What is the current best-practice for prevention of eating disorders among adolescent/young adults based on reduction of eating disorder risk factors (as determined by previously validated eating disorder behavior questionnaires)?
Elizabeth Parker, RD and Margery Lawrence, PhD, RD
December 6, 2017
Introduction: The purpose of this study was to determine the current best intervention program for reducing the risk of developing an eating disorder (ED), based on previously validated eating disorder behavior questionnaires. With over 10% of adolescent/young adult females developing eating disorders, prevention is increasingly important. Method: An evidence-based review was conducted looking at programs designed to reduce risk factors that have been shown to be associated with developing an eating disorder among high school and college students. The research found was limited to females, and primarily focused on those experiencing body dissatisfaction. Results: Twelve studies were reviewed, nine of which found cognitive-dissonance prevention programs to be significantly more effective than control groups. Conclusion: Cognitive dissonance-based programing (the Body Project) was found to be the most effective way to change negative beliefs and behaviors that lead to EDs among females. Further research should include studies that look at broader population bases, creating programming for males and those of the lesbian, gay, bisexual, transgender, and queer community (LGBTQ).
The prevalence of eating disorders (ED) has grown quite high, with approximately 10% (or more) of adolescent girls/young women meeting the diagnostic criteria for eating disorders based on the DSM-IV or DSM-5.1, 3, 4, 6, 7, 9, 10, 11 Additionally, roughly 50% of college-age women may have subclinical disordered eating behaviors.10 Behaviors and conditions commonly associated with disordered eating include: dietary restraint, purging (self-induced vomiting, over exercise, laxatives, diuretics, diet pills), binge-eating, self-deprecation, negative affect, difficulty regulating emotion, anxiety, depression, self-harm, thin-ideal internalization, and body dissatisfaction to name a few.
Many women who do receive treatment do not fully recover from their ED (e.g. 44% of those with bulimia nervosa do not, and that percentage is greater for those suffering from anorexia nervosa)10 which is why prevention of these disorders is so important. Early assessment and intervention is crucial for the best odds of recovery and restoration of health, especially in those under the age of 19.4 EDs generally develop in adolescence and prevention programs are more effective in early adolescence.6 On average, body dissatisfaction peaks in later adolescence but these older adolescents may be able to better comprehend the need for intervention of socially promoted “thin ideal.”6
It is concerning that only one-third of people with an ED have been asked about eating-related issues by their primary health care provider.4 Furthermore, less than one-third of people with EDs receive treatment!4, 6 Given that more people will see a primary medical provider than a specialist, primary care providers have an opportunity to assess patients for eating disorders and should be trained in how to screen for them.4 Many medical providers said they felt “ill-equipped” to screen for or treat eating disorders.4 Since schools have a unique opportunity to track and influence students over a longer period of time, many studies have looked at prevalence and prevention strategies among students.
Prevention programs are relatively new in the field of ED research, and are not widely practiced. In fact, most of the available studies performed to evaluate these programs were performed by the same pool of researchers. The purpose of this evidence-based review was to determine the current best intervention program for reducing the risk of developing an eating disorder, based on previously validated eating disorder behavior questionnaires.
Several programs were seen repeatedly among the various studies, suggesting that there was already some consensus on what programs might yield the most significant reductions in ED risk factors. The studies looked at reduction of ED risk factors, especially surrounding thin-ideal internalization, dieting practices, body dissatisfaction, depression/negative affect, and used similar self-reported scales.
Overall, the studies indicate that features of useful ED prevention programs include: cognitive-dissonance-based programing, multiple sessions (instead of a single session), interactive sessions (group, or other interaction), facilitation by professionals (as opposed to peers, teachers or other endogenous staff), use of validated assessments, and avoiding education about EDs and effects of EDs.
A Pubmed search was performed on August 21st, 2017 using the following search criteria: ((feeding and eating disorders/prevention & control*)) AND ((young adult OR adolescent) AND students) AND (risk factors AND eating disorders) AND ("last 10 years"[PDat] AND Humans[Mesh] AND English[lang])
The search yielded 35 articles, twenty of which were initially selected based on the abstract. This was further reduced to twelve by excluding any age groups that were not high school or college (undergraduate/graduate level). Since this is a relatively new topic (especially in areas of peer leaders; 2,9,12 internet-based program; 7 and female athletes 10), all study designs were initially included due to the small number of available studies. The significance was held at p= or <0.05 for all studies.
Of the resulting 35 articles, 23 were excluded due to: age of population, abstract not indicating ED prevention, or study types such as interview, reviews or meta-analyses. Twelve articles were selected for review as follows in table 1.
Of the 12 articles, 10 looked at cognitive dissonance-based (CD) prevention programs. Of those 10, 9 concluded that CD programs produced more significant reductions in ED risk factors than other prevention programs. The one exception was the study that focused specifically on athletes.10
Table 1. Study Comparison Table (click file to see PDF of table)
There are previously validated assessments for mental health and eating disorders as seen in the assessment methods used in the studies (see “key to abbreviations” at the end of this paper). These assessments were used to determine if there was a reduction in negative thoughts and disordered behaviors among participants.
The four most common interventions examined in studies were in-person cognitive dissonance-based programs (CD), internet-based cognitive-dissonance based programs, the NEDA brochure, and the documentary “Dying To Be Thin.” The most effective of these was in-person cognitive dissonance-based programs.
