Eating Disorders: All Guides

Eating Disorders: General Information

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Eating Disorders Awareness

Eating disorders affect millions of people around the world. They’re most common in cultures that focus on weight and body image and can affect people of all genders, races, ages, and ethnic backgrounds. People who have a negative body image and those who diet are at risk of developing an eating disorders such as anorexia nervosa, bulimia, binge eating disorder, or a category called other specified feeding or eating disorder (OSFED). Eating disorders have serious health consequences and require treatment. Recovery is likely with the help of specially trained health care providers and a supportive family.

What are eating disorders?

Eating disorders are complicated psychological conditions that affect a person’s physical and emotional health. They involve intense emotions and behaviors about food. Eating disorders are very dangerous illnesses and can lead to permanent physical and psychological consequences if left untreated.

The five classifications of feeding and eating disorders are anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating disorder (OSFED) and avoidant restrictive food intake disorder (ARFID).

  1. Anorexia Nervosa (pronounced: an-or -rex-e-ah) involves food restriction (limiting or not having certain foods or food groups). People with anorexia drastically limit their food intake and have an intense fear of gaining weight, even though they are significantly low weighted.
  2. Bulimia Nervosa (pronounced: bull-e-me-ah) involves cycles of binge eating followed by a purging behavior. People with bulimia will eat an unusually large amount of food in a short period of time and then exercise excessively or purge by self-inducing vomiting, using laxatives, enemas, or diuretics in an attempt to avoid gaining weight.
  3. Binge eating disorder involves eating an unusually large amount of food in a short period of time and feeling a loss of control during this episode. People with binge eating disorder do not purge afterwards, but often feel shame or guilt about their binge eating.
  4. Other specified feeding or eating disorder (OSFED) involves some combination of symptoms of the other eating disorders such as an intense fear of weight gain and a preoccupation with food (thinking about food or having food related thoughts most of the day). Many people with OSFED have symptoms of the other eating disorders, but may not meet the exact clinical criteria, and therefore are diagnosed with OSFED.
  5. Avoidant restrictive food intake disorder (ARFID). A person who has ARFID does not eat enough which is marked by unhealthy weight, nutritional deficiency, and/or interference with social functioning. The main difference between anorexia and ARFID is that someone with ARFID does not have a fear of gaining weight or body image concerns. ARFID may be characterized by a limited list of foods someone will eat, extreme pickiness, or fear or adverse reaction to food such as choking or vomiting.

Disordered eating is a term used to describe when someone doesn’t have a diagnosed eating disorder, but their eating patterns and behaviors put them at risk for developing an eating disorder. For example, anorexia can start when dieting becomes too extreme; binge eating disorder or bulimia can start because dieting often restricts the amount and types of food, so when a diet is broken, it can lead to uncontrollable eating and loss of control around food. Sometimes extreme healthy eating is referred to as “orthorexia” which is not a diagnosable eating disorder but may still be a problem if interfering with health or day-to-day functioning.

Prevalence rates or how often eating disorders occur varies with each disorder. While anorexia nervosa and bulimia nervosa are fairly rare, binge eating disorder and OSFED are slightly more common. A study done in 2011 estimated that 0.3% of Americans between the ages of 13-18 suffer from anorexia, 0.9% from bulimia, and 1.6% from binge eating disorder (Swanson et al. 2011). Estimates of OSFED differ from study to study, but may be as high as 15%.

Body Image and Self-Esteem:Teens are constantly exposed to unrealistic standards in the media such as airbrushed images, very skinny models, and constant celebrity images on social media and may feel pressure to lose weight or look a certain way. Because of these pressures, many teens develop negative body image and self-esteem. It’s important for teens to find ways to feel comfortable with the natural shape and size of their bodies.

Body distortion: Body distortion is when someone sees their body shape, size and appearance differently from what everyone else sees. Body distortion causes a person to over-focus on flaws or imperfections that they are insecure about. Most people who struggle with an eating disorder have body distortion issues and often worry about how they look or what people will think of them. These negative thoughts can be difficult to get rid of, and it is helpful to learn positive self-talk strategies with a therapist.

How do I improve my body image?

  • Write down things that your body can do when it’s healthy (running, dancing, hiking, biking, etc.).
  • Write down 10 qualities you like about yourself (caring, responsible, funny, smart, creative etc.).
  • Make a list of accomplishments you are proud of.
  • Buy clothes that you feel comfortable in and give away any that make you feel self-conscious or uncomfortable.
  • Relax using all your senses. Take a bath, listen to music, play a game, sing, or meditate.
  • Spend time with positive people who make you feel comfortable and you can be yourself around.
  • Remind yourself that everyone’s body is unique and not everyone is meant to be the same shape or size.
  • Be critical of advertisements, magazines and the media. Many people will write letters to a company if they find their ads or articles upsetting or hurtful.
  • Make yourself smile when you look in the mirror. It might feel weird at first, but after a while, you could start to notice a difference in the way you see yourself.

What do I do if I think my friend has an eating disorder?

