Clifford D, Curtis L. Motivational Interviewing in Nutrition and Fitness, 1st Edition. New York, NY: The Guliford Press, 2016 (1). This review was written for graduate nutrition class "Obesity," 2016.
Elizabeth Parker, MS, RD
About the Authors
Author Dawn Clifford is an Associate Professor and Director of the Chico State University Didactic Program in Dietetics (1). She earned her B.S. in Dietetics from Northern Arizona University, and M.S. and PhD in Nutrition Science from Colorado State University (2). Clifford is a speaker on topics of motivational interviewing (MI) and non-diet health and wellness, as well as a published researcher. She has received the “Outstanding Dietetics Educator,” and is a member of the “Motivational Interviewing Network of Trainers” (1).
Author Laura Curtis is the Director of Nutritional Services at Glenn Medical Center (1), she also teaches Medical Nutrition Therapy at Chico State University where she earned her B.S. and M.S. in Nutrition, and where she followed-up with her dietetic internship (2). She had held several positions as a Registered Dietitian, including nutrition counseling where she pairs her extensive MI skills with non-diet principles and “Health at Every Size” (1).
This book, written for nutrition and fitness professionals, is broken down into five sections, with an introduction and appendix. The introduction covers motivational interviewing basics, starting with an introduction mentioning the latest research in a shift of how health practitioners counsel - from “weight-focused” to “weight neutral”(1). This helps prevent eating disorders, fat-shaming, yo-yo-dieting, and “miserable exercise regimens” (1). The focus has shifted to more realistic lifestyle changes for health and emotions that occur with eating, not weight-focused counseling. The chapters aim to break down parts of Motivational Interviewing (MI) both in descriptions, and examples of dialogues in vignettes.
Section one: Motivational Interviewing Basics
Chapter one briefly discusses why habits form (benefit or reward outweighing the cost), and the “Stages of Change” or “Transtheoretical Model,” that was created by Prochaska and DiClemente (1). Other topics explained are “ambivalence” or uncertainty of wanting to change, neural plasticity, when your client wants a “quick fix,” and the “righting reflex” of the practitioner to correct the client’s wrong beliefs.
Chapter two talks about the “Spirit of MI”: partnership, acceptance, compassion, and evocation. This puts the practitioner and client on the same level, and places the client as the “expert” of their own body, instead of the practitioner telling them “you should [do what I say]...” This chapter is about respect and building a trusting relationship between the client and practitioner.
Section two: The Four Processes of Motivational Interviewing
Chapter three starts with two of the processes: engaging and focusing. This is the start of the MI process, where rapport is built and the focus of the session is determined. This is done through warm interactions and asking questions that invite the client to pick a direction or topic to focus on. Chapter three also points out the similarities of MI and the Nutrition Care Process (NCP) of “Assessment, Diagnoses, Intervention, and Monitoring” (1), as well as the importance of nonverbal communication (body posture, eye contact, etcetera).
As any good practitioner knows, listening is of utmost importance, and this chapter devotes a section to the benefits of really listening. By listening effectively, the practitioner can help the client choose a topic to focus on for change, and can break an overwhelming health concern into smaller, simpler, steps. By working on just one step at a time, the client is set up for success, is more likely to build confidence in tackling future change, and the practitioner has a solid topic to bring focus back to when conversation strays.
Chapter four: Evoking. Listening for certain communication cues, the practitioner can pick up on the client’s ambivalence and/or preparation to make a change. A mnemonic device that the authors like to consider where a client stands, is “D.A.R.N. C.A.T.” (4); this stands for: “Desire to change, Abilities to change, Reasons to change, Needs for change, Commitment to change, Activation, Taking steps.” When these intentions are missing the client is likely using “sustain talk,” or the lack of desire to change.
Chapter four explains how to respond to ambivalence to nudge a client toward “change talk” (1). One way that this can happen is by using “scaling questions” which ask the clients, on a scale of 1-10, where do they stand in terms of confidence to change, importance of changing, or readiness to change (1). Additional sections of chapter four go over what to do if a client is crying in a session, and why to not “jump the gun” when getting to the planning process, at risk of losing motivation for follow-through.
Chapter five offers advice on how to plan for change without giving unsolicited advice. Asking permission is a key concept to MI, in which the practitioner asks the client if they would like to hear the information they have. This can be done in many ways, but overall it follows the format of “elicit-provide-elicit”(1). Elicit-provide-elicit, means finding out what the client already knows and asking them if you can give them information they are missing, providing the information once you have their permission, and following up with a check-in to see how they feel about that information. Chapter five finished up with assessing confidence to change, and potential barriers to making the change.
Section Three: Mastering the Microskills: OARS
Chapter six, the “O” in OARS is for “open-ended questions.” Open-ended questions (versus closed-questions) elicit thoughtful responses that are more likely to promote change talk (1). The chapter gives several examples of good open-ended questions for a variety of ways to direct the conversation, as well as closed-questions to avoid. Scaling questions are once-again used to question readiness to change.
Chapter seven, “Affirmations” is the “A” in OARS, building self-efficacy through how the practitioner acknowledges positive changes. This chapter explains that affirmations are not “cheerleading,” but building self-confidence through empowering the client by acknowledging what they have done and how they have noticed the benefit of the change. Affirmations can also help reduce defensiveness.
Chapter eight, “R” is for “Reflections,” or a statement paraphrasing what the client has said in a way that shows they are heard and understood. Reflections can be used after nearly every client statement, and the book covers several types of reflections for different occasions or goals. These include: how to reflect when the client is expressing change-talk, ambivalence, or sustain talk; using metaphors or reframing negative statements, double-sided reflections (using “and” in place of “but” when listing both sides); and several other types of strategic reflections.
Chapter nine, “Summaries,” rounds out OARS. Similar to reflections, summaries can, and should, be used frequently throughout a counseling session. Summaries work well to show the client you are hearing them, and are a way to assess if you have understood exactly what the client is expressing. Summaries are good for transitioning to another topic, bringing the conversation back on track, and bringing closure to a session.
Section four: Beyond The Basics
Chapter ten covers common pitfalls of trying to direct a client that is not ready for change. Some poor choices include, “the expert trap,” the “question and answer trap,” using “scare tactics,” “information overload,” and others. The chapter goes over how to “read” and work with a client who feels forced to be in the session.
Chapter eleven covers “what to do when there’s little time.” How to use MI with brief interactions, covering all four processes of MI, is coupled with how to keep a client on track. The chapter emphasizes the importance of staying true to the MI structure and focusing on one small change instead of taking on too much and/or driving the client away by providing information without asking permission.
Chapter twelve teaches how to address misinformation that the client has picked up, in an unthreatening way. This involves the practitioner letting go of their own agenda, and focusing on what the client finds important. Diminishing the “righting reflex,” or “temptation to provide unsolicited advice” (1) gives the client autonomy and feel they are in control. Providing information (in easy to understand terms) should only come after asking permission from the client. This chapter also covers how Cognitive Behavioral Therapy (CBT) fits into the MI process.
Section Five: A Closer Look at Motivational Interviewing in Nutrition and Fitness Industries
Chapter thirteen is about how to use MI in nutrition counseling, specifically. This is broken down into subtopics, including: dealing with a new diagnosis, meal planning, grocery shopping, expanding food variety, and more. This chapter does a good job addressing emotional eating, disordered eating, and when it would be helpful to refer to someone when the issue is out of the practitioner’s scope, or needs other professionals on the treatment team.
Chapter fourteen explains how to use MI in fitness counseling. It problem solves how to fit depth of MI into training sessions, when talking becomes more limited. The differences in “autonomous” (internal) and “controlled” (external) motivation are explained, with tips to progress each type through the stages of change. This chapter addresses potential barriers to change with tips to guide a client through each.
