By Alyssa Los
Alyssa is in the process of becoming a Registered Dietitian through the California Polytechnic State University of San Luis Obispo. Alyssa has worked with the fabulous Not Your Average Nutritionist for two weeks learning about how to implement motivational interviewing and sensitivity when discussing body image into her future practice. In her free time, Alyssa enjoys yoga, hiking the beautiful Central Coast mountains and trying out unique, new foods.
Recovery from eating disorders is a process.
When one restores their weight a state known as hypermetabolism is likely to occur. So what does this complex word mean? To break it down, hypermetabolism is the increased rate of how the body processes food into energy. When our bodies are put into a starvation state such as Anorexia Nervosa, it is common that our metabolic rate or the speed of which we process energy is slowed down. Therefore, when food is reintroduced at a higher rate our bodies have to learn how to process food as well as it needs even more calories to replenish our body’s hair, nails, bones and other essential cells our amazing bodies form!
Due to hypermetabolism, increased energy needs are required to meet our body’s demands. If you are in the process of recovering, a trusted health care professional will guide you to restoring you back to your individualized body weight. For those in recovery, approximately 50-60 kcals/kg of body weight is needed, but a Registered Dietitian is still essential at this stage as ranges can differ (1).
If you are in the process of weight restoration you may have experienced waking up at night soaked in sweat. Night sweats are a common occurrence caused by hypermetabolism seen in recovering anorexic clients. The reasoning behind this incidence is due to human bodies relearning how to utilize their new energy intake. Often our bodies end up turning the energy we are feeding ourselves into heat in the process. A study by Marzola and colleagues shows that anorexic patients had approximately a 15% higher energy expenditure with elevated body temperatures at night time compared to non-anorexic counterparts (1). Other common symptoms of hypermetabolism include gastrointestinal problems, headaches, low blood sugar and anxiety (2). Please see a professional for help as introducing foods should occur at a low pace to prevent refeeding syndrome, a disorder characterized by low Phosphorus, Potassium and Magnesium levels leading to heart irregularities, respiratory failure and seizures (3).
Remember, food is the reason we are alive. Without it our hair falls out, our nails don’t grow, our bones become brittle and many other negative consequences can occur. Reduction of fat stores in the body also results in a common condition in anorexic patients called amenorrhea, loss of your menstrual period for over 3 months (4). Therefore, when our bodies are restricted from food intake our internal biological system only focuses on the most essential parts of keeping us alive.
The metabolism is a complex and astonishing part of our bodies. It makes up every cell and practically has a mind of its own adjusting to fluctuations in intake. So the next time you wake up sweating know your body is working hard to get back on track and replenish itself back to its regular state!
Today I wanted to explain a little more about my virtual nutrition counseling (eek! I'm excited).
I have been counseling individuals with eating disorders for 5 years now, and have had an occasional phone or facetime client (they signed papers stating they knew it wasn't HIPAA compliant), and with that I learned what worked/didn't work for me.
Along with some research into security, and my own policies, I now have HIPAA-compliant (secure, from a health-care/insurance standpoint) video ability along with my already HIPAA compliant electronic health records.
That's a lot of fancy words for saying that I have confidential video conferencing ability wherever you can get internet.
Virtual counseling can be just as effective as in-person counseling. If you show up, not just physically - but mentally, and do the work, it is not really different from in-person counseling.
It is great for those who cannot get to a specialist in their area either due to travel ability/time, or availability of counselors; as well as those who are more comfortable having the distance (for instance, because of social anxiety).
When we work together virtually, I can send you handouts via email (paperless = save the earth, and you are less likely to lose track of them), and pull up notes and your types questions/food journal while we chat. I treat the time just like an in-person session (same length of time, same information covered, same contact/communication). The only downsides are that I (usually) cannot see your whole body (which might sound great to you, but visuals are important for some medical issues, and body language is such a big part of how we communicate), and I can't give you a hug if you are having a rough day.