Approaching a friend who you think has an eating disorder can be very hard. People who have eating disorders might be in denial, and therefore very defensive about their behaviors. They also tend to be very secretive about their behaviors, and often refuse to talk about their problems. Despite the strong reactions, it’s very important to continue to try and help someone you care about. In most cases, they need a lot of support and encouragement from friends and family to help them take the first step to seek treatment.

What are some suggestions for supporting someone you care about?

  • Talk about the issue in a supportive and caring way
  • Remind them how much you care about them and how important they are to you
  • Read as much as you can about eating disorders to better understand what they’re going through
  • Be direct
  • Talk to them in private, not around other people or in public
  • Instead of using the word “you” say “I” (ex. I’ve noticed that you have been eating less, or I’ve noticed that you always go to the bathroom after meals)
  • Be patient and go slowly, it may take them a while to come to terms with their issue, and admit that they are struggling
  • Always be there as a support and encourage them to seek treatment, if necessary
  • If you feel uncomfortable talking to them directly or feel as if they won’t listen, write them a letter
  • Talk to your parent(s) or a professional such as a teacher, school counselor, health care provider, nurse, or another trusted adult that will respect your friend’s privacy
  • Be encouraging

Things to avoid:

  • Sounding threatening or judgmental
  • Talking about food or weight
  • Offering them advice regarding food, exercise, etc.
  • Controlling what they eat and how much
  • Being the “food police” (watching or commenting on everything they eat), which could cause them to feel uncomfortable and not trust you
Remember, you’re there to support and be a source of encouragement throughout the process, not to be a therapist or tell them what to do.
Additional Resources

Eating Disorders: Symptoms

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Eating Disorders Awareness

Anorexia Nervosa: Symptoms of anorexia can be hard to notice because people with this condition can be very good at hiding their eating disorder behaviors. They may take small bites, organize their food, or “pick” at food when they eat. They often avoid eating around others to hide their behavior or because it causes anxiety.

Some of the signs of anorexia nervosa are:

Physical:

  • Brittle nails
  • Constant tiredness
  • Constipation (trouble having regular and soft bowel movements)
  • Dehydration (not enough fluids in the body)
  • Dizziness
  • Dramatic weight loss
  • Dry skin
  • Extreme thinness
  • Growth of lanugo (soft furry hair) on face, back, and arms
  • Hair loss
  • Loss of periods (amenorrhea)
  • Low blood pressure and irregular heartbeat
  • Orangey color to the skin
  • Paleness
  • Poor concentration
  • Sensitivity to cold
  • Slow heart rate
  • Slow or stunted growth
  • Swelling of legs, feet, or ankles
  • Weak bones (that can lead to fracture and osteoporosis)

Emotional:

  • Anxiety or nervousness
  • Denial of a problem
  • Depression
  • Distorted body image (believes their body looks different than it actual does)
  • Fear of weight gain
  • Irritability
  • Lack of emotion
  • Low self-esteem
  • Obsession with food
  • Perfectionism
  • Withdrawal from friends and activities

Bulimia Nervosa: Most of the time, you can’t really tell if someone has bulimia just by looking at them because many of the symptoms aren’t as obvious as with anorexia nervosa. People with bulimia can be average weight and often hide their eating habits and behaviors so friends and family won’t always notice there’s a problem.

Some of the signs of bulimia nervosa are:

Physical:

  • Constipation (trouble having regular and soft bowel movements)
  • Dehydration (not enough fluids in the body)
  • Dry, flaky skin
  • Electrolyte problems (not the right balance of the fluids in the body)
  • Irregular heartbeat (caused by low potassium levels)
  • Irregular periods
  • Sore throat
  • Swollen face (from extra fluid in the body or enlarged salivary glands)
  • Tooth decay/loss (cavities, loose teeth)
  • Weight fluctuations (weight loss and gain)

Emotional:

  • Anger that is hard to control
  • Denial of a problem
  • Depression or anxiety
  • Distorted body image (believes that their body looks different than it actually does)
  • Fear of weight gain
  • Impulsivity
  • Intense focus on “flaws” and physical appearance
  • Shame or guilt
  • Withdrawal from friends

Binge Eating Disorder: Most of the physical signs of binge eating disorder are related to overeating and the obesity that may develop. Binge eating disorder is very different from obesity, though, because the loss of control that happens in binge eating disorder can lead to significant emotional distress.

Some of the signs of binge eating disorder are:

Physical:

  • Gallbladder disease
  • High blood pressure and cholesterol levels
  • Insulin resistance
  • Joint pain
  • Type II Diabetes
  • Weight gain

Emotional:

  • Anxiety
  • Depression
  • Shame, loneliness, and self-hatred
  • Withdrawal from friends

What happens when a person doesn’t eat?

Our bodies use food as fuel to keep all the important organs and cells running well. When a person doesn’t eat, their body doesn’t get the fuel it needs and then organs and body parts can suffer.

Heart & Circulation: The heart is a muscle that can shrink and weaken when a person doesn’t eat. This can create circulation problems and an irregular or very slow heartbeat. Blood pressure can get very low during starvation and a person may feel dizzy when they stand up.

Stomach: The stomach becomes smaller when a person doesn’t eat so when they start eating again, the stomach will likely feel uncomfortable (stomach aches and/or gas). Also, the stomach will not empty as fast, making a person feel full longer.