Chapter fifteen, “putting motivational interviewing to work to address weight concerns and disordered eating,” focuses on weight-neutral talk, and “health at every size” (HAES) (1). It takes away using weight as a measure of “goals” to meet, and focuses on being healthy and happy at whatever size your body wants to naturally maintain. Although this chapter addresses eating disorders, it does not go into depth on counseling clients with eating disorders. This chapter does promote a smart way to speak to any person to not trigger negative body image feelings.
Appendix 1 covers when and how to make a referral to a therapist or other health professional. It covers “scope of practice,” specifically the scope of a registered dietitian, and when it is smart to add to the treatment team or refer to a specialist. This chapter gives a script of what to say to a client when making a referral, so the client feels supported and is more likely to follow-through.
Appendix 2 is additional resources for counseling techniques. This appendix lists more books on MI, resources for nutrition counseling techniques, resources for fitness counseling techniques, and resources for addressing body image concerns.
Personal commentary and evaluation
The authors are extremely qualified to write this book on MI. Both are registered dietitians with a master’s degree (and Clifford has a PhD in Nutrition), and have had personal experience using MI to counsel and teach the principles of it in their other work. Curtis was a student of Clifford’s, so they should be of the same mindset and training.
The authors have written a strong book for teaching the essential counseling skills, laying them out in a well-organized fashion. Although this book was somewhat “dry” reading, it could not have come to me at a better time, as I was finding my counseling becoming very complacent. Working slowly though this book, I was able to shake-up my counseling practice and have better interactions with clients using the MI skills I had let slide.
The only weaknesses I can think of with this book are not covering every area of
nutrition and fitness that could come up in a session (which would be impossible to do), and that there are already many books on MI available, many of which from the same publisher. This being said, a strength is that they filled a specific need by tailoring the book to the specific issues that credentialed nutrition and fitness professionals face, staying true to science-based information and not teaching fad diet principles. I was very pleased to see the use of weight-neutral talk and how to speak to promote positive body image.
It was too difficult to pick out very specific tidbits of information that were supported by other works of literature, because MI is so prevalent in the counseling world. In light of that, I choose two books that I have used, as support for Motivational Interviewing in Nutrition and Fitness. In their book on treating eating disorders, authors Herrin and Larkin state that the process of nutrition counseling should allow clients to make their own decisions (except in the case of harming self or others), and that advanced training in counseling skills including MI is expected of the nutrition professional (5). A section on MI is included in their book, highlighting the same skills that are laid-out in depth in Motivational Interviewing in Nutrition and Fitness. Likewise, the book Counseling Overweight Adults (6) has a section devoted to MI practice and its importance in the counseling process for nutrition professionals, including using “scaling questions” to determine confidence in making a change.
I would highly, highly, recommend this book to nutrition and fitness professionals (and even other health professionals). This resource breaks down each step of MI into useable tactics, and gives clear examples of when the principles are being used or not used. While the general public might not need this nutrition and fitness-specific book on MI, MI is a skill all professionals should have, regardless of what type of counseling you do, and this book is a wonderful resource to teach it.
1.Clifford D, Curtis L. Motivational Interviewing in Nutrition and Fitness, 1st Edition. New York, NY: The Guliford Press, 2016.
2.Linked-in profile: Dawn Clifford. https://www.linkedin.com/in/dawn-clifford-38210b19. Accessed October 17, 2016.
3.Linked-in profile: Laura Curtis. https://www.linkedin.com/in/lccurtis. Accessed October 17, 2016.
4.Rollnick S, Miller WR, and Butler CC. Motivational Interviewing in Health Care. New York, NY: The Guilford Press, 2008.
5. Herrin M, Larkin M. Nutrition Counseling in the Treatment of Eating Disorders. New York, NY: Brunner-Routledge; 2013.
6. Kushner RF, Kushner N, Blatner DJ. Counseling Overweight Adults: the Lifestyle Patterns Approach and Toolkit. Chicago: American Dietetic Association; 2009.
This review was written for my college class "Psychology of Eating," 2016.
Elizabeth Parker, MS, RD
About the author
Dr. Brian Wansink, who has been called the “Sherlock Homes of eating behavior,”1 founded the Food and Brand Lab at Cornell University in 1997. He was born in Iowa in 1960, and at the time of publication of this book (2007), he has created and lead over 250 studies in consumer behavior. Wansink has a PhD in Consumer Behavior from Stanford University, and has since taught marketing and consumer behavior at both Dartmouth and Cornell Universities. He is the recipient of numerous accolades including, “Humorous Ig Nobel Prize”, and was named “ABC World News Person of the Week” in January 20081. Current work includes, Executive Director of the USDA's Center for Nutrition Policy and Promotion, promoter of the 2010 Dietary Guidelines, professor of Consumer Behavior at Cornell University, and most notably author of “Mindless Eating,” and Slim By Design.”1
Mindless Eating aims to share with the American population exactly what is influencing our food choices and eating habits through explaining research on consumer behavior. Dr. Wansink and his team of researchers have completed hundreds of studies on why people eat what they eat, and what influences how much we eat. Using easy-to-read, and entertaining anecdotes of his studies, Wansink share tips and strategies for “mindlessly” changing our food environment to promote better health and weight loss, without deprivation.
Chapter-By-Chapter Synopsis and Main Messages of Mindless Eating2
Chapter 1, The Mindless Margin: Wansink’s studies showed that we have a “mindless margin”2 of approximately 100 Calories more or less from our calorie needs that we do not really notice, and can lead to weight loss or gain. To make this easier, Wansink suggests serving yourself 20% less of most foods (food that you want to cut back on), and 20% more fruits and veggies than you normally would have.
Chapter 2, The Forgotten Food: Seeing evidence of how much you are eating in real time (for instance, leaving the bones from chicken wings you have eaten on your plate, or wrappers from candies in front of you) you are far more likely to eat less than if there was no evidence of what you ate. Since we eat with our eyes first, having large volumes of food (regardless of calorie density) works. Our stomach really has only three settings: starving/ could eat more/ stuffed; so we use external cues to stop eating instead of relying on hunger.
Chapter 3, Surveying the Tablescape: The size of food packages (how we buy or store food) has a direct influence on how much people eat. The larger the container the larger the serving size. This directly impacts the waistline. We drink more from short, wide, beverage glasses, and eat more from larger diameter plates or bowls, and more from larger serving scoops. This chapter also discusses why restriction-diets, such as Atkins and grapefruit diets, work through limiting variety of food options, making dieting “mindless” through “sensory specific satiety.” More options = more consumption.
Chapter 4, The Hidden Persuaders Around Us: We tend to eat more of what we premeditate or see before eating. If we know a food is there, we will think about it and be more likely to eat a larger amount than if we just happen upon the food. This can be helpful for choosing more healthy foods. Wansink suggests setting a bowl of fruit out where it is easily seen, and you will eat more fruit. Proximity to food is another trap for eating more. If food is easy to get to we will eat more than if the food is farther away/ harder to get to. Chapter 4 explains why bulk shopping causes weight gain - having more of the same food at your disposal means you eat more to get to “the right number”2 of items in the pantry. We can counteract this by “hiding the extras” of multi-packs in an opaque container, another room, or adding any level of difficulty. Some other tips from this chapter: Make a shopping list, and eat before you shop.
Chapter 5, Mindless Eating Scripts: We have “scripts” or habits when it comes to how and when we eat. These can be situational (like eating by the time on the clock), or influenced by others (taking more food until everyone at the table has finished). Watch how much and how fast your dining companions eat - we are easily swayed by them! Multitasking while eating (say, watching TV, reading, or driving) distracts us from our food and will lead to more mindless munching than if we were not multi-tasking. The longer the “distraction,” the more we eat. Another influencer in how fast we eat is ambiance. Lighting, music, sound level and other mood-settings influence our pace and consumption of food. Similarly, the scent of food can draw us in to purchase/eat food that we had not planned on eating. Temperature and time of year also influence our eating habits. When it is getting colder/is cold, we eat and drink more to stay warm. When it is warm we move more and drink more water to stay cool.
