By Marissa Pendlebury
Marissa is a "compassioneer" helping others recover from eating disorders like she did. Her passion for helping others break away from their eating disorder led her to develop "Nourishing Routes" a platform for empowering others who suffer from EDs. She is also author of Nourishing Routes - Love Food, Adore Your Body, Become Yourself. More about Marissa, here: www.nourishingroutes.com
(Not Your Average Nutritionist is not an affiliate. The ideas/opinions in this post are not necessarily the ideas/opinions of Not Your Average Nutritionist staff.)
Recovery from an eating disorder is quite a contested area.
For one, not everyone believes that full recovery is possible - particularly among the medical community, who might suggest that there will always be some element of control around food in a person’s life. However, there are many testaments out there, my own included, that recovery actually IS possible. So why is there a bit of a divide between the view of recovery of medical professionals and those in recovery?
In short, full recovery for me and many others, has its roots in the meaning that recovery holds for each individual - based on unmeasurable personal experiences and not a text book full of calculations and people’s opinions. Full recovery is a unique concept for every person who has encountered an eating disorder first hand, and is not for any medical professional - notably those who have never had a true insight into the eating disorder mindset - what recovery truly is or means. Still, look into any research journal and article related to eating disorders, and the word recovery and categorising recovered and non-recovered individuals is batted about more times than a hyperactive tennis ball.
For me, recovery is about regaining life, freedom and love of oneself. It is not just based on gaining a certain amount of weight, or getting within a Body Mass Index range that is deemed ‘healthy’ by medical standards (which tend to be flawed anyway). Equally, just because someone does get to a ‘healthy’ weight, which is the bench marker most research findings on eating disorders tend to use to assess recovery, doesn’t necessarily mean that individuals are free from restriction and control. For example, when a person does gain weight to a point that seems ‘healthy’, they may still be engaging in behaviours that provide them a feeling of safety, such as limiting the consumption of certain food groups and/or ensuring that they follow a particular diet (e.g. clean eating or plant-based food only). They may still, after eating over a certain quantity of food or Calories, feel an uncomfortable pang of guilt or an urge to compensate what they have eaten by using exercise or restricting food at the next meal or day.
Some individuals suggest that ‘normal eating’ should be the goal of recovery. However, there are many negative behaviours and feelings are encountered by the majority of the population in terms of the way they eat and see food. In particular, over recent years, we have created a diet-obsessed culture where fixations around healthy eating, alongside developing unhealthy relationships with food and body, is the norm for the many rather than the few.
With the above issues in mind, making ‘normal’ eating or getting to a ‘healthy’ weight the aim of recovery seems to be a substandard goal in reclaiming back life following an eating disorder. Moreover, what might seem a healthy weight to a medical professional, is not the true healthy weight for the person in recovery, since their body might naturally function more optimally at a higher weight - even above the optimal weight medically set out for their height. What we have to understand here is that, despite living in a world with an advanced medical system and forms of monitoring wellbeing, that medical standards of recovery are still flawed and not applicable to every individuals’ unique recovery journey.
So what does this mean for your own recovery and where do you set your own bar and goals?
In a nutshell, your recovery goals need to, ideally, be focussed around attaining a lifestyle that will allow you to feel free, able to socialise, revolve your activities around life rather than food, and be able to eat whatever foods you like without feelings of guilt or an urge to compensate. This lifestyle might look completely different to someone else’s in recovery, but it is important that your journey is founded upon your own values and what is ‘healthy’ to you. This might exclude the need to regularly consume nutritionally dense, low sugar plant based foods for the rest of your life (as might be advised for the majority of the non-eating disorder population). Alternatively, your values might involve being able to relive positive food memories and socialise with friends while eating pizza or your favourite fast food to your heart’s content - rather than a Calorie Quota or diet regime.
To help you gauge what recovery means for you, I’m going to share some of the key things that allowed me to understand what real recovery would look like in the context of my own life. These are listed below:
-Being able to go to sleep and wake up without wondering what I'm going to be eating in the morning.
-Scheduling my day around life, rather than around what I will and won’t be eating.
-Not spending hours planning meals for the next day or obsessively calculating Calories.