Some important things to note if you do want to work with me:
1. I only take outpatient-level eating disorders, disordered eating, and occasional performance artists.
2. Because of state licensure I cannot work with individuals from most states (or out of the U.S.A.). At the moment I can work with individuals in the following states: California (always, as I live in CA), New York, Alaska, Washington state, Colorado, Michigan, New Jersey, Connecticut, Massachusetts, Pennsylvania, Arizona, and Virginia. (Subject to change at any time).
3. I REQUIRE that you have an in-person therapist that I can communicate with about your care. This is for your safety, to make sure we are on the same page with helping you, and that I know there is someone seeing your whole-self that can help you if things go downhill or you need other local services.
See the details page of my website for all the info.
Interested? Contact me to discuss if we would be a good fit.
I can't wait to meet you!
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.
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.
What is the current best-practice for prevention of eating disorders among adolescent/young adults based on reduction of eating disorder risk factors (as determined by previously validated eating disorder behavior questionnaires)?
Elizabeth Parker, RD and Margery Lawrence, PhD, RD
December 6, 2017
Introduction: The purpose of this study was to determine the current best intervention program for reducing the risk of developing an eating disorder (ED), based on previously validated eating disorder behavior questionnaires. With over 10% of adolescent/young adult females developing eating disorders, prevention is increasingly important. Method: An evidence-based review was conducted looking at programs designed to reduce risk factors that have been shown to be associated with developing an eating disorder among high school and college students. The research found was limited to females, and primarily focused on those experiencing body dissatisfaction. Results: Twelve studies were reviewed, nine of which found cognitive-dissonance prevention programs to be significantly more effective than control groups. Conclusion: Cognitive dissonance-based programing (the Body Project) was found to be the most effective way to change negative beliefs and behaviors that lead to EDs among females. Further research should include studies that look at broader population bases, creating programming for males and those of the lesbian, gay, bisexual, transgender, and queer community (LGBTQ).
The prevalence of eating disorders (ED) has grown quite high, with approximately 10% (or more) of adolescent girls/young women meeting the diagnostic criteria for eating disorders based on the DSM-IV or DSM-5.1, 3, 4, 6, 7, 9, 10, 11 Additionally, roughly 50% of college-age women may have subclinical disordered eating behaviors.10 Behaviors and conditions commonly associated with disordered eating include: dietary restraint, purging (self-induced vomiting, over exercise, laxatives, diuretics, diet pills), binge-eating, self-deprecation, negative affect, difficulty regulating emotion, anxiety, depression, self-harm, thin-ideal internalization, and body dissatisfaction to name a few.
Many women who do receive treatment do not fully recover from their ED (e.g. 44% of those with bulimia nervosa do not, and that percentage is greater for those suffering from anorexia nervosa)10 which is why prevention of these disorders is so important. Early assessment and intervention is crucial for the best odds of recovery and restoration of health, especially in those under the age of 19.4 EDs generally develop in adolescence and prevention programs are more effective in early adolescence.6 On average, body dissatisfaction peaks in later adolescence but these older adolescents may be able to better comprehend the need for intervention of socially promoted “thin ideal.”6
It is concerning that only one-third of people with an ED have been asked about eating-related issues by their primary health care provider.4 Furthermore, less than one-third of people with EDs receive treatment!4, 6 Given that more people will see a primary medical provider than a specialist, primary care providers have an opportunity to assess patients for eating disorders and should be trained in how to screen for them.4 Many medical providers said they felt “ill-equipped” to screen for or treat eating disorders.4 Since schools have a unique opportunity to track and influence students over a longer period of time, many studies have looked at prevalence and prevention strategies among students.
Prevention programs are relatively new in the field of ED research, and are not widely practiced. In fact, most of the available studies performed to evaluate these programs were performed by the same pool of researchers. The purpose of this evidence-based review was to determine the current best intervention program for reducing the risk of developing an eating disorder, based on previously validated eating disorder behavior questionnaires.
Several programs were seen repeatedly among the various studies, suggesting that there was already some consensus on what programs might yield the most significant reductions in ED risk factors. The studies looked at reduction of ED risk factors, especially surrounding thin-ideal internalization, dieting practices, body dissatisfaction, depression/negative affect, and used similar self-reported scales.
