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.
I have been working on this for a while, and now can share that my first YouTube video has been posted!!!!
This first video is a shorter version of my free course on the different types of eating disorders.
Other videos are coming soon on debunking popular fad diets (starting with the "keto" diet) and medical complications of eating disorders.
Please go check out my channel, and subscribe to the channel to be notified when a new video comes out. Here is the link: www.youtube.com/channel/UCfmXodqj-5iWPqLYOVQI67Q
....and the video!
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By: Lauren Goette
Lauren Goette received her B.S. in Psychology from Cal Poly, San Luis Obispo June 2017, and plans to become a licensed professional counselor in the future. Having personally struggled with anorexia, Lauren has become an advocate for mental health, working as a Peer Health Educator at Cal Poly and speaking out against the stigma surrounding mental illness. This was a paper she wrote her senior year (published with permission).
The deadliest mental disorder in existence, Anorexia Nervosa (AN) threatens the lives of millions of US citizens each year. According to Arcelus, Mitchell, Wales, and Nielsen (2011), anorexia has the highest mortality rate of any mental disorder. In fact, it has been estimated that anywhere from five to twenty percent of individuals with AN will die from the disorder (“Anorexia Nervosa,” n.d.). This exceptionally high mortality rate is largely the result of anorexics’ self-induced starvation, which can be achieved through methods such as calorie restriction and excessive exercise (“Feeding and Eating Disorders,” 2013). As a result of these behaviors, anorexia can lead to serious physical problems, such as slow heart rate, low blood pressure, reduced bone density, severe dehydration, fatigue, hair loss, and a plethora of other physiological issues (“Health Consequences of Eating Disorders,” n.d.). And while there are numerous physical complications that result from this disorder, a significant amount of damage is also inflicted on the cognitive level. A variety of studies conducted in the past two decades have shed light on the devastating cognitive impacts of anorexia, as well as the promising positive effects of refeeding. Current evidence shows, as a result of semi starvation, individuals struggling with anorexia can experience drastic structural brain changes, inhibited cognitive abilities, and memory impairments, which may be improved with weight restoration.
Structural Brain Changes
One of the most severe physical and psychological costs of anorexia is structural brain changes, which can cause significant harm to the cognitive functioning and overall mental health of anorexia sufferers. In the short term, a diet deficient in calories and nutrients, often coupled with excessive exercising, can lead to loss of both white and gray matter (Sidiropoulos, 2007). Prolonged caloric restriction promotes “abnormal reward responses to food and a deviation from a healthy feeling/perception of the body when eating.” These structural changes may, in part, explain why anorexics continually avoid food consumption, as the act itself appears to elicit a negative perception and/or sensation of the body. Additionally, this reduction of gray matter in may also contribute to the disturbance of the brain’s typical reward responses which encourage food consumption.
Often the direct result of structural brain changes, AN sufferers can experience a wide range of cognitive difficulties. Higgs (2009) explored the impact of interference from diet-related thoughts on anorexics’ cognitive abilities. On a cognitive task, restrained eaters’ reaction times when imagining eating cake were significantly slower compared to when they imagined drinking water. On the other hand, unrestrained eaters' reaction times did not significantly differ between the cake or the water conditions. Higgs maintained that the cognitive impairments displayed by restrained eaters were the direct result of a “reduction in processing capacity due to interference from diet-related thoughts.” With this reduction in processing capacity, dieters’ ability to perform basic cognitive tasks was drastically diminished, highlighting how impactful caloric restriction can be on AN individual's thoughts and on their execution of simple cognitive tasks.
In addition to these milder cognitive issues, AN sufferers can also develop chronic cognitive deficits. Specifically, Gillberg et al. (2010) found, eighteen years after AN onset, anorexics had more attention, executive function, and mentalizing problems. Anorexia was found to be associated with “a range of neuropsychological problems that are present long after the eating disorder… is no longer an important feature.” Even after starvation has ceased, weight-restored anorexia survivors can experience lingering cognitive issues. Gillberg et al. suggested that this is the result of severe structural damage which can leave important cognitive facilities critically damaged. Moreover, Fowler et al. (2006) found that even “relatively severe” neurocognitive impairments have the potential to adversely affect AN sufferers’ daily social and occupational functioning in the long term. These impairments can have a substantially negative effect on recovered individuals’ quality of life, making typically simple cognitive tasks exceptionally difficult to accomplish.