-Going to a restaurant spontaneously, rather than planning in advance and scrolling through menus online to pick a "healthy" or low-Calorie option.
-Ordering a meal to come as it is stated on a menu rather than making a billion adjustments so that it feels safer, ‘healthier’ and guilt-consuming to eat.
-Enjoying the prospect of eating with others rather than creating very safe and lonely spaces to eat in (with rigid controls and the need for everything to be perfect).
-Planning a day with social activities in mind first, and then food, without worrying about where and when we will be eating .
-Going into the supermarket and choosing foods that I genuinely enjoy, including my favourite chocolate bars, rather than healthy cereal bars that are lower in Calories but taste dreadful.
-Choosing snacks based on how appetising they look rather than looking at Calorie labels or how much fat and/or sugar that they contain.
-Looking forward to planning time out with friends without worrying about food or wearing a fake smile and personality.
-Feeling part of the real world and able to be fully myself while stepping outside the small bubble that used to keep me feeling safe but also restricted and lonely.
-Laughing whole-heartedly and finding joy and fun in everyday life.
-Not worrying about eating meals at certain time periods, and being able to eat spontaneously at any time of day.
-Baking cakes and tray bakes, licking the mixture out of the bowl before it goes in the oven, and actually eating the results myself.
-When going out to a cafe, ordering coffee and tea with ‘normal’ or full-fat milk without asking for skimmed or ‘skinny’ alternatives.
-Being able to eat a main course AS WELL AS a starter and/or dessert without guilt - and continuing to still eat throughout the day or evening if I feel peckish.
-Honouring feelings of hunger, even if I might feel like I have probably eaten my energy requirements for that day already.
-Hearing about a new diet or wellness regime on social media and not being tempted to follow it; knowing that it is just a lure away from what is going to help you find life rather than more restriction and rules.
-Being able to have a full day of relaxation and spending large amounts of time sedentary without worrying about how much exercise or physical activity I "should" be doing.
-Walking around the block for enjoyment rather than trying to walk a certain number of steps and obsessively trying to walk further in order to burn off more energy.
-Being able to move my body for pure fun and enjoyment rather than because it makes me feel like I can deserve food, or compensate for what I have recently eaten.
-Looking in the mirror and feeling appreciative of my body rather than focussing on the parts that don’t appear perfect or like someone else’s body I admire.
-Being able to listen to other people talk about dieting, losing weight, or their body shape without feeling the urge to restrict food.
-Not feeling guilty for eating more than other people I am eating with.
-Not feeling triggered or having the urge to restrict food when encountering someone who is slimmer than me, or has an eating disorder.
-Carving out time for self-care everyday without needing to "earn" permission to take care of myself and enjoy things.
-Allowing myself to buy nice things that I like or enjoy without feeling that I don’t deserve them or have to earn them in some way (other than actually earning money).
-Sometimes eating more than my body needs or what i’m hungry for, just because I can and am enjoying eating, without directing negative thoughts and feelings towards myself afterwards, or trying to compensate later.
-Knowing that my identity and purpose of existence on this planet is not to worry about the quality of food I eat, what I weigh, or the thickness of my thighs.
-Being able to love who I am right now, unconditionally, while being able to think about life goals that don’t involve or revolve around food, exercise or trying to control weight.
With these different aspects and dimensions of recovery in mind, you might be able to see how ‘real’ recovery is not just solely based on a physical marker of health. Recovery is just as much about emotional and social functioning in the real world, alongside an identity that is separate from a being who revolves their world around food, weight and/or exercise. Real recovery, for me, requires us to not only to gain weight, but also the courage to step out a transparent bubble that has held us feeling both safe and a captive prisoner. We may have been able to see the real world, and even believe that we were a part of it, but this bubble has been an unbreakable barrier between the life we currently live and the one we deserve and were born to thrive in.
When we can step outside of this bubble, or even burst it all together, of course the world is going to feel overwhelming, scary and even foreign in terms of your ability to navigate every day social and emotional situations. However, the more your identity and self-worth grows beyond the limitations of a specific weight or the amount and types of food you eat, the chains of restriction become looser and looser every single day. Real recovery isn’t about waking up one day and having your eating disorder cast aside by a magical spell that bursts the bubble. Real recovery is the journey itself - each day making a choice to choose life and your long term happiness rather than pleasing the anxiety relief of succumbing to the controlling voice of an eating disorder.