Intestines: The intestines will move food slowly often resulting in constipation (trouble having a bowel movement) and/or stomach aches or cramps when eating meals.

Brain: The brain, which controls the rest of the body’s functions, does not work properly without food. For example, a person may have trouble thinking clearly or paying attention. They could also feel anxious and sad.

Body Cells: The balance of electrolytes in the blood can be changed with malnutrition or with purging. Without food, the amount of potassium and phosphorous can get dangerously low which can cause problems with muscles and brain functioning.  Low potassium or phosphorus can also cause life-threatening heart rhythm problems.

Bones: When a person doesn’t eat, their bones often become weak due to low calcium and low hormone levels, which increases the risk of breaking a bone now (like a stress fracture) and developing weak bones as someone ages.

Body Temperature: The body naturally lowers its temperature in times of starvation to conserve energy and protect vital organs. When this happens, there is a decrease in circulation (blood flow) to fingers and toes which will often cause hands and feet to feel cold and look bluish.

Skin: Skin becomes dry when the body is not well hydrated and when it does not get enough vitamins and minerals from food. The skin will naturally protect the body during periods of starvation by developing fine, soft hair called “lanugo” that covers the skin to keep the body warm.

Hair: When hair doesn’t get enough nourishment from the vitamins and minerals that are naturally found in food, it becomes dry, thin, and it can even fall out.

Nails: Nails require nutrients in the form of vitamins and minerals from the diet. When a person doesn’t eat, nails become dry, brittle, and break easily.

Teeth: Teeth are bones that need vitamin D and calcium from food sources. Without both of these minerals, a person can end up with dental problems such as tooth decay and gum disease. Purging can also destroy tooth enamel.

Eating Disorders: Causes and Risk Factors

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Eating Disorders Awareness

There are many theories about what causes eating disorders and for each person the reason can be different. However, most eating disorders are caused by a combination of biological, psychological, and environmental factors and sometimes the cause may not be completely clear.

Biological

  • A family history of anorexia, bulimia and/or binge eating disorder may make certain people more at risk to have an eating disorder because of their genes or family upbringing
  • Chemicals in the brain that control hunger, digestion, and appetite
  • Hormones (such as leptin and ghrelin) that control satiety and hunger

Psychological

  • Obsessive compulsive disorder (OCD)
  • Past or current trauma such as physical, emotional, or sexual abuse
  • Anxiety
  • Depression
  • Desire to have control over some aspect of life
  • Inability to control behaviors
  • Personality traits such as perfectionism (wanting to be perfect), extreme desire to succeed, and impulsivity (doing things without planning or considering the consequences)
  • Family values about body size, appearance and food
  • Low self-esteem or self-worth
  • Sense of loss

Environmental

  • Society’s intense focus on thinness and dieting
  • Participation in sports that focus on body shape and size such as dancing, rowing, gymnastics, track, wrestling, etc.
  • Abusive or troubled relationships that cause emotional stress and feelings of loss of control
  • Stress at school, sports, with peer groups, etc.
  • Specific cultural attitudes about how a woman/man should look and behave

You can’t tell whether a person is struggling with an eating disordered just by looking at them, but there are often warning signs. Warning signs or “red flags” might suggest that a young person may develop or already has an eating disorder. Below are lists of signs that are linked to certain types of eating disorders. A person who has an eating disorder may have one or more of these signs. These signs may also mean that a person has another kind of health condition, so it’s best to talk with a trusted adult about your concerns before jumping to any conclusions.

Red flags for Anorexia Nervosa:

  • Skips meals
  • Makes excuses not to eat
  • Over-exercises (makes exercise a top priority)
  • Eats only “safe” foods (low calorie, low-fat)
  • Doesn’t eat certain food groups (ex. carbs, fats)
  • Has unusual behaviors around food (organizing food, cutting food into small pieces, always finding something wrong with food, pushing food around the plate)
  • Cooks or bakes food for others but doesn’t eat it
  • Watches food shows or visits food websites constantly
  • Obsessively reads nutrition information or counts calories
  • Constantly weighs themselves, or “body checks” (looks at their body in the mirror or feels their body with their hands)
  • Chews a lot of gum or drinks large amounts of water, coffee, diet soda, or calorie-free beverages
  • Denies that there is a problem despite weight loss
  • Recent switch to vegan/vegetarianism
  • Withdraws from social gatherings involving food

Red flags for Bulimia Nervosa:

  • Uses the bathroom after eating or in the middle of meals
  • Consumes unusually large amounts of food at one time
  • Loses control around food
  • Has scars or calluses on hands and knuckles from using their finger to vomit
  • Hides food or empty wrappers
  • Diets often
  • Food may be missing from cabinets at home or disappears rapidly

Red flags for Binge Eating Disorder:

  • Frequently eats large amounts of food in one sitting
  • Loses control around food
  • Eats when not hungry
  • Eats alone
  • Eats as a way to control emotions
  • Hides food or empty wrappers
  • Others notice food disappearing rapidly
  • May hoard food

Eating Disorders: Evaluation and Treatment Team

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Eating Disorders Awareness

Teens with eating disorder behaviors or symptoms may be referred to an eating disorder program by their pediatrician, family doctor, or nurse practitioner. While no two programs are exactly the same, outpatient programs usually perform a complete assessment to provide appropriate treatment for teens with eating disorders and support for family members. The approach is usually multidisciplinary, which means that more than one specially trained health care provider will be involved in the evaluation and treatment plan. All of these team members will likely involve the family as well, to plan the guidance and support  needed at home. College students and young adults often see the team alone, but may still work with parents or other family members.