Cognitive Dissonance-Based (CD) ED programs (The “Body Project”):
Cognitive dissonance “is based on the presumption that creating an inconsistency between a belief and a behavior will elicit a feeling of discomfort in an individual”2 and that the individual will need to change the behavior to remove the discomfort. Programs focused on CD help to promote behavioral changes because consistency between beliefs and behaviors is human nature. By challenging disordered beliefs, behaviors are challenged; and to remain consistent behaviors must change along with the belief.7
The Body Project is an in-person CD group program, typically: 4 weekly 1-hour sessions, with 7-9 participants per group, led by a trained (for 9 hours) and scripted facilitator (counselor or peer).1 CD programs had the greatest effect on reducing ED symptoms in all the studies that included the “Body Project” as an intervention. 1, 2, 3, 4, 6, 9, 11, 12 CD challenges the thin ideal by creating cognitive dissonance with written, verbal, and behavioral exercises.1 With adequate training it worked for peers to “teach” the material, but not facilitate difficult discussions.10 Group programs, like the Body Project, further increase behavior change by the extra layer of public accountability.7
The Body Project has the greatest amount of research (relative to similar programs) and has a strong evidence-base.12 All researchers who used this intervention cited efficacy trials for dissonance-based programs that showed promise. The American Psychological Association (APA) supports dissonance-based prevention programs for interventions, for creating replicable results, and creating significant results against the control groups at 2 and 3 years, and to a 60% greater effect than assessment-only control groups.10 Many of the study authors commented that more sessions may have produced greater results.2, 4, 10
Internet-based Cognitive Dissonance Based Programming (The “eBody Project”):
The e-Body Project is CD-based like the Body Project, but delivered via the internet. The program was designed to remain interactive, and contains 6 modules to be completed over 3 weeks, at 30-40 minutes/session.1 The internet has become a constant source of thin-ideal, so to have the internet challenge that ideal through this program is very timely.1
Two studies reported that many schools and other settings found it difficult to recruit clinicians (school counselors/nurses/teachers) to learn the Body Project and lead the groups.7, 9 With over 95% of adolescents having internet access,1 a larger population can be reached via the internet.
The e-Body Project showed promising results where the in-person Body Project could not be performed. The ED risk reduction results were not as strong which may be due to the fact that participants could go through this program faster, meaning that there was less time submerged in the messaging. This had less impact on reduction of thin-ideal internalization.7
“Dying To Be Thin”:
This is a 55-minute documentary (McPhee, 2000). Widely-available at no-cost, this video covers body image, pressures to be thin, eating disorders, treatment, recovery, and consequences of eating disorders.1
This is a two-page brochure (National Eating Disorders Association, 2002) covering negative and positive body image and how negative body image may lead to eating disorders. The brochure lists ten steps to positive body image.1, 11
Quality of Studies:
The studies were inconsistent in quality. Though the majority (8 of 12) were randomized control trials (RCT), the criteria and methods left many of them lacking, with five of the twelve receiving a negative (-) grade. Four were well organized and received a positive (+) rating. Most of the studies had a strong conclusion, but due to lack of generalizability (homogeneity) or sample size, most (8 of 12) were categorized as a grade II, with only one study deserving of a grade I. Overall, the grade of research is: II, neutral.
All of the studies focused solely on females, with relatively homogeneous populations. Demographically, studies were representative of female students at American universities, but not the population at large.1, 3, 4, 5, 7, 11 Additionally, all of the studies had sample sizes of less than 1000 participants, the majority having less than 200.
There was a great likelihood of selection bias in all of the studies, as participants could voluntarily opt-in to the study or opt-out at any time. Several researchers noted that the participants who stayed in the studies may have had more interest in the topic of body image. Therefore, it is difficult to draw conclusions on how effective the interventions would be with a more universal population. Furthermore, as the study assessments were self-reported surveys, there was potential for error in interpretation of questions, or in answering questions how they think the researchers want to hear.
In conclusion, based on the studies reviewed, cognitive dissonance-based prevention programs in group settings (such as the Body Project) created the greatest reduction in ED risk factors, even at 3 years-post intervention, compared to control interventions. These CD-based programs have a greater likelihood of success in settings such as schools, especially Colleges/Universities. This is because of the unique setting schools offer in which it is often easier to deliver prevention programs. Although trained counseling clinicians were most effective, several studies noted that training peer leaders or other endogenous staff (such as teachers or school nurses) led to a statistically significant reduction of ED risk factors compared to control groups.
The one study that had participants go to a medical clinic, rather than having programming done at school, had high dropout rates.4 The authors explained that this was due to the greater time and effort needed to go to an off-campus clinic. This further shows how much more effective campus settings can be for prevention programs. With over 11.5 million female college students in 2017 in the U.S.13 (meaning approximately 1.15 million of which will develop a diagnosable eating disorder, given a 10% prevalence) this is utterly important.11
Universal programs (inclusive of all genders):
It was stated in one paper that there was research showing that programs targeting high-risk participants led to greater effects than programs that were “universal.”9 However, none of the studies evaluated for this review were universal, in that they were aimed at only females with body image concerns who did not have a diagnosed eating disorder. We believe that further studies could be done to assess whether or not cognitive dissonance-based prevention programs would be effective for males or those of the LGBTQ community. Due to body image differences among genders/gender identity, there would likely have to be different content for the CD programming to make it effective.
Programs for those with active EDs:
Potential participants with diagnosable EDs were excluded from all of the studies reviewed. This leads us to believe there is a gap in the research for programs that will reduce ED risk factors in those with clinical levels of EDs. This may be because at the point of having a diagnosable ED, it is not “prevention” anymore, but rather treatment. The disheartening piece is that according to background research in two studies (Linville, Cobb, Lenee-Bluhm, et. al; and Muller and Stice) over two-thirds of people who have EDs do not get diagnosed or receive treatment.4,6 Further research in programming that can help those with active EDs (who have not yet been identified as such) would help bridge the treatment gap.
Using this information in practice, we believe that all colleges should offer cognitive dissonance-based group programming (the Body Project). Ideally these groups would be led by trained counselors, but training peer leaders was also proven to reduce ED risk factors, and in remote areas (distance-learning / places where they cannot recruit leaders) internet versions of the Body Project can be offered. Challenging what people believe about body image and eating habits changes their behaviors to remain consistent with new beliefs. By inviting them to publically (in a group setting) denounce the thin-ideal (or other body image fads) they set themselves up for creating positive changes.