Maybe real recovery for you still involves hearing a foreign voice every now and then, tempting you back into the false sense of security an eating disorder one offered, but then having the strength to say no and walk away. For example, despite feeling unworthy of food or needing to earn it through exercise or hard work, you choose to eat that biscuit with your tea anyway and order whatever the hell you like off a menu without succumbing to immense guilt.
Recovering from any type of trauma follows a similar path - recovery from trauma isn’t about never experiencing trauma again, but it is about having the strength to conquer anxiety, tackle fears and navigate your own life again. In a similar way, real recovery is the non-relinquishing strength and determination to reclaim back our lives. If we can think of it like this, then there really is no black and whites of recovery, no specific weights and nothing we can set in stone on a medical chart or research article. The realm of real recovery is within the depths of your own mind and personal functioning. No one on this earth can determine or understand your real recovery other than you, but this is part of the beauty that makes the journey towards recovery such a wonderful one. Not only does it make us stronger, but it allows us to ask ourselves questions about our true values, beliefs and purpose. In this way, even though eating disorders can be soul destroying, and recovery seems like a constant uphill battle, it prepares us for an inner journey. This is a journey to really know, in our hearts, who we are, how we are connected with the world, and the enormity of what we are capable of.
On a final note, I would just like to say, your eating disorder and mission for recovery so far, no matter where you are at, is not wasted time. Every day you have battled on, even when you have felt you couldn’t fight any longer, have all played a role in making you YOU. Your real recovery is all about you - finding the courage to look inside the darkness, but also the immense beauty, intelligence and wisdom that you were born with. Never lose hope, because real recovery is always just a heartbeat away. When you choose the life your heart beats to no one other than you can say that real recovery isn’t possible.
How I experienced “To The Bone” as an eating disorder expert & Why you need to carefully consider if you should watch it
There was a lot of buzz leading up to the release of Netflix’s “To The Bone” on July 14, 2017. As a Registered Dietitian who specializes in eating disorders I was intrigued. In this film, actress Lily Collins played Ellen, a young woman with anorexia nervosa who goes into a couple of different treatment centers and bounces back out to home or hospitals. Collins has been very forthcoming that she previously struggled with anorexia nervosa, which made me more nervous about her losing weight for the role.
When I first heard that there was going to be a film made about eating disorders, I thought this would be a great opportunity to raise awareness of what eating disorders are like. And hopefully get people talking in a productive way about the different types of eating disorders and how it is not a good thing to get one...but as the trailer and initial interviews came out in the weeks leading up to the release, I instead became worried that it would not only depict the stereotypical white emaciated anorexic girl (which it did), and be triggering to those dealing with body image issues (it probably will), or teach new bad habits (for some it will - that scares me most of all!). Here is my take on the film as I watched it and took notes, the good, the bad, and the triggering (spoiler alert).
OPENING: I must commend Mockingbird Productions for starting the film with the statement, “The film was created by and with individuals who have struggles with eating disorders, and it includes realistic depictions that may be challenging for some viewers.” I hope they don’t consider that their liability statement, but they tried. In the opening scene we see “Ellen” at a residential treatment center in art therapy class. She looks visibly bony, and it only gets worse through the film (not sure if it changes due to eating less, make-up tricks, or what, they did claim the use of some prosthetic bones, though). In articles that came out prior to the film release, it was said that Collins lost weight under supervision of a “nutritionist.” I don’t know who this “nutritionist” was, but there is no way in a true health professional that knows a thing about eating disorders would allow someone to lose that much weight, ethically, especially since she has a history of anorexia and might suffer physical and mental complications of going through the trauma of extreme weight loss again. I also use “nutritionist” because that is the word I found for the unnamed person who guided her weight loss, and if it was actually a Registered Dietitian or other licensed health professional they would (or should) have their license revoked for unethical behavior.