The first visit typically includes:

Medical Evaluation by a health care provider (HCP) who is specialized in caring for teens.

Your HCP will:

  • Check your blood pressure, pulse, temperature, and weight
  • Ask you and your family about your medical history
  • Ask you questions about your eating habits and menstrual periods
  • Order tests such as labs (blood tests), urinalysis (to see if you are drinking the right amount of fluids), EKG (a test which looks at the activity of your heart if your heart rate is low), and/or bone density test (DXA scan), if needed

Mental Health Evaluation by a psychologist or social worker experienced in eating disorder treatment.

You and the mental health provider may talk about:

  • How you feel about the way your body looks
  • Your food related behaviors
  • Your family’s concerns about your health
  • Your thoughts and feelings about being evaluated for an eating disorder
  • Your treatment goals
  • Anything else you feel is important for the counselor to know
Working with a mental health counselor or therapist is an important part of getting well and improving body image, self-esteem and any other emotional issues that may affect your eating habits.

Nutrition Evaluation by a registered dietitian experienced in eating disorder treatment.

You and your dietitian will:

  • Talk about your food likes and dislikes
  • Talk about any behaviors you have related to food
  • Discuss common myths about food and eating disorders
  • Talk about your health goals and concerns about changing your behaviors
  • Work with you and your family on creating a healthy eating plan for you
In a culture obsessed with dieting and body image, it can be challenging to have a healthy relationship with food. A specially trained registered dietitian can help you create a personal plan for healthy eating and discuss harmful myths and confusing messages about food and diets.

After the evaluation:

Your HCP will talk to you about a personal treatment plan that will likely include:

  • Individual and family therapy
  • Medical monitoring by your primary care provider
  • Nutritional counseling and support from your dietitian

The Treatment Team: Eating disorders are both medical and psychological conditions. Therefore, treatment usually includes working with a team of specialists including: a doctor or nurse practitioner, therapist or counselor, a dietitian, and sometimes a psychiatrist or family therapist.

The Health Care Provider’s (HCP) role is to:

  • Keep track of a person’s medical health by checking height, weight, blood pressure, pulse, and temperature.
  • Draw blood or take urine samples, if necessary, to make sure the chemicals in the body called electrolytes are balanced.
  • Order special tests such as an EKG to monitor heart rhythm, or a bone density test (DEXA) to see if osteoporosis (thinning of the bones) is present or developing.
  • Offer suggestions on achieving weight goals, calcium and vitamin supplements, exercise, hormone replacement, and possibly medication for anxiety or depression.
  • Determine the best treatment option for you. The HCP may suggest meeting with a therapist and nutritionist, going into residential treatment, having a family-based therapist, or being hospitalized until medically stable.

The Therapist/Counselor’s role is to:

  • Help improve self-esteem, body image, and confidence.
  • Involve parents and other family members in providing support, guidance, and supervision of meals.
  • Teach healthy ways to manage emotions and stressful situations.
  • Address other emotional problems that may be related to the eating disorder, such as depression, obsessive-compulsive disorder, or substance abuse.
  • Create a place where someone can (privately) discuss her/his needs and goals.
  • Provide a safe place to experience feelings of sadness, anxiety, anger, etc.
  • Discuss disordered eating thinking and behaviors, and teach strategies to become mentally healthy.

The Family-based Therapist’s role is to:

  • Provide parents guidance and support around refeeding their child.
  • Teach parents how to manage mealtime conflict.

The Registered Dietitian’s role is to:

  • Help create a safe and healthy eating plan that is balanced in all the food groups.
  • Answer questions about food.
  • Teach why our bodies need specific nutrients and which foods provide them.
  • Offer suggestions on healthy eating, how to achieve weight goals, vitamin and mineral supplements, and exercise.
  • Discuss the harmful myths and confusing messages about food and diets.
It’s very important for you and your family to meet with a medical provider, therapist, and a dietitian who specialize in working with young people with eating disorders.

Eating Disorders: Treatment and Therapy Options

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Eating Disorders Awareness

Treatment for an eating disorder is a very individualized process. Therefore, there are different types of treatments depending on how medically stable a person is and how much emotional support they need.

What to expect at each level of treatment:

Outpatient: for someone who is beginning to struggle with an eating disorder, or who is stepping down from residential or intensive outpatient (sometimes called IOP). There are two approaches to outpatient treatment: multi-disciplinary and family-based.

Multi-disciplinary: This type of treatment often involves regular meetings with ALL members of the treatment team. Medical providers usually schedule weight-checks for patients who are recovering from an eating disorder anywhere from 3 times a week to once a month. They may also want to check blood pressure, heart rate, and urine to make sure the patient is drinking enough fluids. Meetings with the therapist and dietitian may be scheduled weekly or bi-weekly.

