By Sheila Flavin, RDN, Supervising Dietitian
Narins Eating Disorder Center

Supporting your loved one during mealtime at home can be challenging and frustrating.  This task can’t be done alone, so please know that you have the help and support of the NEDC team.  We want to give you the confidence that you can do this by using “best practice” meal support strategies.  This will help us to achieve the goal of recovery and maximize meal plan compliance after discharge.
 
Nutrition Goals
Eat enough food to meet bodily needs (instead of restricting)
Flexibility and Variety of Foods (instead of rule driven, avoidance eating)
Eat socially (re-integrating food into normal life)
 
Supportive eating at home requires STRUCTURE, ROUTINE and PREDICTABILITY.
 
Follow the meal plan.  Meals planned beforehand. No choices/changes prevent negotiating and limits internal struggle.  However, you can offer ‘limited choices’ of option A or option B. 
 
Establish goals and expectations of mealtimes at home.

• 100% completion of meals and snacks (breakdown into manageable tasks)
• Completion of meal in 45 minutes and snack in 30 minutes.  Eat by the clock.
• Have a “plan B” (e.g. replace calories with Boost/Ensure or take a very short calming break)
• Track percentage of food consumed.
• Meals eaten and supervised by a family member
• Normal eating style (includes no tiny bites, pushing-spreading or playing with food, tearing or hiding food.)  Point out behavior and redirect.          
• Establish appropriate mealtime topics.  Fun/relaxing/non-stress discussions. 
• No talking about calories, fat grams, carbs, good or bad food, change in body, weight gain

 
Acknowledge the positives, point out progress (any progress).
 
Avoid fighting during mealtime. Try to stay calm and relaxed during the meal. It helps to identify and acknowledge your feeling and/or the feeling of family member with eating disorder instead of the behavior.   CONNECT BEFORE YOU CORRECT.
 
No bathroom breaks during the meal. No bathroom visits for 30-45 minutes after meal.
 
Expect post-meal anxiety and have activity planned. Use this time to practice coping techniques and/or incentive for meal completion.
  
                                       HOW DO I DO THIS???
 When you hear:
“You are making me fat”
 “I am not hungry, I am so full, I am so uncomfortable”
 “Will this make me gain weight- do I look like I have gained weight”
“NO! I will not eat this”
“OMG, this is covered in butter/sugar/oil”
 
Try This:  
Start by identifying the emotion- I can see you are really scared/upset/stressed/ anxious/afraid
This meal plan meets your nutrition needs right now.
This is the meal plan that NEDC staff has prescribed for you.  
Unfortunately eating is not an optional activity.
This food plan is your prescribed medicine.
If you are upset by the meal plan, after you finish the meal write down the questions you want to ask the dietitian.
I can see you are crying, terrified, nervous.  This is intense, this is really hard work. Just try to do best you can.

 When you hear this:               
“When can I stop following this plan?”
 “What is my goal weight, and when will I reach it?”
 “I can’t keep doing this,  how am I ever going to eat after this?”        
 
​Try this:
Keep statements in the immediate and present day. Focus on short term goals for now.

    

By Tracy Narins Welchoff, Ph.D

What are “Accommodation Behaviors”?
Accommodation behaviors involve participating in or supporting the Eating Disorder behaviors.
 
Examples of Family Accommodation

• Providing reassurance regarding the ED concern (“You look thin!”)
• Waiting for them to complete ED behaviors (i.e. staying out of the kitchen while they cook)
• Directly participating in compulsions (e.g., weighing food, reading nutrition labels)
• Providing items needed to do compulsions (e.g., purchasing special foods, buying a scale)
• Taking on individual’s household responsibilities that he/she cannot complete due to ED
• Modifying family routines because of the ED (i.e. eating at an inconvenient time)
• Supporting avoidance of feared situations such as restaurants or family parties

 
Accommodation behaviors interfere with learning new information:
Assisting a family member in avoiding anxiety (with the intention of being helpful to them) interferes with an opportunity to experience the anxiety, do nothing to “protect” themselves, and realize that the anxiety reduces on its own (this is called “habituation”). 
 
Family accommodation behaviors can cause stress in the relationship:
Over time, it is easy for family members to develop resentment and frustration at having to make accommodations (such as buying special foods, changing who is “allowed” in the kitchen during cooking and eating, etc.).  Using accommodations (which are often unreasonable) to “keep the peace” will backfire when the anxiety returns.  It can stress the entire family system that is working hard (without benefit) to provide relief (often with the family’s inconvenience). 
 