Along with cognitive difficulties, AN can also cause notable memory impairment. Kemps, Tiggeman, Wade, Ben-Tovim, and Breyer (2006) found that anorexic individuals’ frequent obsessive eating-disordered thoughts actively prevent their working memory from operating effectively, which can lead to various issues with basic memory functions such as recall. Chan et al. (2013) also found anorexic’s impairment in memory functions to be positively correlated with BMI. In other words, the lower an AN sufferer’s BMI, the worse their memory functions were, and vice versa. Kingston, Szmukler, Andrewes, Tress, and Desmond (1996) also discovered an association between anorexics’ lower weight and poorer performance on memory tasks. Kingston et al. maintained that this poor performance was directly related to anorexics’ degree of weight loss, concluding that anorexics’ memory performance declines with their decrease in weight. Chan et al. proposed that this correlation between BMI and memory impairment indicates that anorexics’ memory deficits may, in part, be associated with malnutrition, however current research remains inconclusive.
Having focused largely on the starvation-induced structural, cognitive, and memory impairments of AN, it is also imperative to recognize the simplest yet most effective treatment for such damage: weight restoration. Though not a “cure-all,” weight restoration, accomplished through the refeeding of the anorexic patient, has the potential to reverse much of the structural and cognitive damage caused by the disorder. In terms of brain matter recovery, Sidiropoulos (2007) demonstrated how weight restoration resulted in the return of white matter to premorbid levels. Simply by increasing caloric intake, anorexic patients were able to recover all of the white matter they had lost throughout the course of their disorder. Similarly, Wagner et al. (2006) found that weight restoration in long-term recovered anorexic individuals resulted in the reversal of structural brain abnormalities. These results imply that weight restoration has the power to reverse structural brain damage, and restore any and all white matter lost to anorexia.
Focusing on the psychological implications of structural brain recovery, Bernardoni et al. (2016) found a strong association between partial weight restoration and improvements in affect and eating disorder symptoms. With even minor increases in weight, recovering anorexics experienced significant improvements to their psychological wellbeing. On the cognitive side, Hatch et al. (2009) discovered that weight-restored individuals were notably faster on cognitive tasks, and exhibited superior verbal fluency and working memory. Hatch et al. concluded that, with refeeding and weight gain, cognitive impairments in weight-restored AN sufferers appeared to normalize.
Despite the existing support for weight restoration, it has noteworthy limitations. First and foremost, complete structural brain repair is not entirely possible through weight restoration While Sidiropoulos (2007) did find significant improvements in the quantity of white matter recovered in weight-restored individuals, in truth, some gray matter loss persisted. In spite of the recovery of white matter to premorbid levels, previously anorexic individuals sustained irreversible gray matter loss, which remained unaffected by their increased weight. Secondly, weight restoration fails to improve distorted cognitions about body image. Even after weight restoration, Bernardoni et al. (2016) revealed that patients remained dissatisfied with their bodies. Lastly, weight restoration fails to recover weight-restored individuals’ memory abilities. Nikendei et al. (2010), discovered that deficits in immediate and delayed story recall in currently ill AN patients persisted even after these patients were weight-restored. Nikendei et al. suggested that this was the result of a so-called “scar effect” on the brain caused by chronic starvation. They maintained that this scar effect may play an important role in the etiology and/or persistence of AN, and might also explain why memory impairments sustained during AN are seemingly irreparable.