*Key to abbreviations:
AIM = Affect Intensity Measure (Larsen, 1984)
BDI = Beck Depression Inventory (Beck, Steer, & Garbin, 1988)
BMI = Body Mass Index
BSQ = Body Shape Questionnaire (Cooper, Taylor, Cooper, & Fairburn, 1987).
CDI-SF = Child Depression Inventory - Short Form (Kovacs, 1992)
CES-D = Center for Epidemiologic Studies - Depression Scale (Radloff, 1977)
DERS = Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004)
DRES = Dutch Restrained Eating Scale (van Strien, Frijters, Van Stavern, Defares, & Deurenberg, 1986)
DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. (American Psychiatric Association, 1994)
DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, Fifth edition. (American Psychiatric Association, 2013)
EAT-26 = Eating Attitudes Test (Garner, Olmstead, Bohr, & Garfinkel, 1982)
ED = Eating Disorder
EDDI = Eating Disorder Diagnostic Interview (Stice, Burton, & Shaw, 2004)
EDE = Eating Disorders Examination (Fairburn & cooper, 1993).
EDE-Q = Eating Disorder Examination-Questionnaire (Fairburn & Beglin, 1994).
EDDS = Eating Disorder Diagnostic Screen (Stice, Fisher, & Martinez, 2004)
EDI = Eating Disorder Inventory (Garner et al., 1983)
HWI = Healthy Weight Intervention (program) (Stice, Chase, Stormer, Appel, 2001; Stice, Shaw, Burton, & Wade 2006)
IBSS-R = Ideal Body Stereotype Scale-Revised (Stice, Ziemba, Margolis, & Flick, 1996).
PANAS-X = Positive Affect and Negative Affect Scale-Revised (Watson & Clark, 1992)
PSPS = Perceived Sociocultural Pressure Scale (Stice, Presnell & Spangler, 2002)
PSPS^ = Perceived Sociocultural Pressure Scale (Stice, Ziemba, Margolis, & Flick, 1996)
SATAQ-3 = (Sociocultural Attitudes Towards Appearance Questionnaire - 3 (Thompson et al., 2004)
SD-BPS = Satisfaction and Dissatisfaction with Body Parts Scale (Berscheid, Walster, & Bohrnstedt, 1973)
TOSCA-3 = Test of Self-Conscious Affect-3 Scale (Tangney, Dearing, Wagner, & Gramzow, 2000)
1. Stice E, Rohde P, Durant S, Shaw H. A Preliminary Trial of a Prototype Internet Dissonance-Based Eating Disorder Prevention Program for Young Women with Body Image Concerns. Journal of Consulting and Clinical Psychology. 2012;80(5):907-916. doi:10.1037/a0028016.
2. Black Becker, C, Bull, S, Smith, L, Ciao, A. (2008). Effects of Being a Peer-Leader in an Eating Disorder Prevention Program: Can We Further Reduce Eating Disorder Risk Factors? Eating Disorders.16(5), pp.444-459.
3. Stice E, Rohde P, Shaw H, Gau J. An Effectiveness Trial of a Selected Dissonance-Based Eating Disorder Prevention Program for Female High School Students: Long-Term Effects. Journal of Consulting and Clinical Psychology. 2011;79(4):500-508. doi:10.1037/a0024351.
4. Linville D, Cobb E, Lenee-Bluhm T, López-Zerón G, Gau JM, Stice E. Effectiveness of an Eating Disorder Preventative Intervention in Primary Care Medical Settings. Behaviour Research and Therapy. 2015;75:32-39. doi:10.1016/j.brat.2015.10.004.
5. Levitt DH. Participation in Athletic Activities and Eating Disordered Behavior. Eating Disorders. 2008;16(5):393-404. doi:10.1080/10640260802370556.
6. Müller S, Stice E. Moderators of the Intervention Effects for a Dissonance-Based Eating Disorder Prevention Program; Results from an Amalgam of Three Randomized Trials. Behavior Research Therapy. 2013;51(3):128-133. doi:10.1016/j.brat.2012.12.001.
7. Stice E, Durant, S, Rohde P, Shaw H. Effects of a Prototype Internet Dissonance-Based Eating Disorder Prevention Program at 1- and 2-year Follow-up. Health Psychology. 2012:77-86. doi:10.1093/med:psych/9780199859245.003.0007.
8. Gupta S, Rosenthal MZ, Mancini AD, Cheavens JS, Lynch TR. Emotion Regulation Skills Mediate the Effects of Shame on Eating Disorder Symptoms in Women. Eating Disorders. 2008;16(5):405-417. doi:10.1080/10640260802370572.
9. Stice E, Rohde P, Durant S, Shaw H, Wade E. Effectiveness of Peer-Led Dissonance-Based Eating Disorder Prevention Groups: Results from Two Randomized Pilot Trials. Behaviour Research and Therapy. 2013;51(4-5):197-206. doi:10.1016/j.brat.2013.01.004.
10. Becker CB, Mcdaniel L, Bull S, Powell M, Mcintyre K. Can We Reduce Eating Disorder Risk Factors in Female College Athletes? A Randomized Exploratory Investigation of Two Peer-Led Interventions. Body Image. 2012;9(1):31-42. doi:10.1016/j.bodyim.2011.09.005.
11. Stice E, Rohde P, Butryn ML, Shaw H, Marti CN. Effectiveness Trial of a Selective Dissonance-Based Eating Disorder Prevention Program with Female College Students: Effects at 2- and 3-year Follow-Up. Behaviour Research and Therapy. 2015;71:20-26. doi:10.1016/j.brat.2015.05.012.
12. Greif R, Becker CB, Hildebrandt T. Reducing Eating Disorder Risk Factors: A Pilot Effectiveness Trial of a Train-the-Trainer Approach to Dissemination and Implementation. International Journal of Eating Disorders. 2015;48(8):1122-1131. doi:10.1002/eat.v48.8.