Chapter 6, The Name Game: We taste what we expect - based on visual cues such as colors and descriptions, how appetizing the food looks (or does not), presentation (including what it is served on), as well as our other senses. We also associate brand name with superiority.
Chapter 7, In The Mood For Comfort Food: A study done in favorite “comfort foods” showed a marked difference in male and female choices. Males choose more “hot meal” foods (like pasta) that evoked feeling of being taken care of, and females choose more “snacklike foods”2 like chocolate, not because they do not like the food the men mentioned, but because those foods made them think of the work of making the meal. Comfort foods tend to be associated with specific happy memories or traditions that supply positive emotions. In the same way, negative associations can cause dislike for foods. We also choose foods based on personality, as this chapter explains. Competition for food (knowing whether or not it will still be there later) influences our decision to “eat the best first, or save the best for last.”2 Youngest children or those from large families, thus set themselves up to eat the more calorically dense parts of the meal first (as opposed to veggies/ salad) and are more likely to gain weight.
Chapter 8, Nutritional Gatekeepers: Nutritional gatekeepers are the person(s) in the household that makes and buys most of the food - and they have the most influence over what we eat. Most often, those with “good cooks” in the house ate, and liked, more vegetables. This is due to veggies taking more work to prepare, and thus need a “cook.” Parents and caretakers influence children’s food preferences from very early on. Children are able to recognize facial expressions of love and disgust, and notice what the person making the face is eating. They use these associations to decide how they will feel about the food when offered it, and future behaviors around foods. Additionally, using creative names and associations for commonly disliked foods, increased children’s consumption when labeled “dinosaur trees,” as opposed to “broccoli.”
Chapter 9, Fast Food Fever: We are designed to seek out “safe foods” that have salt, sugar, and/or fat. It is no coincidence that restaurants, food companies, and even home chefs add these ingredients to food when they want diners to eat. Much of this chapter focuses on marketing and packaging done by food companies. Restaurants also use “health halos” to make us believe that, because they advertise healthy options, that all of their menu items are lower-calorie. By doing this the average diner is likely to add on sides, drinks, or dessert, because they thought they had eaten a “healthier” main dish. Low-fat options also have this health halo effect, and cause many to eat more calories than if they had been told it was the regular fat version. Another factor in how much we eat is the “serving” we are eating from. Where is the natural stopping point- with a single-serve package, or one “sleeve” of cookies? We are influenced by where there are built-in stopping points.
Chapter 10, Mindlessly Eating Better: Fighting an obesogenic culture is not about making huge changes, but eating “better” with do-able “mindless” strategies, laid out in chapter 10. Here Wansink gives strategies including, “food trade-offs,” “food policies,” and “the power of three [behavior changes].”2 These strategies are explained to help us break habits and, in an achievable way, mindlessly eat a little better.
Appendix A: Description, advantages, and disadvantages of popular diets (including this book).
Appendix B: Quick tips for “dieting danger zones”2.
Frequently Asked Questions.
The intended audience for this book is anyone who eats. We make hundreds of food options every day, so there is no one who would not find at least a small tidbit of helpful knowledge from this book. The main aim of book is to educate consumers on simple ways to make eating smarter easier.
Commentary & Evaluation
I enjoyed reading the quick, to-the-point, research abstracts throughout the book. The use of psychology in the explanations of study findings was especially informative, for example, how males and females chose different types of comfort foods based on what made them feel “pampered”2. Each chapter made specific points and ended with strategies, influenced by the studies discussed, for the reader to use; this dispelled the myth that you “can’t teach an old dog new tricks,” or an adult new eating habits.
Overall the strengths of the book included: easy to read format; promotion of slow, steady weight loss by changing just 100 Calories per day or ~10 lbs per year; simple tips to be more mindful of what you are eating and potential for weight loss; and solid research that is referenced in other periodicals, including Rowland and Splane’s Psychology of Eating.3 One example is the description of “sensory specific satiety” 2,3 referenced in both books, as well as our idea of what a portion size is, based on what is placed in front of us.3
Weaknesses of the book included: 3,500 Calories = 1 lb. Other research proves this is not necessarily true. Authors Herrin and Larkin make a specific point to show that “3,500 Calories = 1 pound myth”4. These eating disorder experts explain that mathematically 3,500 Calories seems correct, but taking into account body processes for making muscle, bone, and other tissues, 3,500 Calories is only an approximation, and not a hard rule of weight loss or gain.
I would recommend this book for most people. Wansink’s tips are easy to follow, and his research study descriptions are eye-opening. As a Registered Dietitian, I have shared verbal synopsis of some of his research with clients I am counseling (for weight loss), that make them re-evaluate how they are choosing their food. Several clients have bought the book, themselves, and reported finding it fascinating and helpful in restructuring how they store and plate food. The only people I might not recommend this book to those suffering from anorexia nervosa. This is because the book is structured more for weight loss and maintenance, and eating more “healthy” foods, which could trigger someone who is restricting intake.
Eating Disorders, A Guide to Medical Care and Complications, 2nd Edition. By Philip S. Mehler, M.D., and Arnold E. Andersen, M.D. This book was published in 2010 by John Hopkins University Press. The original edition was published in 1999. This review was written for "Nutrition Therapy for Eating Disorders" college paper (2016).
Authors Mehler and Andersen, are both medical doctors, and professors at Universities. Dr. Andersen is a board-certified psychiatrist who, with colleagues, has started programs for inpatient, PHP, outpatient diagnostic and continuing care for eating disorders. He attended medical school at Cornell, and has spent 15 years as faculty at John Hopkins Medical Institution. He has published research focusing on many aspects of eating disorders.
Dr. Mehler is a graduate of University of Colorado Medical School, and is now the Chief Medical Officer of Denver Health Medical Center. He is a Certified Eating Disorder Specialist (CEDS) and a professor at the University of Colorado Medical School. He is widely published, and is especially interested in research of patients with weights 30% or more below ideal body weight, and treatment of anorexia and bulimia nervosa.
The goal of Eating Disorders, A Guide To Medical Care and Complications, is to provide a single-source of most treatment recommendations for the medical treatment of patients presenting with an eating disorder. The authors provide a step-by-step approach: determining a diagnosis of an eating disorder, the purpose of the treatment team, medical evaluation, nutrition recommendations, specific complaints/ signs/ and symptoms patients present, special topics (including athletes and males with eating disorders), ethical conflicts, and information for non-medical educators. The authors use each chapter to give case studies and answer specific frequently-asked questions about the topic of the chapter in hopes to increase best treatment practices.
Eating Disorders, A Guide to Medical Care and Complications is a reference manual for both medical doctors seeing patients with eating disorders, as well as non-medical professionals (psychiatrists, psychologists, dietitians, nurses, sport coaches, and others who interact with individuals at risk of eating disorders). There are 15 chapters, plus an appendix, in this nearly 300 page book. I will go into more depth on the main messages from these chapters in the following paragraphs.
Chapter 1, “The Diagnosis and Treatment of Eating Disorders in Primary Care Medicine.” This chapter (as well as many parts of the book) emphasizes that eating disorders (ED) present in “many disguised forms” (p. 3) to clinicians, and that the diagnosis of an ED is not made by ruling-out every other possible issue. This chapter focuses on risk factors that increase chances of getting an eating disorder, as well as diagnostic factors to be assessing (including cultural value of thinness), and an overview of treatment modalities such as Cognitive Behavioral Therapy (CBT). Tables throughout the book give concise lists of things to look for (in this chapter, list of myths and facts about EDs, for example), questionnaires, and laboratory ranges.