The vast body of anorexia research available today highlights both the extensive damage AN can cause to anorexics’ brain structure, cognitive abilities, and memory, in addition to the reparative power of weight restoration. Tragically, for individuals struggling with AN, the damage sustained throughout the course of the disorder can inhibit their brains’ basic cognitive functions. The structural brain changes caused by AN can lead to an irreversible loss of brain matter, as well as serious complications with cognitive and memory functioning. Anorexia nervosa can make simple cognitive and memory tasks, such as attention and recall, exceedingly difficult to accomplish. These cognitive and memory impairments, which can be caused by both structural brain damage and cognitive interference, can make everyday functioning a challenge. Not to mention, the irreversible nature of some of this damage can cause long-term impairment, even in weight-restored individuals. Despite the seemingly endless list of structural, cognitive, and memory complications caused by AN, weight restoration may hold the key to the recovery of both brain matter and cognitive abilities. In spite of its shortcomings, weight restoration has the ability to effectively repair the structural brain damage and cognitive impairment caused by anorexia nervosa.
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,
As a RD, I have gotten so many questions about the fad diet du jour: the "Keto" or "Ketogenic" diet. I finally decided to just write down the research in a reader-friendly version. Additional video on the history and use of the ketogenic diet at the bottom of this post. Here you go-
The ketogenic (or “keto”) diet is just another fad diet.
The Keto diet is an amped-up Atkin’s diet (that we all know now was/is terrible for your cardiovascular system, and not a sustainable way to keep weight off) where the majority of what you eat comes from fat, and carbohydrates are extremely limited (In contrast, a healthy diet should be a much more balanced macronutrient distribution of 20-35% protein, 45-65% carbohydrate, and only 10-35% fat). This skewed macronutrient distribution is actually very dangerous for the human body for several reasons -
#1, We use carbohydrate as fuel for our brain. Glucose is needed for cognitive function, and many people on the Ketogenic diet experience brain fog and difficulty focusing. Ketone bodies (specifically: beta-hydroxybutyrate (built up in blood serum), acetoacetate (found in urine), and acetone (responsible for that bad breath)), which are created when carbohydrates are not present, are not as effective (or healthy) for our brain. This may also cause metabolic acidosis which is characterized by a reduced pCO2 and/or lower pH (we need to stay in balance!).
#2, On a ketogenic diet, your intake of fruits and vegetables is extremely limited (if eaten at all) and we all know how important the fiber, vitamins, minerals, and other compounds in fruits/veggies are. On that note…
#3, The keto diet is extremely low in fiber! Fiber is not only protective against many gastrointestinal cancers, it is also a big factor in fullness and weight loss. Furthermore, constipation is very common on low-fiber diets like the Keto diet.
#4, Ketosis/ketoacidosis is what is happening in the body/brain on a chemical level – this is the body making fat into something the brain can use when carbohydrates are not available. It's a lot of work for the the body to produce, not as efficient as carbohydrate, and can be incredibly dangerous for diabetics. Additionally, we have some cells with few-to-no mitochondria. These cells are carbohydrate-dependant and must be fueled by glucose. These cells include certain cells with no mitochondria in our blood (erythrocytes), eyes (cornea, lens, and retina); cells with few mitochondria include renal medulla, testis, and leukocytes. (https://link.springer.com/article/10.1007/s11883-003-0038-6)
#5, “Keto breath.” Halitosis (bad breath) from (acetone) ketone bodies makes for an acetone-like smell on your breath that no amount of brushing/mouthwash can fix. Medical professionals look for (smell for?) this in malnourished patients.
#6, High blood lipids/cholesterol/blood pressure. It’s a high fat diet- you didn’t see this coming? The body can only break nutrients down at a certain rate, and high levels of fat in the diet may lead to high levels of blood lipids are responsible for blockages (atherosclerosis), and other cardiovascular complications up to death. While you can reverse the numbers, the plaque buildup in arteries is almost impossible to reverse. Not worth it! (note: some people do see lowered blood lipid profiles on this diet).