Family accommodation behavior can be motivated by the many reasons:
Accommodations are often motivated by guilt, anxiety, or difficulty tolerating the anxiety of the ED sufferer.  Though intended to be helpful, they rarely provide comfort or protection but rather support the continuation of ED behaviors.  It is understandable to want to accommodate because “at least they will eat”, but this actually reinforces the abnormal or symptomatic behaviors.  Although it may seem to help in the short run, it typically fails to reduce symptoms in the long run (and in fact can strengthen the symptoms). 
 
What does work?
What works is careful adherence to the Exposure Therapy protocol developed by the treatment team.  Supported by a wealth of research, Exposure Therapy is the treatment of choice for Eating Disorder (and many other anxiety-based) behaviors.  This involves gradual exposure to what is scary (i.e. eating a dessert, eating in front of other people), preventing the unhealthy response such as avoidance or purging), and teaching the individual that the feared outcome will not occur, or if it does, is really no big deal.   Although hard to watch a loved one experiencing anxiety, rest assured that this technique is highly effective.
 
“Feel the Fear and Do It Anyway.”
 

By Maddie Welchoff, Nutrition Intern

During treatment, well-intentioned friends or family members often ask “Why does my loved one need to eat [Insert Food]?” The implication is that the food stated is somehow a bad (or unhealthy, or junk, or processed) food, or at least not a good (or healthy) one. This often comes from a place of compromise, of relief that the person is at least eating in a normalized way. But for treatment to be successful, you cannot compromise with the eating disorder. 
A very practical reason is as follows. Once your loved one leaves treatment, they should (eventually) feel comfortable going out to parties or even friends’ houses to eat. But what if the only foods available at the place they go are “bad foods”? They may feel that they should not, that they cannot eat them. This inability to join others in eating could very easily lead someone in recovery to use symptoms to cope with the fact that their choice is “bad food” or no food. Leaving such a significant opening for symptom use in recovery is just asking for a relapse. 
You may think “They can just bring something to eat!” but by separating themselves from others and eating different (“healthier/safer”) foods, they are still giving in to a disordered mindset. This is because they are following a food rule. Food rules are a very integral part of many eating disorders. Some eating disorders even start with “sensible” food rules that spiral out of control. So having rules about what foods you are and are not “allowed” to eat, even if the foods you are not “allowed” to eat are “unhealthy/bad” foods, these rules are eerily similar to those many people have in their disorder. This can lead individuals to spiral back into stricter and stricter rules, which can lead to symptom use and eventually relapse. 
The last, and largest, problem with this mindset is that your loved one ends up basing their worth on what they eat. When they eat “good” foods they feel that they have been well behaved, virtuous, moral. But when they eat “bad” foods, they feel that they have been bad, disgusting, weak, or other negative characteristics. This is often subtle and not even something people are conscious of. But by basing self-worth and self-image on what is eaten, they are once again giving in to the disordered mindset that they are only as “good” as the foods they eat. Basing self-image on what you eat is a huge trigger to relapse for many people. 
So why do they need to eat that? Simply put: to reinforce that all foods are okay, and no matter what they eat, it does not affect their value as a person. ​

By Tracy N. Welchoff, Ph.D.

Supporting your loved one through eating disorder recovery can be confusing, frustrating, and worrisome.  In some instances, meals may become a battleground as family members try to beg, bribe, cajole, threaten, or scare the ED sufferer into completing a meal.  It may be a silent, angry affair, full or arguing or tears, or empty seats as family members (including the ED sufferer) storm off or refuse to come to the table.  For the patient, meals can feel agonizingly long and stressful, feelings which are compounded by being in the “spotlight” as the rest of the family watches to see what will happen.  Other family members may resent the tension at the table, become too worried to eat, or talk about topics that are upsetting or “triggering” to the patient.  Often, families give up on eating together. 
 
If any of this sounds familiar, don’t despair.  We are here to walk you through the process of returning some normalcy to the family meal.  It may take some time, but with patience and willingness to try new ways of managing meals, improvement will come.  
 
Although it is unrealistic to run your kitchen at home as we do in our therapeutic kitchen, understanding how we handle meals at NEDC can be a helpful place to start.  First, the structure and consistency of meals are critical in containing anxiety and normalizing eating.  When meals are predictable experiences, they contribute to a set of expectations in terms of mealtime behavior, food completion, and managing emotion at the table.  Making sure that the atmosphere is supportive matters as well, perhaps even more so.  Understanding that your loved one is not deliberately being difficult helps them feel less judged, hopefully countering the self-judgment that they are undoubtedly experiencing.  In the NEDC kitchen, meals are at the same time every day, the table is set beforehand, and when food is served, everyone remains seated for the duration of the meal.  All food and drink must be completed with no exceptions.  There are no substitutions once food is served, no playing with food, and no using the bathroom during or immediately after meals.  Meal plans are made in advance to prevent last-minute indecision or negotiating about what to eat.
 