Weight cycling (large fluctuations up or down) is very hard on the body, which likes to maintain homeostasis (or “same-ness”). Every time we lose weight our metabolism (calorie needs) goes down. When we gain weight back our metabolism does not go all the way back to “normal,” this is why it gets harder and harder to lose weight if you have been on many diets. In addition to lowered metabolism, as was briefly mentioned in the film, the body has to rely on energy (calories) from muscle and organ tissue to survive, which can cause irreversible damage. Having Collins go through extreme weight loss again could have done real damage to her body (organs, bone density, fertility, cardiovascular system) that she might not know about until years later.
CALORIE TALK: In the following scenes there are definite strengths and weaknesses apparent to anyone who is in the field of eating disorders. As seen in the trailer, there is a scene where Ellen is quickly counting calories on a dinner plate. This is a strength in that it is very realistic to how a person with anorexia’s mind typically works, but any time calories are brought up (in a few scenes) it is a potential trigger for some viewers. It also glamorizes the “ability” of knowing what is in your food. With so many people on diets that require calorie counting, I am sure many think it would be “easier” to have anorexia to be able to not only count fast, but to abstain from eating. If you are one of those people reading this - IT IS NOT WORTH IT! (Contact me personally, I will walk you through the why nots, I don’t have the space in this article). By the way, eating disorders (ED) are not a choice. They have genetic and environmental components and are a person’s way of coping with a perceived problem or trauma, similar to the way an alcoholic turns to alcohol to numbs themself from emotion.
BEHAVIORS: Continuing on, maybe it is because I live in a part of California where cigarettes are banned in public spaces, but smoking is not nearly as common among ED/weight loss as it was 10+ years ago. Ellen is seen smoking throughout most of the film, and I hope people don’t continue that stereotype along with most EDs being anorexia nervosa (they’re not - binge eating disorder and “other specified feeding and eating disorders” are much more prevalent).
Other behaviors throughout the film that the director/actors got right are body checking (Ellen keeps checking her arm circumference with her hand, and her roommate calls her out on it), flushing meds down the toilet due to fear of weight gain (don’t go off meds without Dr approval), the roommates “barf bag” and laxatives, cutting breading off of chicken, passing out when she stood up fast (this is caused by low blood pressure when not eating enough), stair running to “burn” calories, and the doctor noticing the bruises on the bones of the spine and calls her out on doing sit-ups.
WEIGHT: More triggering, but truthful scenes, include Collins taking off her shirt to get weighed, and at the end of the film you see her naked (artfully laid on the ground to cover private areas). She is truly emaciated. This took my breath away- as you can only do so much with makeup, she had to lose a lot of weight for this role. It makes me so sad. Near the end of the film (spoiler) she has a “dream” where she is healthy and happy, and she has some weight on (probably shot first before she lost the weight), and she is gorgeous. There are no bones protruding, she is on the slim side of normal weight.
The treatment facility where most of the film takes place did a good job of having a range of body types and disorders. Most people with ED are not underweight. There was a larger binge-eater, some average-size people with bulimia and anorexia, a male, a pregnant woman, and different races (though still overwhelmingly white). While the other behaviors of binge eating and bulimia were touched on, the film was primarily about anorexia. I wish they had shown more of the other disorders, to make a point that EDs are not just thin white girls.
PROFESSIONALS: I thought the doctor, therapist, and nurse were all very well written and played. Any of their interactions were probably my favorite part of the film. In group therapy, the therapist was great at getting the participants back on topic in a realistic way, and concluded a talk with “there is never thin enough.” The nurse and doctor being more upfront and brazen with their speech is likewise true to life. They all easily call out Ellen on her behaviors and things happening to her body (ex: lanugo hair, body burning muscle and organs when not eating) in very realistic ways.
TREATMENT: The treatment facility that most of the film takes place in is a good depiction (though a bit cleaner/newer than most) of a residential treatment center. They call it inpatient in the film, which is incorrect, it is residential. Something that seemed off to me, but maybe some places do this, is that the patients were allowed to eat what and how much they wanted for every meal with no real consequences, and most of the time no professionals ate with them. From my visits to and talks with treatment centers, there is always at least one staff member present, and if they do not finish their meal, typically a liquid supplement like Ensure or Boost would be required. I did like that the anorexic man said he gets a “crazy burst of energy” when he eats. I have heard that from a lot of my clients when they start eating again.