13. Back To School Statistics. National Center for Education Statistics Website. https://nces.ed.gov/fastfacts/display.asp?id=372 Published 2017. Accessed November 11, 2017.
Hello my lovely readers,
I know post a lot of educational and technical stuff, and I bet you wonder (if you don’t know me in real life) what I am actually like. Honestly, I’m a normal (albeit, busy!) person. So here is a bit about me, and an action for you to take.
Probably my biggest passion is musical theatre. I have been on stage since I was 11 years old, and continue to find my happy place on stage especially when I am dancing. Last year, among my jobs I was in 4 musicals, and a short film. Acting, dancing & singing are my personal anti-depressants.
One of those musicals, Hairspray, was especially meaningful in regards to my practice (for those who think this musical is just “fluff” - look deeper!).
Here’s why it was so meaningful to me:
One major theme in this show is body acceptance. The main character, Tracy, and her mother, Edna, are very overweight. This causes bullying and rejection in their lives (anyone else been there?), but they learn that their clothing size does not determine how far they can dream. The learn how to love themselves as the amazing women they are and rise above the criticism to prove to everyone that size does not determine who you are or what you can achieve.
“I’ll eat some breakfast then change the world.” - Tracy, Hairspray
Another important theme in the show is racism. In addition to rejecting people of larger sizes, the (1960’s set-show) white characters reject the black characters and try to prevent integration on TV. This was supposed to be a historical context, but unfortunately our world is still proving the relevance of needing to learn to accept everyone for who they are.
It is never ok to judge someone by the color of their skin, the size of their body, or by other trivial means! Thankfully, the show has a happy ending (sorry, spoiler alert!) and by the end of the show everyone is singing and dancing together on television, proving that it takes all kinds. This is the kind of show I love, it sparks hope for the future.
If you haven't seen Hairspray - watch it for some inspiration (the movie version with Zach Efron is good).
So, obviously I don't act every day. And I often have people ask me (especially when they find out I am majorially self-employed) What are my typical days like?
Well, “typical” is a stretch, as I feel like no two days are the same, but I wouldn’t have it any other way.
Normally, a few days a week I go to a coffee shop for several hours and work on my business (including writing these emails), If not at a coffee shop, then my home office (but it is harder to work from home). I actually really enjoy this work, and often 4+ hours slide by before I even think to look at the clock. It takes a lot of work to keep up the website, write emails and blog posts (looking for guest bloggers - btw!), posting and responding on social media, coming up with video ideas/scripts, responding to client emails, answering journalist requests (check out the articles I have been quoted in HERE), and all of the tiny tasks of running a business.
I see clients most days of the week, some days only 1, or up to 8 on fridays! I take dance classes, watch netflix with my dogs, clean the house/run errands, sleep in when I can, and eat pizza frequently (hubby recently got a pizza oven - we have been eating a lot of pizza!).
Why did I just tell you all of this?
To show you I am a person, just like you. I’m not a machine, or “wonder woman” as one client called me. I am a complex, passionate, (and lately tired) human being.
I am not defined by my body.
Neither are you.
Who are you without the labels others put on you? What are your passions and hobbies? What gets you fired-up? What would life be like if you didn’t use food as a crutch to hide behind?
Are you ready to re-define yourself?
Share who you really are on the Not Your Average Nutritionist facebook page or Instagram with the tag #MoreThanILook
I can not wait to hear who you are!!
In the words of another powerful musical (Newsies):
“Now is the time to seize the day,
Stare down the odds and seize the day,
Minute by minute that's how you win it,
We will find a way,
But let us seize the day.
Courage cannot erase our fear,
Courage is when we face our fear.
Tell those with power safe in their tower,
We will not obey!”
Love, Your complex Dietitian,
In 2012 I started my private practice with one client, a pad of paper, pen, and a business license.
5+ years later I have a thriving business of clients, online work, contractor positions, and my own office; but it took some work to get there and figure out all the details along the way.
In this article, I am going to give you the quick guide of necessary things to do/get and what to skip to get your practice up and running without taking out a loan.
Assuming you are already a licensed professional (RD):
1. Get malpractice insurance. You want to be covered if any lawsuits come up (RDs are very low risk). As a sole-proprietor I think I paid $99/year, now I pay $118/year as an LLC (I will explain what these are below). If you have worked elsewhere you might already have malpractice insurance. For RDs, "Mercer Proliability" is the main company used.
2. Depending on where you will be practicing, you need to go to the city or county for a business license. This has an annual fee as well, but it establishes you as a business. There are a few kinds of business structures, but as a one-person business you really only need to know about 2 of them: "Sole-proprietor" and "Limited Liability Company" or "LLC." I am no legal expert, so I won't go too deep into this, but here are the basics (google "sole-proprietor" or "LLC" or "business legal structures" for more info):
A sole-proprietor is what most RDs choose/start as. This is what I chose to start with, and it was easy. It has the lowest fees, and for legal/tax purposes you and your business are one in the same.
LLC is a step-up from sole-proprietor, in that it separates you from the business and adds a buffer of legal protection. LLCs can be single-member, or multiple "members." The cost and taxes are higher/more complicated, but you can hire employees.
3. Choose a "Doing business as" name (aka: "DBA"). This can be your own name (easy) or a business name. Make sure your name has not already been taken. Wherever you register your business they can guide you in how to search names, and the requirements. Chose carefully - this is how the public sees your business; but it can also always be changed later (I did this. It was a hassle, but worth it).
4. Separate your personal money from the business's money. When I started my business I opened a business checking/savings account (which I recommend doing as soon as your business name/license go through) and put $3K of my own money in it to get started (you can probably do this all with $1K, but I didn't know at the time). The fact that that money was basically my whole savings made it so I couldn't fail - it was my money on the line. I recommend this for starting a business. Take a risk on yourself and prove that you can succeed.