Chapter 2, “Team Treatment, a Multidisciplinary Approach,” explains the other members of the treatment team, why different professionals are necessary (not just one clinician doing everything), and how to effectively communicate with the team. This chapter includes the registered dietitian (RD), but explains that the physician, nurse, or RD can do weight restoration and meal plans (more on my thoughts about this later). Chapter 2 also covers the levels of care, how to decide which level is appropriate, and when to change the level of care; as well as the details of treatment approaches, including “having fun.”
Chapter 3, “Medical Evaluation of Patients with Eating Disorders, an Overview,” discusses the role of the physician in assessing clinical signs and symptoms of patients with EDs. This includes which exams and lab tests are recommended for each specific type of ED, how to read them in the context of an ED, and when labs/exams need to be repeated. Lists of physical signs and complaints from patients are given, and differential diagnoses that an ED might present as. The authors again state, “The guiding principle is that a diagnosis of an eating disorder is not made by a rule-out approach of all possible medical disorders, but by confident determination of the presence of an eating disorder through screening questions and a brief mental status examination” (p. 70).
Chapter 4, “Nutritional Rehabilitation, Practical Guidelines for Refeeding Anorexia Nervosa Patients.” It is worth noting, that this is the only chapter on nutrition in the book, and it only focuses on very underweight anorexia nervosa patients – no other eating disorder diagnoses. The majority of the chapter, although short, focuses on refeeding syndrome and enteral/parenteral feeding modes, with help from the “dietician” (yes dietitian with a “c”). Good discussion of medical complications with refeeding accompanies this chapter.
Chapter 5, “Evaluation and Treatment of Electrolyte Abnormalities,” gives excellent information about lab values associated with EDs and what they mean in regards to malnutrition, and different methods of purging. Notes on treatment of abnormal labs are given.
Chapter 6, “Gastrointestinal Complaints.” This topic is of high interest to RDs that read this book. The etiology of several issues with malnutrition and binging or purging are explained, as to what the patient may complain of, and clinical evaluation is provided. The explanations given are great talking points with patients on how to treat their discomfort. For example, gastroparesis, or delayed emptying from the stomach to small intestine is common in restriction. It explains that patients will often complain of bloating, which is worsened with a high fiber diet. Treatment includes weight restoration, resuming eating, and limiting high fiber foods like legumes and bran.
Chapter 7, “Cardiac Abnormalities and Their Management.” It is well known that malnutrition can have horrific effects on the cardiovascular system including sudden death. This chapter explains vital signs, etiology, and when to order EKGs or other tests.
Chapter 8, “Osteoporosis and Gynecological Endocrinology.” Up until the DSM-V, amenorrhea was a diagnostic factor for anorexia nervosa. With the DSM-V it was removed, but it is still important to the health of the individual to understand the hormonal issues that occur with malnutrition. This chapter goes into great detail on reproductive hormones, bone density (including DEXA readings), % of body fat needed for normal menstruation (10%, for most women), hormonal therapy (contraindicated, for the most part), and nutrition for bone health.
Chapter 9, “General Endocrinology.” Beyond female reproductive hormones, there are many other potential endocrine issues with EDs. This chapter covers these hormones, such as cortisol, growth hormone, insulin-like growth factor, thyroid hormones, blood glucose, and more. Complications of diabetes with EDs is discussed here.
Chapter 10, “Oral and Dental Complications.” Dentists and dental hygienists are often the first to see patients with bulimia nervosa and can be an integral player in identifying these patients, who might not be noticed otherwise. These oral signs and symptoms of bulimia nervosa are listed with descriptions, and some treatment methods are given.
Chapter 11, “Athletes and Eating Disorders.” The book explains that many sports increase the risk of a person having an eating disorder, especially those that have a great desire for a specific body type or “making weight,” such as ballet, wrestling, rowing, running, and others. Female Athlete Triad, over-exercise, perfectionism in athletes, and performance anxiety are discussed, along with anabolic steroid complications. Treatment recommendations, and the “role of coaches in promoting or preventing eating disorders” (p. 191), are excellent sections in this chapter.
Chapter 12,”Males with Eating Disorders,” shows that males are often overlooked, and not treated differently than females with EDs. This chapter gives excellent insight into the differences with males, and “reverse anorexia” or the need for a “big, muscular body.” Insight into what males are most at risk, and why males diet are interesting points in this chapter.
Chapter 13, “Using Medical Information Psychotherapeutically.” The main point of this chapter is when, and how, to discuss medical information with the ED patient, to not cause fear or make it sound trivial.
Chapter 14, “Ethical Conflicts in the Care of Patients with Anorexia Nervosa,” covers modern biomedical ethics parameters, and how they apply specifically to treating patients with anorexia nervosa. This is of particular concern when a patient refuses recommended treatment. The authors re-iterate, “patients with severe anorexia nervosa give the illusion of sanity even when they are driven by deadly irrationality, failing to appreciate that anorexia nervosa has the highest death rate in psychiatry…” (p. 234).
Chapter 15, “Medical Information for Nonmedical Clinicians and Educators.” This chapter is geared toward coaches, teachers, therapists, and others with a non-medical background that work with eating disorder patients (or in trying to prevent them). Out of control dieting and excessive weight loss, healthy nutrition, exercise, and risk factors are discussed. Also discussed are when should one be referred to treatment, how to approach someone you think may have an eating disorder, as well as easy-to-read information for coaches and parents.
“Appendix: Behavioral Guidelines for Staff to Use with Patients Who Have Eating Disorders.” This chapter gives guidelines for treatment center meals and other issues, as taken from the University of Iowa Hospital and Clinics, Behavioral Health Services, Eating Disorder Program.
My Thoughts on the Book:
Overall, I found this book to be a wealth of knowledge. Not much is published on the medical complications and treatment of eating disorders, and this was exactly what I was looking for to use when helping the doctors of my clients give the best care. I appreciated the tables, which neatly laid out information such as lists of symptoms, lab results and what they mean, medications, and in-depth explanations of complications such as gastroparesis and cardiac complications.
It was distracting that the authors did not correctly spell the word “dietitian.” Half of the time they spelled it correctly, and the other half they spelled it with a “c” (dietician) or they wrote “nutritionist.” The authors also misspelled “monounsaturated” as “monosaturated” fats (p. 220). Furthermore, they left the RD out of the list of team members in the section on “communicating with eating disorder specialists” (p. 29), listed the “physician, nurse, or dietitian” as the person in charge of weight restoration and refeeding, did not include the RD in learning how to shop for groceries and prepare food, and the fact they said, “…once-a-week psychotherapy with an experienced advanced registered nurse practitioner” (not a psychotherapist?) (p. 44). The International Association of Eating Disorder Professionals states, “RDs are the experts, in both food science and nutrition science, trained through education and experience to understand the complex relationship of food intake to overall physiological health” (IAEDP, 2015). Furthermore, the chapter on nutrition, was short and not very informative, which confirms my understanding that M.D.’s, though able to write diet orders and give “nutrition counseling” legally, are often not well versed in nutrition, or how to effectively explain it to someone else.
This book will be helpful to nutrition professionals, like myself, in understanding what clinical manifestations eating disorders are causing, as well as how to interact with physicians sharing patients, and how to explain to patients what is going on from etiology to treatment. Despite my issues with the author’s lack of understanding what the RD does, I would recommend this book to others working with eating disorders. There are other books specifically for nutrition treatment best practices. For example, Nutrition Counseling in the Treatment of Eating Disorders, 2nd Ed., by Herrin and Larkin, references this book in their description of refeeding syndrome (p. 193, Herrin & Larkin), gastrointestinal discomfort, and in referencing other topics. While Eating Disorders, A Guide to Medical Care and Complications comes from the perspective of treating the symptoms, the fundamental goal of nutrition counseling is behavioral change (Herrin & Larkin, p. 51).