In implementing supported meals at home, please consider the following:

1. Do not encourage patients to deviate from the structure of their meal plan.  Encouraging flexibility, although well-intended, is disruptive and can hinder progress or precipitate a relapse.  Be patient… flexibility will come later in recovery.
2. It is best for patients not to eat alone for a while.  Light-hearted conversations during meals will help provide both healthy distraction and a reminder that your loved one is “more than just an eating disorder sufferer”. 
3. Do not make comments about foods being “healthy” or “unhealthy”, “good” or “bad”, or anything that judges what foods are on an individual’s meal plan.  Also refrain from commenting on food quantity, as the food prescribed is based on individual medical, nutritional, and/or psychological needs.  If you have questions or concerns about the food, please address these with the dietitian.
4. Talk to your family member and the treatment team about what kind of help is appropriate to provide.  You might offer to help meal plan, grocery shop, and/ or prepare meals.  This should be discussed in advance as everyone in different.  The amount and kind of support needed depends on a number of factors such as age, treatment stage, skill level of meal planning and food preparation, motivation for recovery, and other emotional/ developmental factors. 

 

• For older teens and adults, make sure that you are offering though; do not take over or insist on helping.  The amount and type of help your loved one wants and needs will vary from day to day; make sure you are flexible and sensitive to how challenging a particular day might be.
• For younger teens, parents may be instructed by the treatment team as to how to plan, prepare, support, and supervise meals from beginning to end.  As your teen progresses in treatment, you should discuss with the team how to slowly hand responsibility for meals over to them so that they can return to a level of involvement that fits their age and the family’s preferred way of handling meals.  For example, a teen may suggest or request certain meals be included in the family’s plan, but allowing them to decide what everyone in the family eats (or insist on eating only “special” foods themself) is not necessary or even helpful.  Again, the treatment team can walk you through these decisions until you feel comfortable making them on your own. 

 
Despite what you make think, it is not your job to “make” your loved one eat.  Your job is to gently encourage (“try your best” or “try another bite”), support (“I know this is hard”), acknowledge (“I know this is hard” or “I’m sorry you are having a rough day”), and provide positive focus (“we will get through this”).  You can never go wrong with making eye contact, giving a supportive smile, conveying an “I don’t mind this because you are SO worth it” attitude, and simply saying “I love you”.  You do not need to know the “perfect” thing to say or feel responsible for the completion of the meal.  Report to the treatment team what is and is not being eaten, and move forward from there.
 

• Check in regularly (although not constantly) to see what is and is not helpful.  If these conversations become too difficult, consider a session with the outpatient therapist or dietitian present to help stay solution-focused.
• Recovery is rarely a smooth process.  Be prepared for ups and downs, good days and bad days.  Although rough days may scare you, don’t assume a bad day means a relapse.  Also, be careful not to assume the problem is “all gone” to quickly.  Ask, listen, and try to stay positive, steady, and encouraging. 
•  As discharge from PHP approaches, it is normal to be nervous about how you will handle meals outside of the support and structure of NEDC.  Conversely, it is equally normal to be so proud and happy about your progress that you are sure that you can do well with little effort.  Either way, remember that your recovery path after PHP will not be perfect.  There will be challenges, struggles, and successes.  It is important to expect this, and your Relapse Prevention Plan can be of great help in navigating bumps in the road. 
• Meal planning after discharge is extremely important.  It is normal to want to stop meal planning after PHP/ IOP, but consistent meal planning is one of the strongest predictors of a successful recovery.  For the first month out of treatment, try to stick to the same meal schedule as you followed in program unless otherwise discussed with your outpatient dietitian.  Planning and structure are critical at this stage in recovery.  You won’t have to do this forever, but your job for now is to take the structure you have learned at NEDC and transfer it to your home environment. 
• Try to limit challenging meal situations for at least a month.  This includes eating at restaurants, parties, or other situations where you cannot have control over what, when, and with whom you eat.  If you do eat somewhere other than home/ school/ work, make sure you plan ahead, find out what food will be available, and come up with a cope-ahead plan with your therapist to manage any difficulties that may arise.  Ask your support system to help run interference if conversation becomes anxiety-producing.
• Although it is impossible to predict and plan for every scenario, keeping communication open both with your loved one and with the treatment team will go a long way toward promoting a successful recovery.  Please talk to the treatment team (both the NEDC team and the outpatient team) to problem-solve complicated situations and adapt your support to the current stage of recovery.