5. Get the bare office essentials (you probably have most of this): notepad and pens (I like to use legal pads) for taking notes during a session; hanging file folders; a way to lock up client notes (filing cabinet with lock or locking briefcase - I got a locking briefcase for $20 that became my traveling "office" the first 2 years); cards and stamps (it's nice to handwrite thank you notes to clients - I aim to send one to all my new clients).
6. Business cards: don't bother getting more than 250, you will change your info/logo/etc once you figure your business out more. You don't have to have business cards, but it looks/feels more professional.
*bonus tip - skip other physical marketing materials (flyers, banners, rack cards, newspaper ads) when you are just starting out. They are expensive, and really don't work that well. This comes from my personal experience. I spent 100's of dollars on marketing materials that got me maybe 1-2 clients. NOT WORTH IT until you are in the big-time (and maybe not even then).
7. Have a website - even if it is a work in progress! Everyone looks online nowadays, this should be listed on your business card, and potential clients can look at it to see a photo of you and services you offer/philosophy/etc. There are several free (starting) website builders out there. I use Weebly, but Wordpress is very popular, as are Wix and Squarespace. See what you like/seems easy enough for your skill level. I like weebly because it is drag-and-drop, but it doesn't have all the features that something like Wordpress has with "plug-ins."
Things you can wait on:
Ready to go start your practice? I hope this helps you get started with lower start-up costs!
If you have questions feel free to shoot me an email. I am contemplating taking business start-up clients for mentoring (there is a cost for this).
(A lot of people ask me how I started my business, and why I got into the field of eating disorders. While I do usually tell whomever asks, I have put-off writing this for a while. Maybe because I haven't felt that I have really "made-it" yet, maybe because I don't want to get that personal. Anyway, here's how I came to be "Not Your Average Nutritionist."
When I first passed my Registered Dietitian exam, I was about to get married, and was looking for a local job in my field.
That was going to be a lot harder than I first realized.
I spent about a year and a half (!!!) applying for, interviewing (several rounds), and networking for various jobs in any position as a dietitian. Unfortunately, there was always someone with 10 years of experience, or bilingual speaking, that would swoop in and get the job. (Eventually I did end up with a temp job with County Public Health after that year and a half).
While I was looking for my first "real job," an email had come through our local dietetic association from a young woman who was starting college locally, and was relapsing into anorexia nervosa (for which she had previously had some outpatient treatment). She was looking for a female, Christian, dietitian to work with her. I sent an email back asking if she wanted to give me a try (being new and all).
Now to give a little more background on the eating disorder part of this, in school/internship we spend very little time on eating disorders as undergraduate nutrition majors. Of course we had to learn some about it, but it just does not go very deep at that level of education (which is also why I went back for my Master's). So why did I think I could do it?
#1, I was desperate; and #2, I had struggled with restrictive eating during my early college years, and understood her mindset. She agreed, and I met with her and her mom to see if we would be a good fit. This was the start of my entrepreneurial journey.
Fast forward a few months and I had read countless books on eating disorders and sought out a mentor in (who I didn't realize at the time was a founding expert in the field, and whom many others call "a rock-star!") a local RD, Francie White, who allowed me to come watch her work, and help with the IOP/PHP treatment center in Santa Barbara, CA. Since I (still) didn't have another job (other than teaching some group fitness classes), I set my mind towards making a legal business.
With the help of a local non-profit organization, SCORE, I figured out what I needed to do to get a business license, and set up bank accounts. My first business name was "Libby's Fit Nutrition." I thought I would focus more on helping stay-at-home moms with weight loss and fitness. I did have a handful of those clients (whom I met in their homes), but pretty quickly I was finding that a lot of people who desired "weight loss" really had disordered eating or bad dieting practices, and I found myself doing more education around that. The more I worked with these clients and learned about EDs, the more passionate I became. I took some more psychology classes through community college, and contemplated what to get a Master's degree in.
Fast forward another 2 years or so, I was working as a teacher (Allan Hancock College) and in Corporate Wellness (Provant/PG&E). My online presence had generated a lot of interest from college students who were having issues with disordered eating. I was seeing so many students from Cal Poly (the local college), that I was talking on the phone almost every week with one of the school's nurse practitioners (the amazing, June Stanley) about shared clients. One night as we were talking about how many students she was seeing with eating disorders, she (I thought, jokingly) said "we should just have you on campus." Little did I know that conversation would lead to BIG things for me.
A few months later, I turned on my phone to see a voice mail from Dr. David Harris, Cal Poly's Executive Director of Campus Health and Well-Being. His message asked me to call back and set up a time to meet. He heard I was THE person to go to for eating disorders, and wanted to hire me to be on campus to work with the students at no cost to them. (Fun fact: when I walked into that first meeting after saying hello, his first words were, "when can you start?")
I started working at Cal Poly in Spring of 2016, as the first Registered Dietitian (as far as we know) to be specifically hired at a CSU to work with students with eating disorders!
I love my job! It is so nice to have co-workers who respect me and my opinion, since starting we have developed a multi-disciplinary treatment team, getting involved with athletic trainers and coaches for more open communication about the college athletes health and eating disorders, and I have been able to provide some in-service trainings to the medical staff.
This past year I changed my business name to "Not Your Average Nutritionist," to better represent what I was doing (not many RDs are competent in the area of eating disorders, and even less seem to focus more on the person and coping skills than the food piece), and I was no longer focusing on the fitness aspect. I also changed the legal structure from a sole-proprietorship to a LLC, for more legal support and the ability to hire staff in the future. I have a lot of lofty goals for my business in the next 10 years or so, but for right now I want to slow-down and savor the process.
So, where am I with my business now?
- Still working part-time at Cal Poly (over-booked, but feeling competent)
- Seeing some private clients.
- Almost done with my M.S. in Nutrition Science (emphasis in EDs).
- Working with a supervisor (Cynthia Saffell, MS, RD, LCSW, CEDS) for an advanced credential in EDs (IAEDP - CEDRD).