Family-based treatment (FBT): This type of treatment puts parents and/or family members in charge of the recovery process. Family members control their child’s food and offer support at every meal and snack with guidance from a licensed therapist who specializes in family-based treatment. Family-based treatment is usually done at home, and may involve only the family-based therapist and a medical doctor, but other health professionals may also be involved. The focus of the treatment is on weight restoration and behavioral change. Once weight is restored the therapy will focus on normal adolescent developmental issues.  This type of therapy is sometimes referred to as the “Maudsley” approach.

Intensive outpatient program (IOP): This type of treatment is for people either transitioning back into school, work, etc. from residential or partial hospital level of treatment, or for people who are not ready for or do not require a higher level of treatment. Intensive outpatient treatment usually involves evening group meetings 3-5 days per week. The amount of time spent at the program each day varies between programs. Usually 1 meal is supervised which may be provided by the program or brought by the patient.

Partial hospitalization program (PHP): This type of treatment occurs during the day and 2-3 meals are provided and supervised along with group and individual therapy, and nutrition education. Patients in partial programs often attend 5 days per week and go home at night.

Residential: This type of treatment is for medically stable patients who need a very structured level of treatment. Patients live and sleep in a center with other young people. Patients in residential programs have frequent meetings with their team (therapist, dietitian, nurse and/or health care provider, and psychiatrist) and have a lot of group meetings. After residential treatment, patients often meet with an outpatient team, or transfer to an intensive outpatient program.

In-patient: This type of treatment is for people with severe eating disorders who are medically unstable or people who were unsuccessful with treatment at a lower level. Patients receive 24-hour hospital supervision and care and have a very structured schedule. Once medically stable, patients may go home or go to residential treatment.

Treatment of eating disorders varies from person to person. Some people only do outpatient treatment, while others may need to transition through multiple levels of care as part of their eating disorder treatment. Transitioning into outpatient from inpatient or residential treatment may be very challenging in the beginning.

If you are transitioning from inpatient or residential to outpatient treatment, here are some important things to remember:

  • Before you leave inpatient or residential treatment, set up an outpatient team that you can meet with regularly. Ask your treatment team to help you find providers that are the right fit for you and who accept your health insurance. Usually an outpatient team consists of a therapist, dietitian, HCP or nurse practitioner, and often psychiatrist and/or a family therapist.
  • Some days will be easier than others. It’s OK and normal for you to have some challenging days.
  • It will be your responsibility to follow your meal plan when you are in an outpatient setting, not engage in unhealthy behaviors, and maintain a healthy weight.
  • Don’t be afraid to seek support from family and friends when necessary, especially around meals. In some cases, your parents might be asked to be in charge of your meal plan.
  • Think about one meal at a time, and try not to become discouraged if you have a hard time once in a while.
  • Be completely honest with your treatment team and tell them if and when you have any thoughts about disordered eating or if you begin using unhealthy behaviors again.
  • Realize that treatment and recovery are a process and that might mean stepping back up to a higher level of care at some point if your behaviors and/or weight are not improving at the outpatient level of care.

Group Support Meetings can also be helpful before treatment or during recovery. People with eating disorders often find it helpful to meet other people who are experiencing similar challenges. Group meetings are both encouraging and valuable because young people can share stories, feelings, accomplishments, and coping methods. Group meetings can usually be found at local health centers, agencies, or schools.

Therapy: Because an eating disorder is both a medical and psychological condition, most people with eating disorders meet with a therapist or counselor as part of treatment. Although some people may feel embarrassed about going to therapy, it’s important to keep an open mind. Many teens, including those with and without eating disorders, find therapy very helpful.

Why should I see a therapist?

There are a lot of benefits to seeing a therapist and the specific benefits can differ from person to person. Although there are many different types of therapy, therapy tends to be individualized, meaning that you and your therapist will work on what’s most helpful to you.

Here’s what an individual therapist can do for you:

  • Provide a safe place to (privately) share feelings without judgment and without fear of causing problems or hurting someone else’s feelings
  • Give you a place to address other emotional problems that may be related to the eating disorder such as depression, obsessive-compulsive behaviors, and/or substance abuse
  • Help you process parts of your life that may affect your mood
  • Help you figure out reasons why you may have developed an eating disorder, what function/role it has played in your life, and what triggers you to use certain behaviors
  • Help you examine thoughts that might be unhealthy, distorted, or obsessive
  • Teach you healthy ways to cope with stress and manage strong feelings
  • Help you build self-confidence, self-esteem, and a positive body image

One teen wrote: “It has always been hard for me to open up even to my closest family members and friends. When I finally started opening up in therapy and sharing thoughts and feelings that I had never talked about before, I noticed a huge difference in my mood and how happy I was. Since then, my friends have told me what a huge difference they see in me and how much more open I am. I know this sounds cheesy, but there is no way this would have been possible had I not gone to therapy.”

What are the different types of therapy I might find?