Herrin, M., and Larkin, M. (2013). Nutrition Counseling in the Treatment of Eating Disorders, 2nd Edition. New York, NY: Routledge.
International Association of Eating Disorder Professionals (2015).The CEDRD in Eating Disorder Care. IAEDP.
Mehler, P.S., and Andersen, A.E. (2010). Eating Disorders, A Guide to Medical Care and Complications, 2nd Edition. Baltimore, MD: John Hopkins University Press.
There is now an updated 3rd edition you can get HERE.
(originally posted 10/16/2016. libbysfitnutrition.com)
The Power of Habit: A Review
Author Charles Duhigg is a graduate of Harvard Business School (MBA) and Yale University (history major), and is a “Pulitzer-prize winning, investigative reporter for The New York Times” (1) since 2006 (2). Since writing The Power of Habit (New York Times Bestseller List for over 60 weeks!1), Duhigg has written another book, Smarter Faster Better, has appeared on NPR, as well as other well-known media platforms, and has spoken at colleges (including MIT), companies (like SC Johnson), and is available to speak at events by request (2).
The Power of Habit: Why We Do What We Do In Life And Business, is a book written for consumers to figure out how to change habits they do not like, such as smoking, or create new habits, like daily jogging after work. The book uses a simplified “habit loop” to teach readers how to break down their habit into three sections - the “cue” or trigger, the “routine” or habit, and the “reward” or reason for doing the routine. Duhigg uses examples of famous people and companies to illustrate why certain patterns develop, and how changing certain patterns can influence more than one area of work or life.
In Chapter 1, Duhigg describes “The Habit Loop”: where a “cue” triggers us into our “routine” which produces the “reward” (1).
The habit is built from doing something that gives us a “reward” (positive reinforcement). Once someone has experienced the “reward” in correlation to the “cue,” memory starts to connect the two in the basal ganglia of the brain (a primitive part of the brain near the spinal cord). The “routine” part of the equation (how we get from the cue to reward) is formed into habit that requires less and less thought every time we do it. This is how fast food chains get us. They keep everything the same so every time you visit the restaurant, whether in Minnesota or Tennessee, you have the same visual, auditory, and verbal “cues” prompting a sense of routine or habit to the reward of cheap/ easy/ tasty food.
Chapter 2, discusses how marketing moguls created new habits to sell mass quantities of products like toothpaste and Febreze. Creating new habits comes from creating a “craving” as the “cue” or trigger.
By creating a trigger to do something you can create a habit every time that trigger emerges. Duhigg uses the example of marketing toothpaste: the trigger is removing the “film” of plaque you notice as time elapses (usually over several hours, or a day), feeling this film (which naturally occurs) causes a cue to want to clean it off. The action? - Brushing your teeth. The reward - clean, film-free, teeth. This is the habit loop as explained in chapter 1. While people had always had this “film” on their teeth, the advertiser brought attention to it, and made a craving for “clean.”
The moral of this? Find a cue that comes up naturally to elicit a habit response. The author makes the example of: after work you put on your running shoes and go run, afterwards you reward yourself by watching tv. By choosing a specific cue (after work = run) and reward (run = tv), the habit is more likely to occur.
Chapter 2 also covers anticipation of rewards being a driving force to action. When one has experienced a reward for doing something enough times, the anticipation of reward makes the action automatic. The anticipation of the endorphin rush can make it easier for someone to continue exercising on a regular basis, but the first time it occurs will not be enough to develop the reward loop to create the habit. This must be repeated several times before the reward is worth the action. The expectation of the reward must be great enough to drive the action when the cue is presented.
Chapter 3 shows that to change a habit, the cue and the reward are kept the same, and the routine is changed. Routines are hard to change, so what makes it possible? Believing. Chapter 3 details how Alcoholics Anonymous (AA) works, not through scientific method, but through belief in a power greater than oneself to change the routine of an old cue. This is done by creating a list of triggers for the old routine (like triggers to drink, example: get off work), and the reward desired (example: socializing) and change the routine by addressing the desire for socializing by meeting up to talk to their sponsor. Belief that God (“as we understand him”/ a belief that things can get better/ belief there is something bigger than ourselves) will give strength to change the routine, when the triggers arise, is the premise of AA.
Groups are another major catalyst for maintaining change in routine. Whether it is seeing something as being for the greater good of the group, having accountability, or changing the status quo of life, groups give people a network of like-minded individuals to help them stay on course. As Duhigg put it,” Belief is easier when it occurs within a community”(1).
Chapter 4 looks at “keystone” habits that influence everything else. By finding the small habit that affects others, and changing it, you can make huge waves in the system. By creating a routine that builds on other routines, you can prepare yourself with small “wins” that make the bigger “victory” just the logical next step. This chapter uses Michael Phelps, Gay Pride, and safety in the workplace as examples of changing one, seemingly tiny, action to create big victories. Another example from this chapter is writing down what you eat to lose weight. As people make food journaling a habit, without being asked to do anything else, they start changing their diet to be healthier because they notice patterns emerging.
Chapter 5 tells us that self-discipline (willpower) is a learnable skill but, like a muscle, can be worn out over the course of a day and works best when rested. This means that we have less willpower to do hard things/ detailed work after a long day of using willpower and making decisions, than if we had a day where we did not have to think too hard. Strengthening willpower and discipline in one area of life makes that more automatic, and will spill over to other areas of life. A favorite quote from this chapter is, “That’s why signing kids up for piano lessons or sports is so important. It has nothing to do with creating a good musician or a five-year-old soccer star, when you learn to force yourself to practice...you start building self-regulatory strength”(1).
Planning ahead is another skill that foresees progress towards a goal. People who think through potential obstacles and how they will deal with them, in detail, are able to push through hard times and make the most progress toward their goal. Likewise when people are empowered to do something because they enjoy it or have it explained how it will help someone else, they use less willpower than if they were forced into doing something.
Chapter 6 shows how crises situations can change organizational habits. Vignettes of companies that had major crises showcase how big problems can lead to big changes.
Chapter 7 shares how companies like Target gather data on individual customers to drive marketing and sales. Retailers note that people tend to change brands of products when they are going through a life change such as marriage or divorce. The biggest life event for change in purchasing? A new baby. New parents will buy anything the need/want in one place because it is easy. If a company can get them to start buying diapers at their store, they know they can get them to buy other things because they are already in the store. Target looks at purchases made and, by looking at common trends, can determine fairly accurately when a woman is pregnant and due. What do they do with this information? Slip in subtle marketing cues next to the familiar. If a woman received coupons for just baby stuff she would get suspicious as to how the company knows, but mixed in among common items it does not see as personalized.
Chapter 8 explains how personal ties and social peer pressure can influence people to do things that they would find hard to choose on their own, at the risk of losing social benefits. “Weak social ties,(1)” as opposed to close friends, tend to have the strongest pull on obligation. An acquaintance could tell unfavorable comments about you to others for not fulfilling an obligation, where a close friend might understand why you would pull out of a commitment.
Chapter 9 looks at the neurobiology of habits and what is free will. Examples are sleep-terrors and gambling addiction. Do people have choice in these scenarios? It comes down to the primitive brain and ingrained habits. The parts of the brain (basal ganglia and brainstem) where habits form are the same parts where sleep terrors stem from. Duhigg believes that any habit that is cognizant can be changed with the decision to change it, and the knowledge of what your cue or trigger is.
The “Afterward” shares stories from people who contacted the author after the initial publication of the book on how it helped them. This chapter discusses lapses and relapses, and not looking at them as failure but as learning experiments.
The “Appendix: A Readers Guide To Using These Ideas” is a step-by-step guide to figuring out your own habit loop and how to make a plan to change the habit.