- Teaching at Allan Hancock
- Feeling better about my own body image than ever.
- ...and getting ready to launch a new phase of my business in 2018! Stay tuned for online nutrition courses!
Moral of the story:
Do great work.
The rest will fall into place.
You got this!
So exciting! This is now my third "Top Nutrition Blog" list to be included on:
"Top 21 Nutrition Blogs You Should Know About"
I have previously been listed on "Top 100 Nutrition Blogs" (2016), " 100 Leading Sites for Holistic Nutrition Consulting & Therapy" (2014), and " Best 150 Health and Nutrition Blogs" (2017).
Thank you to all my readers! You are the reason I do this.
How I experienced “To The Bone” as an eating disorder expert & Why you need to carefully consider if you should watch it
There was a lot of buzz leading up to the release of Netflix’s “To The Bone” on July 14, 2017. As a Registered Dietitian who specializes in eating disorders I was intrigued. In this film, actress Lily Collins played Ellen, a young woman with anorexia nervosa who goes into a couple of different treatment centers and bounces back out to home or hospitals. Collins has been very forthcoming that she previously struggled with anorexia nervosa, which made me more nervous about her losing weight for the role.
When I first heard that there was going to be a film made about eating disorders, I thought this would be a great opportunity to raise awareness of what eating disorders are like. And hopefully get people talking in a productive way about the different types of eating disorders and how it is not a good thing to get one...but as the trailer and initial interviews came out in the weeks leading up to the release, I instead became worried that it would not only depict the stereotypical white emaciated anorexic girl (which it did), and be triggering to those dealing with body image issues (it probably will), or teach new bad habits (for some it will - that scares me most of all!). Here is my take on the film as I watched it and took notes, the good, the bad, and the triggering (spoiler alert).
OPENING: I must commend Mockingbird Productions for starting the film with the statement, “The film was created by and with individuals who have struggles with eating disorders, and it includes realistic depictions that may be challenging for some viewers.” I hope they don’t consider that their liability statement, but they tried. In the opening scene we see “Ellen” at a residential treatment center in art therapy class. She looks visibly bony, and it only gets worse through the film (not sure if it changes due to eating less, make-up tricks, or what, they did claim the use of some prosthetic bones, though). In articles that came out prior to the film release, it was said that Collins lost weight under supervision of a “nutritionist.” I don’t know who this “nutritionist” was, but there is no way in a true health professional that knows a thing about eating disorders would allow someone to lose that much weight, ethically, especially since she has a history of anorexia and might suffer physical and mental complications of going through the trauma of extreme weight loss again. I also use “nutritionist” because that is the word I found for the unnamed person who guided her weight loss, and if it was actually a Registered Dietitian or other licensed health professional they would (or should) have their license revoked for unethical behavior.
Weight cycling (large fluctuations up or down) is very hard on the body, which likes to maintain homeostasis (or “same-ness”). Every time we lose weight our metabolism (calorie needs) goes down. When we gain weight back our metabolism does not go all the way back to “normal,” this is why it gets harder and harder to lose weight if you have been on many diets. In addition to lowered metabolism, as was briefly mentioned in the film, the body has to rely on energy (calories) from muscle and organ tissue to survive, which can cause irreversible damage. Having Collins go through extreme weight loss again could have done real damage to her body (organs, bone density, fertility, cardiovascular system) that she might not know about until years later.
CALORIE TALK: In the following scenes there are definite strengths and weaknesses apparent to anyone who is in the field of eating disorders. As seen in the trailer, there is a scene where Ellen is quickly counting calories on a dinner plate. This is a strength in that it is very realistic to how a person with anorexia’s mind typically works, but any time calories are brought up (in a few scenes) it is a potential trigger for some viewers. It also glamorizes the “ability” of knowing what is in your food. With so many people on diets that require calorie counting, I am sure many think it would be “easier” to have anorexia to be able to not only count fast, but to abstain from eating. If you are one of those people reading this - IT IS NOT WORTH IT! (Contact me personally, I will walk you through the why nots, I don’t have the space in this article). By the way, eating disorders (ED) are not a choice. They have genetic and environmental components and are a person’s way of coping with a perceived problem or trauma, similar to the way an alcoholic turns to alcohol to numbs themself from emotion.
BEHAVIORS: Continuing on, maybe it is because I live in a part of California where cigarettes are banned in public spaces, but smoking is not nearly as common among ED/weight loss as it was 10+ years ago. Ellen is seen smoking throughout most of the film, and I hope people don’t continue that stereotype along with most EDs being anorexia nervosa (they’re not - binge eating disorder and “other specified feeding and eating disorders” are much more prevalent).
Other behaviors throughout the film that the director/actors got right are body checking (Ellen keeps checking her arm circumference with her hand, and her roommate calls her out on it), flushing meds down the toilet due to fear of weight gain (don’t go off meds without Dr approval), the roommates “barf bag” and laxatives, cutting breading off of chicken, passing out when she stood up fast (this is caused by low blood pressure when not eating enough), stair running to “burn” calories, and the doctor noticing the bruises on the bones of the spine and calls her out on doing sit-ups.
WEIGHT: More triggering, but truthful scenes, include Collins taking off her shirt to get weighed, and at the end of the film you see her naked (artfully laid on the ground to cover private areas). She is truly emaciated. This took my breath away- as you can only do so much with makeup, she had to lose a lot of weight for this role. It makes me so sad. Near the end of the film (spoiler) she has a “dream” where she is healthy and happy, and she has some weight on (probably shot first before she lost the weight), and she is gorgeous. There are no bones protruding, she is on the slim side of normal weight.
The treatment facility where most of the film takes place did a good job of having a range of body types and disorders. Most people with ED are not underweight. There was a larger binge-eater, some average-size people with bulimia and anorexia, a male, a pregnant woman, and different races (though still overwhelmingly white). While the other behaviors of binge eating and bulimia were touched on, the film was primarily about anorexia. I wish they had shown more of the other disorders, to make a point that EDs are not just thin white girls.