 
This information may seem overwhelming, but with some practice, patience, and ongoing communication, long-term recovery is absolutely possible.  No matter how worrisome, challenging, or endless this process may seem right now, the effort is worth it, so never, ever give up.  

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.

1. Acknowledge how hard this is for them.  Without judgment, let them know that you see how difficult it is to fight the eating disorder.  Say that you are proud of them for facing this battle, remind them that you are on their side, and just be there to support, hug, or listen.
2. Repeat as often as necessary: “Giving up is not an option- I will never stop fighting to rescue you from your eating disorder.”
3. Separate the eating disorder from “real” person.  Remind them often: “You are not your eating disorder”.  You can say this directly, and it is equally important to demonstrate this by talking about other aspects of their lives, such as friends, interests, activities, school… whatever matters to them.  Trust me, they have had enough food/weight/ body/ therapy talk!
4. Ask: “How can I support you?”  Everyone has their own preferred (and effective) kinds of support- talking, crying, distraction, humor, help with meal prep, or just sitting quietly together.  And after you ask, listen.
5. Don’t talk about diet, exercise, food (good or bad, healthy or unhealthy), or comment on other people’s bodies (including strangers, TV characters, etc).  Even if you think your comment is helpful (or “right”), it will not likely be heard as you intended… best to just not go there.
6. During meals, engage in light, pleasant conversation and provide minimal, gentle encouragement only if necessary.  Remember, it is not your job to make them eat, but a quiet prompt to “do the best you can” may help.
7. Run interference at parties, dinners, or other occasions where people may engage in diet talk.  Distract, change the subject, provide supportive eye contact, or pull your loved one away from a potentially triggering conversation.
8. Plan meals ahead or time and try to avoid last minute changes, at least for a while.  These changes often cause distress and decrease chances of a successful meal experience.  Be patient… flexibility with meals will come later in recovery.
9. Finally, please take care of yourself.  You cannot be a good support if you are overwhelmed and suffering.  This may sound like a tall order when someone you love is hurting, but if you fall apart, you will not be there to lean on.   For more information, please refer to the Caregiver Self Care blog at www.narinsedc.com .

Hopefully, you now have a sense of what might help.  Never be afraid to consult your professional team if you need additional guidance.  Narins EDC staff are here to help!

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.
 
BIOLOGICAL FACTORS

• Having a close relative with an eating disorder.
• Having a close relative with a mental health condition. Anxiety, depression, and addiction can run in families and may increase the chances of developing an eating disorder.
• Negative energy balance- burning off more calories than you take in leads to a state of negative energy balance. This may be due to dieting, growth spurts, illness, and intense athletic training.
• Type 1 Diabetes
• Malnutrition- this can lead to severe physical and psychological problems, put the brain in an altered state, and lead to an inability to make rational food decisions.
• Genetic factors may account for 40-60% of the risk for eating disorders.
• Disruption in elements of the appetite system such as chemical/ hormonal reactions
• Neuroimaging studies have revealed an ability to ignore hunger signals as well as changes in the role of dopamine in the reward signals that usually occur with eating.

 
PSYCHOLOGICAL

• Perfectionism.
• Body image dissatisfaction and an internalization of the appearance ideal.
• Issues of  depression, isolation, low self-esteem, and obsession with weight loss.
• Anxiety disorders: generalized anxiety, social phobia, and obsessive-compulsive disorder often precede the eating disorder.
• Behavioral inflexibility: Tendency to always follow the rules and feel there was one “right way” to do things.
• Adolescent Onset: many eating disorders appear during adolescence, but there are plenty of cases of onset being in early childhood before puberty or in later life.

 
SOCIAL

• Weight stigma. The message that thinner is better is everywhere, and exposure to this can increase body dissatisfaction and lead to eating disorders.
• Teasing or bullying, especially about weight.  This includes seeing others being targeted and worrying that one will also become a target.
• The socially-defined “ideal body” concept increases the risk of an eating disorder by increasing the likelihood of dieting and food restriction.
• Acculturation: People from racial and ethnic minority groups may be at increased risk due to complex interactions between stress, acculturation, and body image.
• Limited social networks, loneliness, and isolation.  This may be a cause, effect, or both.
• Gender: Significantly more females than males suffer from eating disorders, although the difference is likely exaggerated due to the under-diagnosis and under-reporting of males with eating disorders.  Additionally, those on the LGBTQ spectrum are at higher risk for eating disorders due to a combination of factors already mentioned such as body dissatisfaction, teasing or bullying, family or peer rejection, or other identity issues.
• Athletic involvement: Athletes experience additional pressure to perform at a high level and are often led to believe that “thinner equals better/ faster/ stronger”. 

In Conclusion…
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. 
 

​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.   
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