This book is aimed at readers who are looking to change a “bad” habit they have. It gives real-life case-studies of companies and people that readers have heard of, to explain how a habit change works. By breaking down how habits form, the author explains how habits can be broken and changed into more desirable habits that will get the reader to their goal. The design of the book is similar to a “business-help” book, which might draw in more readers that are in either a traditional corporate or entrepreneurial business sector.
Personally, I loved this book. It was engaging to read how prominent public figures from Michael Phelps to Rosa Parks made small habits work towards bigger goals, as well as how every-day habits, like eating an afternoon snack, are a summation of cues, routines, and rewards.
The strengths I identify in this book are: extensive research - mostly in personal interviews and scientific articles; easy-to-read format; a singular focus throughout the entire book; and the idea of “classical conditioning,” as Ivan Pavlov explained, to describe Duhigg’s “habit loop.” The ideas of “habit loop” and “classical conditioning” are very much the same in a stimulus or cue eliciting a routine that leads to a reward or positive reinforcement3. Another factor Duhigg lists is obligation towards an outside influencer (chapter 8), which authors Rowland and Splane liken to reasons of success in dietary restraint often stemming from religious “diets” such as Lent or Ramadan, or ethical reasons (Ex: vegetarian for animal rights)(3).
Duhigg is very effective at making his main point - the habit loop- clear, through writing that is both engaging, and easy to follow. His extensive background as an investigative journalist allows him to be an effective writer and good at finding necessary information. He shows how to take action on research already known, like the fact that overeating is typically due to cues in our environment triggering intake (4).
The weaknesses I see in this book are mainly from credentials and my perception of potential bias. As a journalist, Duhigg is trained to pick up a story and flush it out to make something people want to read. Science is not usually fascinating to the general public, so I wonder if he took any liberties to elaborate where there was not enough information. Additionally, Duhigg is not a science or health professional. Many of the topics he covers are in neurobiology and psychology, of which, I would assume he has not had formal training.
Overall, I highly recommend this book to anyone, professional or consumer, that wants to make a change in a habit they do, or help someone else figure out their habit loops. It brings insight into why we do what we do, and offers a way to pick and choose which habits we keep and change. It is not specific to any one type of change (such as weight loss), but rather encompasses the skills and case-studies to change any habit. I will be re-reading The Power of Habit soon.
(originally posted 8/7/2013. libbysfitnutrition.com)
Geneen Roth, the author, is a well-known author and teacher of workshops on how to stop eating for emotional reasons, and eat when you are truly hungry. Much of the book is the author's personal experiences with emotional eating and weight gain/loss, and the experiences of her workshop participants. This book delves into this topic, with questions for the reader and theories derived from her experience, particularly as it pertains to women. Some take-away messages from this book are:
* Eat what you want when you are hungry for it. No more depriving yourself, dieting, telling yourself you can't have ___. If you eat when you are truly hungry you can eat anything. That's right - anything!
* Learn your individual hunger signals. What is the physical feeling of being: starving? hungry? satisfied? could eat but feel ok? full? over-stuffed? How does your body react before it reaches these stages?
* Don't eat "by the clock" but rather when your body tells you to. If you must due to someone else's schedule (dinner out, etc.) eat a light snack if you are hungry to keep from getting ravenous, then eat until you are satisfied but not stuffed. Take the leftovers home, let someone else have them, throw them away. Don't worry about "cleaning your plate."
* Eat without distractions. Pull up a chair. No TV, computer, book, whatever, just you (and/or other people) and the food.
* Eat what you really want. If you want a specific food - have it. Nothing else is going to satisfy that craving, and ultimately you are going to end with that food if you try to eat other things first because other foods won't satisfy that specific craving. Also think about if what you are hungry for is not food. Are you hungry for attention? Love? Physical touch?
* Figure out what emotion is causing you to eat when you are not hungry. Is it "something to do" when you are bored? Are you trying to fill loneliness or a lack of feeling loved? Are you eating out of anger at someone? Use these findings to do something besides eat. For example, if you are lonely call someone or write a letter to a friend.
* "Remember you will not gain 10 pounds from one meal...most of us miss our own lives [waiting to be thin]. Most of us spend our time preparing for a moment that never comes, while the years slip by unnoticed."
* "Eat when you are sitting down; and that does not include the car." Eat in front of people, eat in as lovely of an environment as you can, and when you eat avoid emotionally charged conversations.
* For those who eat in secret, ask yourself: "If _[person]_ really knew what I ate or wanted to eat....." and, "I sneak food because....." Take your time with these questions. Would your family and friends think you are less attractive? Probably not. Who are you sneaking food from? Why?
* Eating without distraction is hard. Transition slowly. Choose one meal a day to eat without distraction. If you are uncomfortable try to figure out why that is.
* Take time for yourself like you would for a friend. Make dining an attractive experience. Indulge yourself in non-food pleasures. A bubble bath, a fun magazine, time spent doing nothing. This is not a bad thing - this is recharging.
* "Everyone has their own definition of what is wasteful. It seems to me that loading a body with food it doesn't need is the same as throwing it away, and just as wasteful."
* "Binging can be an urgent attempt to care for yourself when you feel uncared for." When what we really want is to do nothing, binging allows us to say we are "doing something" (eating) that is socially acceptable; when what we really need is to indulge ourselves in the way we feel we are lacking. Binging is not a lack of willpower, but a sign that you need to "give yourself more, not less (food, attention, love, etc.)."
*Parents should not comment on their children's weight, or talk about weight or dieting around their children. Be sensitive and aware of what you say and do. You cannot protect your children from pain, but you can let them help with grocery shopping and cooking, and make meal-time a good experience.
*When going back to your childhood home, pay attention to any "reverting back to how you ate" or feelings about food/eating with people. Many people find themselves eating like they did as a teenager or sneaking food when they go back to visit their parents.
*"As long as you are eating emotionally, your anxiety will be about food. When you stop, you leave room to discover the worries and concerns that prompt you to eat. When you discover what they are, they change. Because they are no longer secondary and unnamed fears you can act on them instead of being ruled by them."
*"When someone does think negatively about you, that judgment is a reflection of them and their values; it has little to do with you."
*"Eating out is a treat for which you are paying money. If you are not sure about what is in a certain dish, ask."
*At potlucks/dinner parties, limit yourself to 3 dishes on your plate. Eat, savor, if you want seconds, again, only take 3 items. Do this as many times as needed. By limiting to 3, it gives you some structure, and you are not as likely to overdo it.
*"The danger with compulsive exercising is that we begin to rely on something other than ourselves to monitor our "goodness" and our "badness." We're good when we exercise and bad when we don't." It is not all or nothing.
*"I didn't want [ex-boyfriend]; I wanted to be attractive...When I weighed [high weight], I was in control. People couldn't reject me; I had already rejected myself. I knew I was fat, I knew I was unattractive. They couldn't like me less than I already liked myself."
*Make lists to define the good parts of being "overweight": 1."Being fat enables me to..." 2."Being thin means I can't..." 3."I am waiting to get thin to..." What are you waiting for?
*Work for awareness, not judgment. The difference is the former eat and go on with their day, the latter eat and let it ruin their day. "The difference is not in the action, it is in the attitude about the action."
*Make friends with your body. Touch it gently, rub lotion on yourself, take care of your body, exercise, dress in clothes that fit NOW, get a massage, take a long relaxing bath, journal, see a therapist if you need to, forgive yourself, express anger in a healthy way (not by eating).
*"We spend at least half our lives in either physical or emotional discomfort, yet we persist in believing that happiness is our natural, normal, condition and that when we are not happy we're not normal."