PROFESSIONALS: I thought the doctor, therapist, and nurse were all very well written and played. Any of their interactions were probably my favorite part of the film. In group therapy, the therapist was great at getting the participants back on topic in a realistic way, and concluded a talk with “there is never thin enough.” The nurse and doctor being more upfront and brazen with their speech is likewise true to life. They all easily call out Ellen on her behaviors and things happening to her body (ex: lanugo hair, body burning muscle and organs when not eating) in very realistic ways.
TREATMENT: The treatment facility that most of the film takes place in is a good depiction (though a bit cleaner/newer than most) of a residential treatment center. They call it inpatient in the film, which is incorrect, it is residential. Something that seemed off to me, but maybe some places do this, is that the patients were allowed to eat what and how much they wanted for every meal with no real consequences, and most of the time no professionals ate with them. From my visits to and talks with treatment centers, there is always at least one staff member present, and if they do not finish their meal, typically a liquid supplement like Ensure or Boost would be required. I did like that the anorexic man said he gets a “crazy burst of energy” when he eats. I have heard that from a lot of my clients when they start eating again.
It was realistic for the nurse to go through Ellen’s bags when she arrived at the facility. They check for any diet or self-harm tools as depicted in the film. It might give viewers ideas about how to hide things when not in treatment, though, so that worries me. The bedrooms rooms not having doors is not necessarily typical, but there would not be locks on the rooms or bathroom.
When the families are talking about treatment modalities in the waiting room I did not like that they were putting down methods like “Maudsley” (family therapy for children with anorexia), and family therapy was depicted in a bad light. Both of these can be very helpful in real life.
RELATIONSHIPS: Ellens relationship with her family, though realistic, is not necessarily typical. Though many have tumultuous relationships with family members, they are not usually so blatant (but this is a movie - so it had to be interesting). Families are also typically not the “cause” of an ED, though relationships get harder as someone sinks deeper into their ED. ED is a relationship, and it makes it very hard to get close to, or let others into, your life. It was notable that Ellen was never hugged (except by sister) until the end of the film. Unfortunately, lack of touch (whether by choice, or because family is not affectionate) is a common thing I see in clients.
Something I think was unrealistic or glamorized was the relationship that developed between Ellen and the man in treatment. I have never heard of a relationship coming out of treatment, and if it did it would probably not be a healthy one. Also, can I just say that it was weird that right after she told him about her trauma of men and touch that he kisses her and climbs on top of her without permission? That seemed wrong and was uncomfortable to watch.
CONCLUSION: This film got a lot of things right about EDs and treatment, and the acting was very realistic. So realistic, that I had to process this for a day before I could write this article. Though I have had a healthy relationship with food and my body for years (after restricting in college), and treat people with all of these issues and symptoms every day, I had flash-backs to my personal struggles, and had to go look at myself in a mirror to remind myself I am not scary-skinny. The fact that that happened concerns me for how others who are not as strong in their recovery will handle seeing this. My recommendation is that if you struggle with body image or disordered behaviors (whether or not a diagnosable ED) you should not watch it, or be ready to process it with a therapist or trusted friend. This film has a great potential to trigger people who have these propensities, and to teach bad habits that help them “get away” with disordered behaviors. That being said, viewers could find those behaviors other places online, so it is not necessarily the fault of the filmmakers.
I do think this would be a good film to watch for those who have a loved-one dealing with an ED, especially anorexia. It is a realistic depiction of high-acuity anorexia nervosa, and discusses symptoms other consumer media leaves out.
*Article is re-printable with permission. Please contact Libby for permission to put it on your site.
Registered Dietitian, Libby Parker, is the owner of Not Your Average Nutritionist, LLC - a private practice on the central coast of California. Libby offers nutrition counseling for teen-young adult, specializing in people with eating disorders. Additionally, Libby teaches nutrition courses at a local college, and works to educate on topics of eating disorder recovery with her online training site. Find out more about Libby at: www.notyouraveragenutritionist.com (check out the "online courses").
You can also sign up for free educational emails here:
I have had several people that know me ask why I changed my business name, and more specifically - why "nutritionist" instead of "dietitian" in the name?
First the overall change: "Libby's Fit Nutrition" was the name I set up when I started my practice and I had a very different clientele. I was working with mostly stay-at-home-moms and middle-aged women on getting fit and healthy and losing weight. I was/am a personal trainer and was incorporating fitness into my sessions.
As my business and passions evolved into exclusively working with disordered eating that name didn't fit, and worse, was triggering to some people. A new name was needed, but I didn't want to pigeonhole myself into one niche, nor did I want to make people ashamed of talking about my services by blatantly stating "EATING DISORDERS!"
My wonderful husband actually came up with "Not Your Average Nutritionist" and we played with Dietitian and Nutritionist for a while. Although I am a "Registered Dietitian" and proudly state that that is a far more valid and necessary credential, many people still call dietitians "nutritionists," and search for that when they are actually seeking a dietitian.
(Also, a lot of people spell dietitian wrong - it is NOT dietiCian!)
So, I am a Registered Dietitian, but all dietitians are "nutritionists." It is important to note that not all nutritionists are dietitians, so do watch for that. If you want more of an explanation why the difference is important check out my other post -HERE.
What do you think of the new name?
(originally posted 10/18/2016. libbysfitnutrition.com)
I am honored to have been chosen one of the
"Top 100 Nutrition Blogs You Must Follow to Live A Healthy Life" at http://blog.feedspot.com/nutrition_blogs/
Thank you so much, my readers!