CBT (cognitive behavioral therapy): A type of therapy that teaches you how to be alert to the thoughts you have as you do certain behaviors. CBT targets thoughts and behaviors that are unhealthy or unhelpful. The focus of CBT is to decrease negative thoughts or unhealthy behaviors.

DBT (dialectical behavioral therapy): A type of therapy that encourages you to embrace the thoughts and feelings you have but to think in ways that prevent harmful behaviors. It is primarily a group-based therapy with individual therapy back-up. You keep logs of your thoughts and feelings, and you will learn and discuss coping strategies with your therapist.

Family therapy: A type of therapy that involves you and your family members and or friends meeting with a therapist. Many treatment programs will include family therapy because it can be a very helpful place to discuss family issues and tensions while there is a therapist or counselor there to find a solution. It can also be a good place to talk to your family members and friends about your eating disorder and how they can best support you throughout the process of recovery. Note: this is different from family-based treatment (FBT) which is described above.

Group therapy: Is when you and other peers meet with a counselor as a group and can share experiences, stories, goals, etc. It can be very helpful to talk to other people who are going through the same thing as you and get advice on what has helped them.

Tips:

  • It’s ok to feel uncomfortable at first. It takes everyone different amounts of time before people begin to feel comfortable opening up to their therapist. If this is your first time seeing a therapist, it is totally normal for you to be shy.
  • Be honest. Therapy gives you a chance to share how you genuinely feel without being judged or offending anyone. Everything you say to your therapist is confidential, unless you say something that makes them concerned for your, or someone else’s safety. The more honest you are with your therapist, the more helpful therapy will be.
  • If you don’t think your therapist is a good match for you, find another therapist. It’s very important for you to feel like you can trust your therapist. If you don’t connect with them, don’t be afraid to ask your parents to find you another one. The more comfortable you feel, the easier it will be for you to open up and be honest.

Eating Disorders: Healthy Eating

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Eating Disorders Awareness

What is healthy eating?

Healthy eating is important for both your mind and body. During the recovery process, work with your dietitian to help you learn normalized eating habits. The goal of healthy eating is to keep your body nourished, energized, and strong. Eating in a healthy way helps you concentrate and learn in school, reach and maintain a healthy weight, grow to your maximum height, and keep your muscles and bones strong. Healthy eating is not supposed to be strict; it is flexible and may differ from person to person. It involves incorporating regular meals and snacks during the day, eating when you are hungry and stopping when you are full, and enjoying  treats. To eat healthy, you must eat foods from all of the food groups (carbohydrates, protein, fruits, vegetables, dairy, and fats) because each group has different benefits.

Carbohydrates: The carbohydrates in foods like grains and starchy vegetables supply your brain and your muscles with energy. They help keep your mind sharp and focused, and are needed for sports performance. Carbohydrates provide energy to all of the cells in your body and whole grains especially provide the fiber you need for normal digestion.

Dairy: Vitamin D and calcium-rich dairy foods help keep your bones strong. The protein in dairy foods also helps keep you full between meals. Soy milk is a diary alternative that provides similar amounts of these important nutrients.

Fruits/Veggies: These foods contain many important vitamins and minerals, and the fiber you need for normal digestion.

Protein: Protein has lots of important functions in your body such as  nourishing your hair, repairing and building muscles, and making hormones and enzymes.  Protein helps you feel full after a meal or snack.  It also is important for fighting infections and healing wounds and cuts.

Fats: Fats found in oils (such as canola oil or olive oil), nuts, nut butters, and fish are great for your heart and your skin. Eating these and other fats such as cheese and butter with meals and snacks can boost your hormone levels, which may help regulate your periods.  Fat is also important for satiety (feeling full) between meals, and adds flavor to your meals.

Meal plans: Meal plans are designed to help you transition back to healthy eating. During treatment, you may get a meal plan from your dietitian that breaks down each meal into servings of food (called “exchanges”) from the different food groups. Each meal should include exchanges from all or most of the food groups, and the number of exchanges you need from each food group will be based on your nutritional needs. Your dietitian will help you design meals and snacks based on the exchanges on your meal plan that fit your individual needs.

Snacks: Healthy snacks give you energy between meals and prevent you from getting overly hungry. Healthy snacks should be made of two or more food groups. Check out the sample list of snacks below. You can see how the snack ideas are made from different food groups such as the carbohydrate, fat, dairy, fruit, vegetable, and protein groups.

Sample Snack List:

  • Banana with peanut butter (fruit/protein/fat)
  • Grapes and a cheese stick (fruit/dairy/fat)
  • Vanilla yogurt with strawberries (dairy/fruit)
  • Cheese and crackers (fat/dairy/grain)
  • Hummus and baby carrots (fat/protein/vegetable)
  • Nuts and dried fruit (fat/protein/fruit)

Grocery shopping: Try grocery shopping with someone you feel comfortable around. You can work with your dietitian to help set goals for trying new foods or reintroducing foods you used to enjoy. If going to the grocery store seems stressful, your dietitan can help you create a list of foods you plan to buy before you go. Once you are more comfortable with grocery shopping, take time to explore the whole grocery store and look for different brands or new foods to try.