*On reaching puberty: "We learned fast that breasts and hips got you in trouble...Better to erase any signs of womanhood. Better to be fat [or thin like a boy with no curves] than to be sexual... Emotional eaters are givers...for sex to be satisfying, we must receive, not just give, pleasure." This is not an open invitation to overdo it on sex either, balance is key. "I respect my appetites for food and sex, and trust that if I say no today there will always be either kisses or cookies tomorrow."
*"When you stop dieting you stop being compulsive...when I binge it is usually an indicator that I am unwilling to feel, express, or act on what I am feeling."
You can get the book HERE
(originally posted 7/12/2013. libbysfitnutrition.com)
So, I really should have written this while I was reading the book, but I will give you a very brief overview of this fantastic book.
Gura focuses on sub-clinical (not meeting the diagnostic criteria) eating disorders in women, mostly later in life.
She uses research and her own experience to explain how stressful times of life (new job, baby, getting married/divorced, menopause, etc.) can spur a relapse in people who had previously struggled with using food as a coping mechanism.
Disordered eating does not always neatly fit in a category. There are more people who experience disordered eating than can be clinically diagnosed with an eating disorder, and they suffer from the mental and emotional effects (and sometimes physical) as much as the diagnosable.
Undiagnosable disorders can range from not binging or purging frequently enough to be bulimic or over-eaters, not meeting the low weight requirements or lack of menstruation to be anorexic, or simply having food rituals or specific restrictions for non-medical or religious reasons.
I highly recommend this book to anyone who works with or is interested in eating disorders, or has suffered from disordered eating.
You can get the book HERE.
(originally posted 7/12/2013. libbysfitnutrition.com)
Eating In The Light Of The Moon, by Anita Johnston, PhD.
This book uses storytelling as a metaphor; It explains concepts and help the reader dig deep into their emotions while discovering commonalities in people with eating disorders (ED). For many women, food offers and “escape from reality,” a cover-up for much deeper issues that are suppressed. This book presses you to ask yourself, “why?” “What?” “How did/do I feel?” about a wide array of topics, that can help with the recovery process.
1) Woman Spirit: The Root of Hunger
This chapter covers the history and suppression of “the feminine,” as culture and society move away from traditional “feminine/connected to nature” and “rounded, curved feminine body,” to a much more “masculine/powerful/angular” ideal. From the beginning females were regarded as intuitive, wise, and connected with nature, but time passed and there was a loss of the connection to nature as “man-made” became better. Masculine traits became desirable and women’s connection with the feminine was shamed. Today’s woman is trying to be a man, by shaping her body to be flat, angular, lacking body fat and curves, lacking menstruation. She is denying her emotions and intuition, creating a “spiritual hunger.”
2) The Buried Moon: Rediscovering the Feminine
Our society has come to value masculine traits of,“direct action, single-minded focus, clear, logical thinking, goal-oriented, competitive...” and become “uncomfortable with the feminine [stillness, ambiguity, emotion].” This chapter goes on to explain the importance of “yin and yang” the feminine/masculine energies that make up everything, and must be kept in balance.
Women in our civilization are at an imbalance of yin/yang, and are expected to suppress their emotions, for they must be “irrational” and need to be controlled. “We disregard our gut reactions” by using diet plans, and exercise regimes. We start to believe that our emotions are irrational, and thus we criticise ourselves for them.
“We participate in an endless cycle of diets where we try to control rather than honor our inner desires and appetites... Recovery from disordered eating calls for a deliberate, conscious attempt to reclaim our feminine side.” Reclaiming the feminine is the main focus of this book.
3) The Beginning: Revisioning the Struggle
Women with eating disorders usually start as very smart, intuitive, perceptive people. When this perceptiveness is not well received by others, she learns to hide it as a means of fitting in, “disowning the wise woman inside of her,” and accepts other’s perceptions as reality. This girl denied herself her own desires, and made rules of “shoulds and shouldn’ts.” Her hunger for spiritual and emotional needs, now misunderstood, is taken as physical hunger. This creates a disconnect with her true hunger signals, and she eats compulsively to “stuff-down the emotions” or starves herself to feel physical hunger instead of emotional, as a coping mechanism.
This chapter goes on to tell us that eating disorders are typically not healed by stopping “cold turkey,” but by slowly practicing the skills needed to overcome the ED while still having the safety net of her method of coping until she is strong and confident enough to let go of the ED.
4) The Red Herring: Food is not the issue
Food is a distraction, a coping mechanism, to people have eating disorders. Food is not the reason they started being preoccupied with food, but a mask to a larger problem within. The obsession allows them to “feel” [fat, hungry, sick] instead of feeling their emotions.
The author brings up having “fat attacks” which is where you all the sudden you feel you have put on many pounds overnight, when logically you know you haven’t, it just “feels that way.” These “fat attacks” are often a signal that something else is bothering you that you are not dealing with.
When you eat compulsively you focus only on food. No other problems exist, when consumed with food obsession. This is a relief, because “coping with real problems requires skills you may not have.” The longer you allow your ED to cope for the bigger issue, the more the situation worsens, and the issue cannot be resolved.
5) Addiction: Spiritual and Emotional Hunger
Addictions (food, alcohol, drugs, or other) are only a “symbol” of what the addicted person truly desires. It is not a physical hunger, but an emotional one. “Women who are addicted to eating or dieting are terrified of their bodies. They withhold love and try to abandon their bodies because it is in their bodies that their emotions reside. To be in contact with other bodies means to be in contact with their feelings, and this can be messy and painful...addictions keep us from being fully present.”
Eating disorders are “process addictions,” the person is addicted to the behavior, not the food.
“Her longing for food is a longing for [emotional] nourishment...this is the “something” she searches for as she stands in front of the fridge.” Look back and see where you are emotionally undernourished. What is this hunger for? Then you can start to heal.
6) Symbolism: Hunger as a Metaphor
Hunger can mean an emptiness / longing for “comfort and nurturance,” “self expression,” or “spiritual fulfillment.” By listening to our bodies cues (hunger, pain, emotion, intuition) we can learn what it is we need or desire. Our inner demons (loneliness, fear of rejection, financial problems, self-loathing, not good enough, etc.) show our true hunger (attention, love, money, self-acceptance, etc.). We need to realize that these are not literal hunger, but a “non-physical hunger” that we need to nourish in an appropriate way.
7) Feelings: Gifts from the Heart
The folk tale in this chapter teaches us, to heal, you must explore your emotions rather than try to control them. Even negative emotions can be good. Anger can bring clarity and strength. Fear can teach us what we need to feel safe. Loneliness can bring self-awareness. Sadness teaches us compassion for ourselves. Jealousy can make us aware of what we truly want.
Feel the way a child feels his/her emotions, “Children live from one emotional moment to the next.” Practice being specific about what your feelings are, notice how one emotion feels different than another. By learning to differentiate feelings you can appropriately act to express them.
8) Relationships: Singing the Truth
Interactions with others need not take our feelings out of the equation. Instead of thinking,”what will he/she think? How will they react?” ask yourself, “how do I feel about what she just said?” What is my reaction?” A woman must hear her own voice amongst and above others, and be able to express that voice to live full and free.
9) Power: Dominion versus Domination
Many women with EDs think they are powerless, when in fact it is a fear of their own power, not that they are powerless, that is the issue. A fear of being feminine. Women in all aspects of life are uncomfortable with power. They don’t want to lose, “but they are uncomfortable being the winner.”
This chapter illustrates two kinds of power: domination and dominion. Dominion is the “power from within” the belief in abundance or win-win. Women who are assertive can tap into a power within themselves that do not have to affect others adversely. Honoring instincts can help you let go of that you think you need to control (eating, food) to be “powerful.”