It was realistic for the nurse to go through Ellen’s bags when she arrived at the facility. They check for any diet or self-harm tools as depicted in the film. It might give viewers ideas about how to hide things when not in treatment, though, so that worries me. The bedrooms rooms not having doors is not necessarily typical, but there would not be locks on the rooms or bathroom.
When the families are talking about treatment modalities in the waiting room I did not like that they were putting down methods like “Maudsley” (family therapy for children with anorexia), and family therapy was depicted in a bad light. Both of these can be very helpful in real life.
RELATIONSHIPS: Ellens relationship with her family, though realistic, is not necessarily typical. Though many have tumultuous relationships with family members, they are not usually so blatant (but this is a movie - so it had to be interesting). Families are also typically not the “cause” of an ED, though relationships get harder as someone sinks deeper into their ED. ED is a relationship, and it makes it very hard to get close to, or let others into, your life. It was notable that Ellen was never hugged (except by sister) until the end of the film. Unfortunately, lack of touch (whether by choice, or because family is not affectionate) is a common thing I see in clients.
Something I think was unrealistic or glamorized was the relationship that developed between Ellen and the man in treatment. I have never heard of a relationship coming out of treatment, and if it did it would probably not be a healthy one. Also, can I just say that it was weird that right after she told him about her trauma of men and touch that he kisses her and climbs on top of her without permission? That seemed wrong and was uncomfortable to watch.
CONCLUSION: This film got a lot of things right about EDs and treatment, and the acting was very realistic. So realistic, that I had to process this for a day before I could write this article. Though I have had a healthy relationship with food and my body for years (after restricting in college), and treat people with all of these issues and symptoms every day, I had flash-backs to my personal struggles, and had to go look at myself in a mirror to remind myself I am not scary-skinny. The fact that that happened concerns me for how others who are not as strong in their recovery will handle seeing this. My recommendation is that if you struggle with body image or disordered behaviors (whether or not a diagnosable ED) you should not watch it, or be ready to process it with a therapist or trusted friend. This film has a great potential to trigger people who have these propensities, and to teach bad habits that help them “get away” with disordered behaviors. That being said, viewers could find those behaviors other places online, so it is not necessarily the fault of the filmmakers.
I do think this would be a good film to watch for those who have a loved-one dealing with an ED, especially anorexia. It is a realistic depiction of high-acuity anorexia nervosa, and discusses symptoms other consumer media leaves out.
*Article is re-printable with permission. Please contact Libby for permission to put it on your site.
Registered Dietitian, Libby Parker, is the owner of Not Your Average Nutritionist, LLC - a private practice on the central coast of California. Libby offers nutrition counseling for teen-young adult, specializing in people with eating disorders. Additionally, Libby teaches nutrition courses at a local college, and works to educate on topics of eating disorder recovery with her online training site. Find out more about Libby at: www.notyouraveragenutritionist.com (check out the "online courses").
To answer the second question - you should never skip meals. You can skip snacks if you are trying to lose weight, but really eating several (5-6) small meals (250-350 Cal/each) is your best bet. Have you heard the saying, "your body goes into starvation mode"? To some extent this is true. When you do not eat for several hours (more than about 5) your body instinctively slows its metabolism (the thing responsible for burning calories) to try to hold on for the famine it believes is occurring. Go to long or do this too often and it can really screw up your health and ability to maintain a healthy weight.
What about juice cleanses and detox programs? As a rule - bad idea. Most juice/detox programs on the market (not all, but ~95%) do not contain enough fiber or protein to be good for you. The fruit and veggie juices are basically broken down sugar (simple - carbohydrates) that rapidly raises your blood sugar and quickly crashes (like eating candy). This can hurt your body's ability to regulate blood-glucose and insulin production, as well as brain and body function. What can work if you are determined to use a juice or protein shake is to only change it out for one meal a day, and eat healthy protein-rich and produce/whole-grain filled meals for the other two. Diabetics should be wary of trying juicing at all.
In conclusion, eat balanced meals of lean proteins, whole grains, fruits and veggies in their whole states for best health and weight loss results.
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 be healthy regardless of size. She is a ally in diversity.
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