#7, Following this diet is often a form of disordered eating or may lead to an eating disorder (just as with any restrictive diet). Cutting out whole food groups is not healthy. We need all 3 macronutrients in appropriate proportions (majority coming from carbohydrates) to have a healthy body. Our body needs a variety of foods for best health. The reason this diet “works” for weight loss is that it restricts the types of foods that people tend to over-do-it-on like chips, candy, pastries, etc. Any diet that cuts out your favorite foods will cause weight loss, but at what cost (physically and mentally?)
#8, Not all fats are created equal. Most people starting a Keto diet are not differentiating between saturated (solid at room temp, and not something we want in large quantities) and unsaturated fats (liquid at room temp, and “healthier”). Getting this wrong also increases complications from the diet. Additionally, many people who followed a diet high in medium-chain-triglycerides (MCT) experienced undesirable digestive issues.
#9, It may mess with your thyroid and other hormones – lowering your metabolism (isn’t the point of this diet weight loss? That’s counter-intuitive…), energy, and fertility. Every time we lower our metabolism through dieting it lowers the “set-point” of our metabolism, making it harder and harder to lose weight. This is an adaptive response for mammals in famine, but not what the average person wants nowadays.
Who it the Keto diet appropriate for?
The only population that the ketogenic diet is scientifically proven to be beneficial (and safe) for is a select group of people with epilepsy (seizure disorders). This is the position of the Academy of Nutrition and Dietetics.
The Keto diet especially sucks for athletes (and people working out to lose weight)
Since our preferred fuel source is glucose (carbohydrate) from either blood glucose or glycogen (fancy term for carbohydrate stores in the liver and muscle cells), running exclusively on fat slows athletic performance as the body works much harder to break down fat (dietary and adipose storage).
Additionally, the lower protein intake and change in hormones in the body with a keto diet lower the ability to build and maintain muscle mass. If “mirror muscles” like biceps are not motivating enough to keep you off it- remember that our organs like the heart are also muscle tissue that would be broken down by this diet, causing organ damage or failure.
It’ll get you, mentally and emotionally
Ketogenic diets cause headaches, brain fog, and often irritability and obsession with food. This type of diet will very likely make you think about food an unnecessarily large amount of time, and make it difficult to be social (not being able to eat at the same places as your friends; oh, and that bad breath!).
You may feel more depressed (especially if you are already prone to depression and/or taking antidepressants) as serotonin (the “happy” neurochemical) is produced from carbohydrates. If you take an SSRI know that this class of medications work directly on serotonin that is present, and the diet requires a minimum about of carbohydrate (as we learned from the works of Ancel Keys in his starvation study) to allow the SSRI medication to work.
So, what’s the verdict?
In case you didn’t get it from the above – the Keto diet sucks. Not only is it a fad-diet (aka – not suitable for long-term weight loss/lifestyle), it can be very dangerous.
If you need help figuring out what to eat, contact a Registered Dietitian. In the meantime, if you do need some structure, balanced eating like the Mediterranean diet or DASH diet is a better way to go.
For a YouTube video with more information on this diet: click the image below
Don’t give up the foods you love. There is room for all foods in a healthy diet. We just need to keep proportions and variety in mind to fuel our body optimally.
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It's National Nutrition Month and I have a treat for you!!!
For National Nutrition Month all of my current online courses are on sale for 50% off as my treat for you! You can learn the info that I teach my private clients in the comfort of your home - for a steep discount! Use the code SAVE50MARCH at checkout.
Do you overeat? Check out: "Stop Binge Eating Without Giving Up The Foods You Love"
Are you a performer (dance, acting, musician)? Check out: "Whole Health for Performers"
I'm super excited to share the education I give my private clients with a wider audience that are not able to come to nutrition counseling or cannot afford counseling, or who want a refresher to keep the motivation up between sessions with me or other professionals.
Eating disorders affect approximately 10-13%
of college age females, and about 2-3% of college-age males.
Professionals have noted kids as young as 6 years old talking negatively about their bodies and trying to diet.
How can we help our kids navigate the world with
a healthy body image?
Over the next 3 weeks I am offering a free support group/class for parents in San Luis Obispo.