Food journal: A food journal can help you keep track of what you eat, when you eat, your hunger/fullness, and your feelings at the meal or snack time. Recording this information can also help you tune into your body’s hunger/fullness cues and help you identify areas where you need more support. Talk to your dietitian about whether keeping a food journal is right for you.

Cooking: Helping to plan your meals and snacks ahead of time helps minimize the stress that can be experienced during meal preparation. Your dietitian can assist you with meal planning and how to get the best support around meals and snacks.

Hunger and fullness: Eating when you’re hungry and stopping when you’re full will help your body balance its energy needs and keep you feeling comfortable. Part of normalizing your eating habits includes re-learning how to listen to your body. Throughout the recovery process, your dietitian can help you tune into your body’s hunger and fullness cues. Learning to both listen and understand your body’s cues takes time. Using a hunger and fullness scale can help you better understand your body. Rate your hunger level before you eat and after you finish. As you keep track of your hunger/fullness cues you can start to see a pattern in your eating habits. Picture a range of hunger and fullness from 0-10 where “0” means absolutely starving and “10” means uncomfortably full. Ideally you will learn to eat when you are a “3” or “4” and stop eating when you reach a “7” or “8”. If you already keep a food journal, talk to your dietitian about including your hunger and fullness rating in your food journal.

10Stuffed, painfully full
9Extremely full
8Very full
7Full, don’t need to eat more
6Somewhat full
5Not hungry nor full
4Somewhat hungry
3Hungry, strong desire to eat
2Very hungry
1Extremely hungry
0Starved, feeling faint and weak with hunger

Eating Disorders: Myths

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Eating Disorders Awareness

Myth: Everyone with an eating disorder is underweight.

Truth: Although most people with clinically-diagnosed anorexia are underweight, or have lost a significant amount of weight, people suffering from bulimia, binge eating disorder, and OSFED can be at a normal weight, or even overweight. Also, people with eating disorders usually try and hide their bodies by wearing baggy clothes or dressing differently, so you may not notice visible changes to their weight.

Myth: Eating disorders are just an extreme form of dieting.

Truth: Unlike dieting, eating disorders aren’t just about losing weight. Eating disorders are psychological problems with serious physical consequences.

Myth: Only girls and women have eating disorders.

Truth: Eating disorders affect males as well. According to the National Eating Disorder Association, up to 1 in 3 eating disorder diagnoses in teens are male, and disordered eating behaviors in general are as common among males as they are among females. Similar to with women, risk factors for males include being an athlete  in a sport with weight requirements, like wrestling, rowing, and gymnastics, or endurance sports like track and field, cross country, and swimming. Studies have shown that about the same amount of men suffer from binge eating disorder as women. Men with eating disorders might be focused on gaining muscle mass, so it might appear that they are simply “getting in shape.”

Myth: People choose to have an eating disorder.

Truth: No one chooses to have an eating disorder. There is a combination of things that can start an eating disorder, and recovery involves a lot of time and support from family, friends, and eating disorder specialists such as a therapist, nutritionist, and medical provider.

Myth: People with anorexia don’t eat anything.

Truth: Although some people with anorexia eat very small quantities, some just restrict the types of foods or amounts that they allow themselves to eat. For example, they may only eat foods that are low in fat or calories, or foods that don’t have carbs in them. They might also try to hide their eating disorder and attempt to eat what would appear to be a normal amount when in front of other people.

Myth: The media is the cause for all eating disorders.

Truth: The media’s constant focus on dieting, losing weight, and being thin can definitely contribute to an unhealthy obsession with food and weight, but whether or not someone develops an eating disorder has a lot to do with other factors, too.

Myth: Someone can only have one type of eating disorder.

Truth: People with one type of eating disorder can develop symptoms of another eating disorder over time. For example, some people who restrict their food intake may go on to develop binging and/or purging behaviors.

Myth: It’s almost impossible to recover from an eating disorder.

Truth: Complete recovery is possible, but it can take a long time. Recovery can take anywhere from months to years because it requires someone to change the way they think and act about food, as well as deal with stress, trauma, abuse, and/or other psychological problems. It also takes a team of specialists to address all the issues that led to the eating disorder. Recovery can rarely be done without professional help.

Myth: Only white, upper-class teens suffer from eating disorders.

Truth: Eating disorders affect all races, ages, and socioeconomic groups.

Myth: Eating disorders aren’t very serious.

Truth: Eating disorders are serious psychological conditions and can lead to very serious medical problems. Most of these medical problems are a result of malnutrition (not getting enough nutrients) or weight-loss techniques such as vomiting. There can also be medical consequences as a result of self-harm. Eating disorders must be taken seriously and require treatment before they become too severe.

Myth: Eating disorders are rare.

Truth: One research study showed that 0.3% of US teenagers between the ages of 13-18 suffer from anorexia, 0.9% from bulimia and 1.6% from binge eating disorder (Swanson et al. 2011). An even higher percentage of teens use unhealthy weight control strategies such as an extreme dieting and fasting.

Myth: You can never exercise too much.