10) Nurturance: Mother as an Archetype
As covered in earlier chapters, a woman’s innate being is connected to nature/earth/a mother figure. By pulling away from these things and into a numbness with food, the woman essentially shuts-down her heart to being nurtured and cared for. She loses the “mother archetype...that nourishes her, that keeps her deeply connected to nature.” She feigns a “happy face” to others, hiding other feelings. “For one reason or another, she became disconnected from her internal mother, the aspect of herself that provides nourishment and compassionate guidance. By blocking and judging her feelings she is unable to access the guidance and support she longs for.”
Take care of yourself by listening to your intuition and treating yourself like you would a child. Instead of judging yourself, ask, “knowing what I know now, how would I do things differently next time?”
11) Intuition: The Inner Seeing, Hearing, Knowing
“We are taught to think, not feel.” To be rational instead of intuitive. However, both rational and intuitive sides of the mind must be honored. Intuition is a gift to women that keeps us from danger, rational thinking allows us focus and curiosity. Women who push-aside their intuitive faculties often respond to “gut feelings” with physical food, trying to “stuff-down” their feelings.
We must honor our emotions. Focusing on how you feel as opposed to what you “should” be feeling. Check in with yourself, keep a journal, and be patient with yourself. “Although your intuition can take many forms, it is never wrong.”
12) Dreamtime: The Journey Within
Dreams are believed in many cultures to hold the key to the deep desires and true feelings of the dreamer. Dreams provide symbols that when interpreted can be a useful means for self-exploration. “Dreams, like art, speak to us in symbol or metaphor, and do not follow the same direct, linear, logical thought process as we are accustomed to in most of our waking life...it is important to recognize that the objects, characters, events, locations, in the dream are multi-dimensional symbols, not concrete representations of things”.
A woman with an ED can use dreams to figure out what she is really hungry for, why she struggles (what is she trying to “stuff down”?), what she fears. The author suggests keeping a dream journal by the bed to write down immediately upon waking anything that is remembered from the dream. You can even “ask” for a dream that will give you guidance or insight to a question. The chapter closes with a statement from a woman who formerly struggled with an ED, “...my dreams have helped me to trust my body, because by seeing how all this information was coming from inside myself, I could see how to trust my inner self and my body signals.”
13) Moontime: Reclaiming the Body’s Wisdom
Menstruation in today’s society is not openly spoken of, it is devalued and hidden as much as possible. With all the stigma around it, it is no wonder that many eating disorders begin around the time of the woman’s first period. The onset of menstruation typically coincides with weight gain and fat accumulation needed for sustaining another life. This is when many girls start to become preoccupied about fat and weight, and those without much control in their lives “may start dieting in response to this weight gain to give them some sense of being in control,” and many diet their way to lack of menstruation as a means to fit in with the masculine society, and cover up their “womanliness.” Many women report cravings and compulsive eating when premenstrual, which they take to mean a “lack of willpower,” when in fact it is their emotions that come forward that they attempt to stuff down with food. A woman’s cycle is a reflection of cycles found in nature (the waxing and waning of the moon), and if we listen to our bodies we can learn about our needs, intuition, and individual “internal rhythms.”
“It is not unusual for a woman’s weight to fluctuate throughout the month, just as the moon grows into fullness and then wanes into darkness.
14) Sexuality: Embracing the Feminine
Why are we frightened of or repulsed by our sexual nature? Our culture has women portrayed as sexual objects, calls girls who have sex “sluts” and boys “studs” in double-standard, equates lust with sex, and puts little attention on the role of love. A woman who can trust her instinctive sexuality, be comfortable with herself, and remain true to herself is the archetype of the mermaid (representing a woman who is at ease with emotion and sexuality). Society sends messages to females that “provoke fear, shame, and loathing of her new womanly shape.” Women attempt to change their body in effort to fix relationships with men, whether that is hiding her feminine shape (by starving and creating a boyish body) to men who reject her changing body, or to focus on their desirability (society’s perfect shape “barbie/model”), rather than their desires. “In order to reclaim her sexuality she must learn to focus on her needs, her desires, and not feel guilty or selfish for wanting to be fulfilled... It is not uncommon for a woman who has felt unfulfilled sexually to try to satisfy herself with certain foods, like chocolate...it is sinfully delicious, it is not necessary, she doesn't deserve it, it is bad for her.”
15) The Descent: Meeting the Shadow
The story in this chapter is helpful in understanding the wisdom in self-exploration and digging up undesirable past issues and emotions. The woman with an ED is described as doing anything but confront the aspects of herself that she has “denied, rejected, or repressed...at some point she recognizes that the only solution left is to go within, to explore the dark, hidden places of her being and find out why she does what she does with food...she encounters all her self judgements,” She must be able to treat herself with empathy and allow herself to feel all the feelings she has tried to suppress, to really “be with her pain.”
It is only by understanding her “shadow sister” (the emotions behind the repressed feelings and memories) that a woman can find true nourishment for herself, and no longer need to hide behind food.
16) Assertiveness: Speaking the Truth
What a woman desires most in life is the ability to choose. That is the theme of this chapter, in which assertiveness techniques are taught to the reader. “I have not seen anyone recover without first learning to be assertive. It is probably the most important skill needed because it is the means by which we embrace and express the essence of who we really are without being destructive to others.”
the three assertiveness techniques explained are:
1) A basic formula for expressing yourself: “When you______ I feel _____ because____.”
2) When someone tells you you shouldn’t feel a certain way, use deflection:
Start with (pick one) “that may be so....” “I realize that is your perspective...” “I can appreciate your point of view...” and follow up with (pick one) “...but that is how I feel” “...but I see things differently” “...But I want you to know how your behavior affects me.”
3) Repeat yourself over and over (with variations of the above) when communicating feelings and the other person responds with an attack. You are not telling the other person what to do, you are just letting them know how you feel about it.
“Happiness is a state of mind (not body).”
17) Nourishment: Physical versus Emotional
This chapter focuses on two kinds of hunger- from the stomach, and from the heart. Being aware of your body’s signals for physical hunger and emotional hunger is very important. By being aware of what sensations are happening in your body when you are physically hungry and full, you can learn to recognize these, and differentiate from “emotional hunger” when you are trying to fill a void. The person that is fully in tune with their body can maintain a healthy weight without thinking about it, without dieting, without worrying if she is getting the “right” nutrients. Her body will tell her what she is hungry for, and when she is full. She can understand cravings for emotional needs as well, which can manifest in specific food cravings (examples: warm foods like soups can mean a need for emotional warmth, sweet cravings may desire sweetness in their lives, spicy may need intellectual or emotional stimulation, crunchy/salty may be frustrated or angry, chocolate may mean sexual or forbidden desires).
18)The Journal: Recording the Truth
Consciousness is a crucial step in the recovery process. Consciousness about what we are feeling, how hungry we are, our desires and emotions. The author recommends journaling these specific things to find out more about why you you eat the way you do:
19) Recovery: Out of the Labyrinth
“Recovery from disordered eating requires that a woman come to terms with the uniqueness of her being.” Discovering one's self can be frustrating, as she feels all of her feelings full force. However, as she learns to interact with her feelings, her issues with food/dieting can begin to subside. This is a time of trials, and great need for self-compassion and kindness. Once she can identify feelings that trigger disordered eating habits, she can learn to respond in different ways to nourish the cravings of her heart before she can react with her coping mechanism with food.
20) Storytime: The Tales of Three Women
The last chapter tells the stories of three women who have recovered from eating disorders, and their journeys and wisdom. It recounts the stories told in previous chapters, and their metaphors and symbols.
Book summary by Elizabeth Parker, RD.
Written for the Central Coast Eating Disorder Treatment Center.
Thank you Francie for the opportunity!
Get the book HERE.
Libby is a non-diet Registered Dietitian focusing on eating disorder treatment and prevention. She approaches health from the inclusive standpoint that any "body" can focus on health regardless of size. She is a ally in diversity.
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