We will go over what eating disorders are, warning signs, how to talk to your kid/someone with an eating disorder, what you can do to model healthy behaviors, and whatever else you want to talk about.
This will be a safe space to talk about this stigmatized mental & physical illness.
Please invite your friends! This class is open to all.
While it is aimed at parents of middle/high schoolers, it is for anyone who wants to better understand what eating disorders are and how to help a loved-one.
I am not assuming that you or anyone in your family has an ED just because you showed up - this is good information for everyone, because we all know someone with an eating disorder.
Sundays at 6 pm, March 4, 11 & 18.
(Ideally come to all, but you can drop-in to any of them)
First Presbyterian Church (church library)
981 Marsh Street
San Luis Obispo, CA 93401
Hope to see you there!
Sign up for more free education whether or not you can make it to the classes:
NYAN is growing fast, and I would love to share RD business knowledge/ED counseling knowledge in exchange for some help.
Looking for people to:
-Write blog posts
-Create social media posts/graphics
-Do research for articles/videos
-Help come up with ideas for YouTube educational videos
-EXPERIENCED COPYWRITER for sales pages (this can be a paid contract position)
-Other things I haven't thought of??? I'd love your creative ideas!
Ideally, upper level nutrition or psychology students; but the most important part is personality and philosophy that mesh with the business. More details (click button)
I can't wait to meet you!
nsurance companies are sooooo frustrating to deal with - you are not alone!
Due to individual insurance regulations and federal rules there is no "set" coverage that all insurance companies have to go by. Your best bet when seeking coverage is to call your insurance company and get a Case Manager to walk you through the to-dos.
The earlier you contact your insurance company in the process, the better. Additionally, the more "evidence" for need of treatment (doctor's referral notes, lots of documentation) that you have the better.
I made a round-up of the previous 3 blog posts (updated the links so they are current)
that I wrote about on insurance and packaged it up in a PDF for you.
Get it here:
How to get your insurance company to pay for treatment
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Unfortunately, unless it is part of a treatment program, Dietitians are very rarely covered by insurance. (Wha?!)
You can petition your insurance for some reimbursement by asking your RD ("nutritionists" without the RD credential are never covered because they are not qualified) to send you a "superbill" for services that have been provided (typically annually or quarterly) to submit to insurance (after paying out of pocket) to try for reimbursement. With enough supporting documentation (again, referrals from medical doctors help a lot!!) you can often get reimbursement (no promises, each company has it's own ways of dealing with each individual).
Good luck!! I hope this helps!
If you have more tips on how to get insurance to pay please leave them in the comments below, or email me to have it included.
I am thrilled to have this guest post about vegan nutrition!
Many of my eating disorder clients have adopted a vegan diet, for better or worse, and are not meeting their nutritional needs. Vegan and vegetarian diets are very healthy when done correctly, but if the whole purpose is to cut more things out in the name of restriction, then malnutrition is almost certain.
If you are vegan, or contemplating starting a vegan or vegetarian diet, read-on to learn about plant-based sources of certain nutrients that are often hard to get when animals are off the table.
The Vegan Diet - A Guide to Nutritional Needs
By: Emily Baird
Emily is a 1st year nutrition student at Cal Poly who plans to become a registered dietitian. She has been vegan for 2 years, and plans to incorporate that into her career.
Every year more and more people are making the transition to a vegan diet, and for good reason! The vegan diet can have so many health benefits for our bodies including disease prevention, weight management, and protection against cancers. But with being vegan, also comes the common questions about: “How do vegans get enough protein?” “How are they getting any B12 in their diet?” “How to vegans get calcium if they don’t drink cow’s milk?”. And although these are valid questions, a well-balanced diet full of fruits, vegetables, beans, legumes, and carbohydrates is all a vegan needs to fulfill their nutritional requirements.