Truth: It is possible to over-exercise, and it can actually be very dangerous. Over-exercising or “compulsive exercising” is actually a form of purging. Compulsive exercisers will make exercise their top priority, feel guilty when they don’t exercise, and use exercise as a way to either “earn” or “burn off” food and exercise an obsessive amount. They might exercise despite being injured or sick, or exercise regardless of weather conditions.

Myth: You can never eat too healthy.

Truth: When someone becomes obsessed with only eating foods they think are “pure” or “natural,” and limits their food intake to a very narrow selection of “healthy” or “clean” foods, it can lead to what is called “orthorexia” and may be considered a form of OSFED. People with orthorexia often will avoid eating “unhealthy” foods such as those with fats, preservatives, artificial ingredients, and/or processed sugar. By severely limiting the types of foods they eat, they may not be getting essential nutrients such as calcium and fats, which can lead to malnutrition.

Eating Disorders: Glossary

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Eating Disorders Awareness

Amenorrhea: When a female does not get a menstrual period. Amenorrhea is a sign that someone’s weight may be too low or that the hormones in the body are not working right.

Anorexia nervosa: People with anorexia nervosa drastically limit their food intake and have an intense fear of gaining weight, even though they might be significantly low weighted.

ARFID: Avoidance restrictive food intake disorder, which is marked by unhealthy low weight status, nutritional deficiency, and/or interference with social functioning without having a fear of gaining weight or body image concerns.

Binge eating disorder (BED): People with BED eat an unusually large amount of food in a short period of time and feel a loss of control during this episode. They do not purge afterwards, but often feel a lot of shame or guilt about their binge eating.

BMI: Body mass index (BMI) is a number that is calculated for someone’s weight and height. This number is to help determine whether or not someone is below, in, or above their healthy weight range.

Bone density: A measure of how strong your bones are.

Bulimia nervosa: Cycles of binge eating followed by a purging behavior. People with bulimia will eat an unusually large amount of food in a short period of time and then compensate after in an attempt to avoid gaining weight.  They may compensate by exercising excessively and/or purging  by self-induced vomiting or use of laxatives, enemas, or diuretics.

CBT (cognitive behavioral therapy): A type of therapy that teaches you how to be alert to the thoughts you have as you do certain behaviors. CBT targets thoughts and behaviors that are unhealthy or unhelpful. The focus of CBT is to decrease negative thoughts or unhealthy behaviors.

Challenge foods: Foods that people with eating disorders try to avoid because they may be considered unhealthy or because eating them may lead to binging or purging/vomiting. They may also be called “trigger” or “risk” foods.

DBT (dialectical behavioral therapy): A type of therapy that encourages patients to embrace the thoughts and feelings they have but to think in ways that prevent harmful behaviors. It’s primarily a group-based therapy with individual therapy back-up. Patients keep logs of their thoughts and feelings, and during treatment, they learn and discuss coping strategies.

DXA scan: A test that measures bone density.

ED behaviors: A term used to describe habits that people develop when they have an eating disorder. Behaviors may include vomiting after meals, cutting food into very small pieces, counting calories, exercising obsessively, overeating, skipping meals or eating very small meals, etc.

EKG: A test that looks at the activity and rhythm of the heart.

Electrolytes: nutrients (such as salts in your blood and body) that keep the heart and body working properly. These include sodium, potassium, and chloride.

Exchanges: A term used to describe servings of foods from different food groups. Some meal plans are based on the exchange system, meaning they are divided into main groups (protein, fat, starch/grain, beverage, dairy, fruit, and vegetable).

Family-based treatment (FBT): A type of therapy that empowers parents to learn ways to get their child to eat. The therapist meets with the whole family to support the parents in feeding their child and  the child in their efforts to recover. The goal of family-based treatment is weight restoration. This type of therapy is sometimes referred to as the “Maudsley” approach.

Family therapy: A type of therapy that involves you and your family members meeting with a therapist together. It can be a helpful place to discuss family issues and tensions while a therapist or counselor is there to find a solution.

Group therapy: A type of therapy  where peers share experiences and stories with each other, and is usually led by a therapist or counselor.

Median body weight: The average weight for a particular height.

Meal plan: An eating plan that is designed by your registered dietitian. A meal plan gives recommendations about the amount and types of food you should eat to achieve or maintain a healthy weight.

OSFED: Other specified feeding or eating disorder, which is a combination of symptoms of eating disorders such as an intense fear of weight gain and a preoccupation with food (thinking about food or having food related thoughts most of the day) that does not meet the clinical diagnosis for anorexia nervosa, bulimia nervosa, or binge eating disorder.

Purging: Describes any behavior that someone with an eating disorder uses to “get rid of” calories. Purging behaviors include vomiting, taking laxatives, diet pills, or excessive exercise.

Safe foods: Foods that people with eating disorders can eat comfortably. Safe foods are often unprocessed, low-fat, or low-calorie foods, but can be different for every person.

Trigger: Anything that makes someone want to engage in certain behaviors or have eating disordered thoughts.

Vital signs: Measurements which include body temperature, blood pressure, and pulse.

Weight goal range: A range of weight that your treatment team decides is a healthy weight for your recovery. It takes into account what a person weighed before the eating disorder. A person’s weight range will increase as they grow and get older.