(originally posted 9/19/2016. libbysfitnutrition.com)
I danced from age 3-13 in ballet, tap, jazz, and lyrical before taking a break to pursue my equestrian passions. But at age 16 I had a gnawing feeling that something was missing, and asked to re-enroll in dance lessons. At 16 I had no interest in ballet, leotards on my pudgy adolescent body, or the slow piano music; so I signed up for hip hop and break dancing. That lasted all of 3 months, when I found even with the technical steps in place, I didn't look the part.
Around that same time I got really into east-coast swing dance, and my real love emerged. I started taking ballroom, then teaching my peers. I went off to college, and started the first swing dance club on campus where I taught, performed, and lived out my dream. Then I transferred schools to a major university known for dance. I knew I was going to be a small fish in a big pond, but I joined their swing and salsa clubs, and let the music take me away. Dance became my stress reliever, my social crutch, and the way to make my science degree have a creative side. By the end of college I was known as a dancer at my school, and was president of the salsa club.
photo of my tattoo from last year: a reminder that I need to dance
During college, I had taken a break from acting. A musical theatre geek in high school, college was too demanding to allow for more rehearsals especially with dance taking up my evenings.
When I left to move to California for an internship, the first group I sought out besides a church community was a dance community. My people.
Fast forward a year, and I was getting married, he had dislocated his knee and was not up for dance, and the clubs started too late for this early-bird. Slowly social dance became almost non-existent in my life, let alone studio dance or lessons that I had not touched in 10 years. I was becoming clinically depressed, but had not idea why.
Then I got cast in our community production of "A Chorus Line." Rehearsals were rigorous. 8 hour dance rehearsals on Sundays, 3-5 hours several other days each week. My body had changed from when I had last danced. I did not know where my balance was, I had no idea of the terminology I had long forgotten, and my body struggled with the complicated combinations. But I was so alive!
That show did so much for me. Though I was "only" a swing that never got to go on for any of my overstudies, I had made friends, and re-ignited my passion for dance!
Now three years have passed, and I have been back in the studio taking dance lessons (yes, even ballet) and appreciating every moment in a way I hadn't when I was a kid. Now my struggles are a place to grow from, my hour of class a time of pure freedom and meditation, separate from "real life." I have gone on to act in more shows, dance in more classes, and I am not letting dance out of my life again.
This article was first posted on "OnStage.com" as part of national dance week.
(originally posted 12/25/2015. libbysfitnutrition.com)
Have you been looking at my (or other RD's) websites and brochures and not sure what to expect? Nutrition counseling is a very individualized service just like with traditional psychotherapy. Some dietitians create specific meal plans, analyze intake with nutrient analysis software, help you manage diabetes medications, learn what food do in your body, and so much more.
Make sure whoever you choose to go to for nutrition services has a "R.D." or "R.D.N." credential. This is a indicator of education level and national standards of practice. As with any profession, we hope everyone is ethical in their business practice, but trust your gut, and never be afraid of getting 2nd opinions.
What do I do, specifically?
"The primary goal of nutrition counseling is behavior change."
Herrin & Larkin, Nutrition Counseling in the Treatment of Eating Disorders, 2013.
Here is a list of services that one may experience when working with me.
-Diet "check-ups": I go over your food journals to see what you are eating on a regular basis and what is working for you or areas that need improvement.
-Nutrition education: What does food do in the human body? This is the R.D.'s expertise. We study anatomy, physiology, biochemistry, metabolism, nutrition for specif diseases, and many other sciences involving the human body and food. This is what I studied in college for 5 years, plus a year of internship, and continue to learn about (grad school and beyond). I love helping people understand how proteins, carbohydrates, fats, and micro-nutrients interact in the body and keep it healthy.
-Individual needs: How many calories do you need? How does your exercise affect how much you need to eat? What proportion of carbohydrates/ protein/ fat do you need? What about supplements?
-Have an eating disorder?: My specialty area is figuring out what someone needs to be eating to recover. By working on slowly changing unhealthy habits, I strive to create a safe space using positive body-image talk and educating on what is occurring in the body and mind while in the disordered behavioral mind-set.
-Contact with your other medical professionals: If allowed, I will work with your other health professionals to create a united team approach for your best health.
-Go over lab values: Bring lab results from your doctor and we can look at what might be going on and if there is nutritional deficiencies or medical dietary interventions (note: only RD/RDNs are qualified to make medical diet plans).
-Meal outings/ snack challenges: Optional, but helpful for normalizing eating socially for those with restrictive eating.
-Referrals: To therapists, doctors, websites, apps, books, etc.
-Exercise planning: Though I don't actively train anymore, I use my experience as a personal trainer, fitness instructor, distance runner, and dancer to help you come up with an exercise plan, check form on moves, discern how much exercise you should be doing, and optimal nutrition for your sport.
-Weighing: Need to keep up with weights for your doctor or therapist? Need someone to keep track of weights (blind weighing) or keep you accountable?
-Safe plan for weight loss or gain as needed: Fad diets don't work! Safe rate of weight loss is up to 2#/week, and safe rate of gain is up to 4#/week.
-Confidentiality: I use secure electronic medical records to keep your information confidential, and as with therapy, nothing you say will be shared unless you are going to harm others or yourself, or you give a release of information.
-Contact with family members: If under 18, or given release; I give parents piece-of-mind when students are away at college by giving updates on progress and health.
-I have a good relationship with local therapists, Cal Poly's Health Center, and other practitioners.
-Eating disorder training: I am working with a credentialed supervisor to get my "certified eating disorder registered dietitian" credential (iaedp.com), and continue to take opportunities for continuing education and grad school.
-Wide range of experience: From teen eating disorders to cardiac patients, corporate wellness to low-income nutrition education, I can fit your needs or can direct you to someone who can.
-Constant contact: I am available between sessions by e-mail/text to keep you on the path to success.
-Counseling skills: Motivational Interviewing and behavioral interventions.
Still have questions? Contact me!
Libby is a Registered Dietitian focusing on eating disorder treatment and prevention. She is working on the central coast to create wellness in individuals and the community
Not Your Average Nutritionist, LLC
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