm, and not “fix” the emotions, threaten consequences, or give in to the demands of the eating disorder.  Criticizing yourself when you are doing your best never helps. 
10. Communicate with the treatment team.  Your observations and thoughts are very important in the recovery process.

Remember, no family is perfect and there is no need for perfection to be a strong support system.   Be prepared for ups and downs, good days and bad, tears and arguments, and lots of uncertainty.   Most importantly, keep in mind that even the most serious eating disorders get better with time, patience, and persistence as well as education, support of the team, and loads of compassion.  There will be difficult emotions, inconvenient appointments, and sleepless nights, but staying the course ultimately allows you the joy of reconnecting with your healthy, happy loved one.  

​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.
 
 Hannah Bock

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:

• The vast majority of studies show that 90-95% of dieters regain lost weight, most within five years and many within a matter of months.  This does not mean that the dieter has failed.  Rather, it is the concept of dieting that is flawed.
• Decreasing food consumption to the degree recommended by most diets causes metabolism to drop because the body is biologically programmed to avoid starvation.  Simply put, you eat fewer calories but also cause the body to need fewer calories to function.   This means that body functions must slow down to accommodate having less fuel with which to operate.
• Dieters who gain weight (which is almost everyone) tend to regain even more weight than they have lost.  In fact, dieting is a consistent predictor of weight gain and likely plays a large part in the obesity epidemic.
• Dieting contributes to the myth that there are “good foods” and “bad foods”.  All kinds of food should be included in a healthy food plan.  As Julia Child liked to say, “everything in moderation, even moderation.”
• Avoiding entire categories of food, such as fats or carbohydrates, sets dieters up for both physiological deprivation (as the body requires all food groups for healthy functioning) and psychological deprivation (never allowing yourself treats which often leads to overindulging later.)

 
“So what do I do if I am overweight?”

• Learn to eat intuitively, which means eat when you are hungry, stop when you are full, and don’t eat (or not eat) for emotional reasons.
• Incorporate all food groups, and don’t deprive yourself of treats.
• Exercise regularly, preferably doing something active that is also FUN.  Boring exercise routines will not be followed.
• Ditch the diet plans, diet products, supplements, and anything else not included in the above three points.  Period.
• If your eating has become confusing, chaotic or out-of-control, seek professional help. 
• Although the above advice is simple, it is not easy to follow in this diet-crazed world we live in.  Diets and exercise gimmicks just don’t work except to benefit a billion-dollar diet industry.

​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:

• Sports Drinks are your choice if you are exercising for more than 1 ½ hours or restrict your calories.  This type is beverage is absorbed faster than water and is your choice if you need to drink while exercising.  This beverage gives you energy during exercise without digestion concerns. The longer you exercise, the more you sweat, the greater the need for a sports drink.
• Vitamin water is the same as a sport drink. 
• Energy drinks can vary in terms of calories and caffeine content and can be supplemented with a variety of herbs and or vitamins with little of no value to the exerciser.

 
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.

• Before exercise - If you are hungry before you exercise or want to avoid exhaustion during your exercise, choose low fat, low fiber carbohydrates. You want carbs that are quickly and easily digested and will not cause stomach distress while moving.  Examples are bananas, crackers, pretzels, or classic granola bars. Remember, this should be a small snack to avoid stomach cramps.

 

• During exercise - If you are participating in an endurance event, extra-long bike rides, marathon runs or long hikes, you need carbs that are very quickly digested.  These could be sports drinks, diluted juice, dried fruit, fruit chews, or low fat/ low fiber granola bars.

 

• After exercise - The perfect combination of nutrients after exercise is a high carbohydrate food with some protein.  Real food is always the first choice and chocolate milk is the perfect recovery drink.  A peanut butter sandwich, cheese and crackers , a bowl of breakfast cereal, yogurt and fruit are all great examples of recovery nutrition.

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!

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)
• Constipation/diarrhea/bloating
• 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.   
​

Before approaching someone you suspect has an eating disorder, it is important that you educate yourself so as to be in the best position to help.  This minimizes the chances of accidentally embarrassing or angering the person or, even worse, pushing him or her away.  Eating disorders are much more complicated that simply being food and weight issues.  Rather, they are a complex set of disorders can be made up of psychological, social, family, and biological factors.  An eating disorder is not deliberate, even if it started out with an intention to diet.  An eating disorder can start as a diet, but it becomes whipped into an out-of-control frenzy by these underlying issues and take on a life of its own.
When approaching your loved one, here are a few things to keep in mind:
• Avoid talking about food, weight, or appearance.  Those are not the real issues.
• Assure them that they are not alone and that you love them and want to help in any way that you can.
• Encourage them to seek help and offer to facilitate this process. 
• Never try to force them to eat.
• Do not blame the individual and do not get angry with them .
• Acknowledge the intense anxiety that is involved in the eating disorder.  Often someone does not want to change his or her behavior but is willing to get help for the associated anxiety.  This is a start.
• Be patient, recovery takes time.
• Mention your concern, but do not focus on your own feelings.  This is not about you.  Focusing on your own anger, anxiety, or stress will only cause guilt (but not change). 
• Do not make mealtimes a battleground 
• Listen, but do not be quick to give opinions and advice.
• Do not take on the role of a therapist.
• The person may deny the problem at first.  Don’t argue, just emphasize that you care.
• Watching someone you care about suffering both physically and emotionally is frightening, frustrating, and confusing.  No matter how concerned you are, you cannot force someone to accept help. 
• Be careful what you say to the person who is suffering.  Careless remarks will cause further pain, guilt, and withdrawal.
If you still aren’t sure how to proceed, don’t hesitate to consult with a professional.
​