Iron is an important component of the red blood cells that carry oxygen from the lungs to the rest of the body, as hemoglobin. Think of it like the engine to a car; the engine provides the car with the power it needs to make it move. Similarly iron allows hemoglobin to have the needed strength to get oxygen where it needs to go. Without it, the body cannot make hemoglobin, which means organs and tissues won’t get the oxygen they need.
There are two types of iron - heme and non-heme. “Non-heme” iron is found only in plants foods and is harder for the body to absorb than “heme” iron which is only found in meat products, so we need to eat more plant-based iron to truly get the same amount as if we were eating meat.
Many plant foods are naturally high in iron, but there are also many packaged foods that are now being fortified with iron. The recommended daily allowance (RDA) is between 8 - 18 mg (depending on age and gender, up to 27 mg during pregnancy). Be sure to include a source of vitamin C with your iron for better absorption.
VEGAN SOURCES OF IRON
1 cup soybeans: 8.8 mg
2 tbsp flax seeds: 4.1 mg
½ cup cooked lentils: 3.3 mg
½ cup fortified total whole grain cereals: 8 mg
(For a complete list click here)
Calcium is responsible for building and maintaining strong bones and teeth. When the body isn’t supplied with sufficient amounts, it increases the risk of developing disorders like - osteoporosis, hypercalcemia, kidney disease, and even alzheimer's. Calcium can be included either by nutrient dense foods or by incorporating calcium fortified foods. Most breakfast cereals, milks, breads, and juices contain added calcium, but be sure to read the nutrition label to be sure. The RDA is around 1000 - 1300 mg. Vitamin D intake is essential to adequate calcium absorption.
VEGAN SOURCES OF CALCIUM
100 g calcium set tofu: 350 mg
¾ cup calcium fortified plant milk: 240 mg
⅓ cup cooked kale: 110 mg
¼ cup dried figs: 95 mg
(For a complete list click here)
Zinc is essential for the body’s immune system to function properly. It also works in cell division, cell growth, the breakdown of carbohydrates, and wound healing. Although it is so important for our bodies, not much is actually needed; the RDA for zinc is 11 mg for men and 8 mg for women. Even though plant sources of zinc are not absorbed as easily as animal sources, vegans were shown to only have a slightly lower amount of zinc.
VEGAN SOURCES OF ZINC
Tofurky italian sausage: 9 mg
½ cup hummus: 2.3 mg
1 tbsp nutritional yeast: 2 mg
¼ cup roasted pumpkin seeds: 2.3 mg
(Click here for a complete list)
Your body must have vitamin D in order to properly absorb calcium in the body. Vitamin D is not typically a problem for vegans during the summer months, but those living in colder climate may be at risk of developing a vitamin D deficiency. The RDA is 600 - 800 IU. Just about 10 to 20 minutes (depending on skin tone) in the sun per day will provide the body with sufficient levels. But those living closer to the northern hemisphere, may need to include more vitamin D rich foods in their diet.
VEGAN SOURCES OF VITAMIN D
1 cup portabella mushrooms: 634 IU
1 serving instant oatmeal: 180 IU
1 cup fortified soymilk: 120 IU
1 cup fortified orange juice: 100 IU
(Click here for a complete list)
SHOULD I BE INCLUDING SUPPLEMENTS?
Eating a healthy variety of plants and grains will ensure that the body gets sufficient levels of nutrients. The exception to that is vitamin B12. Vitamin B12 is not as easily accessible through plant based foods, so it can be important to include a supplement in your diet. If you are overwhelmed by what kind of B12 supplement to choose, check out this article. Nutritional yeast is an example of a vegan food that does naturally contain B12. It is usually used as a cheese replacement or topping, and can supply 2.4 mcg per 3 tbsp (which is the RDA).
A well-balanced, plant based diet will supply the body with all the nutrients that it needs to thrive. There are many people who question the vegan diet and believe that vegans are lacking essential nutrients, but with the right knowledge of nutritional needs, a vegan diet can be very beneficial.
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Libby is a Registered Dietitian focusing on student eating disorder treatment and prevention. She is working on the central coast to create wellness in individuals and the community.
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