Overall, the studies indicate that features of useful ED prevention programs include: cognitive-dissonance-based programing, multiple sessions (instead of a single session), interactive sessions (group, or other interaction), facilitation by professionals (as opposed to peers, teachers or other endogenous staff), use of validated assessments, and avoiding education about EDs and effects of EDs.
A Pubmed search was performed on August 21st, 2017 using the following search criteria: ((feeding and eating disorders/prevention & control*)) AND ((young adult OR adolescent) AND students) AND (risk factors AND eating disorders) AND ("last 10 years"[PDat] AND Humans[Mesh] AND English[lang])
The search yielded 35 articles, twenty of which were initially selected based on the abstract. This was further reduced to twelve by excluding any age groups that were not high school or college (undergraduate/graduate level). Since this is a relatively new topic (especially in areas of peer leaders; 2,9,12 internet-based program; 7 and female athletes 10), all study designs were initially included due to the small number of available studies. The significance was held at p= or <0.05 for all studies.
Of the resulting 35 articles, 23 were excluded due to: age of population, abstract not indicating ED prevention, or study types such as interview, reviews or meta-analyses. Twelve articles were selected for review as follows in table 1.
Of the 12 articles, 10 looked at cognitive dissonance-based (CD) prevention programs. Of those 10, 9 concluded that CD programs produced more significant reductions in ED risk factors than other prevention programs. The one exception was the study that focused specifically on athletes.10
Table 1. Study Comparison Table (click file to see PDF of table)
There are previously validated assessments for mental health and eating disorders as seen in the assessment methods used in the studies (see “key to abbreviations” at the end of this paper). These assessments were used to determine if there was a reduction in negative thoughts and disordered behaviors among participants.
The four most common interventions examined in studies were in-person cognitive dissonance-based programs (CD), internet-based cognitive-dissonance based programs, the NEDA brochure, and the documentary “Dying To Be Thin.” The most effective of these was in-person cognitive dissonance-based programs.
Cognitive Dissonance-Based (CD) ED programs (The “Body Project”):
Cognitive dissonance “is based on the presumption that creating an inconsistency between a belief and a behavior will elicit a feeling of discomfort in an individual”2 and that the individual will need to change the behavior to remove the discomfort. Programs focused on CD help to promote behavioral changes because consistency between beliefs and behaviors is human nature. By challenging disordered beliefs, behaviors are challenged; and to remain consistent behaviors must change along with the belief.7
The Body Project is an in-person CD group program, typically: 4 weekly 1-hour sessions, with 7-9 participants per group, led by a trained (for 9 hours) and scripted facilitator (counselor or peer).1 CD programs had the greatest effect on reducing ED symptoms in all the studies that included the “Body Project” as an intervention. 1, 2, 3, 4, 6, 9, 11, 12 CD challenges the thin ideal by creating cognitive dissonance with written, verbal, and behavioral exercises.1 With adequate training it worked for peers to “teach” the material, but not facilitate difficult discussions.10 Group programs, like the Body Project, further increase behavior change by the extra layer of public accountability.7
The Body Project has the greatest amount of research (relative to similar programs) and has a strong evidence-base.12 All researchers who used this intervention cited efficacy trials for dissonance-based programs that showed promise. The American Psychological Association (APA) supports dissonance-based prevention programs for interventions, for creating replicable results, and creating significant results against the control groups at 2 and 3 years, and to a 60% greater effect than assessment-only control groups.10 Many of the study authors commented that more sessions may have produced greater results.2, 4, 10
Internet-based Cognitive Dissonance Based Programming (The “eBody Project”):
The e-Body Project is CD-based like the Body Project, but delivered via the internet. The program was designed to remain interactive, and contains 6 modules to be completed over 3 weeks, at 30-40 minutes/session.1 The internet has become a constant source of thin-ideal, so to have the internet challenge that ideal through this program is very timely.1
Two studies reported that many schools and other settings found it difficult to recruit clinicians (school counselors/nurses/teachers) to learn the Body Project and lead the groups.7, 9 With over 95% of adolescents having internet access,1 a larger population can be reached via the internet.
The e-Body Project showed promising results where the in-person Body Project could not be performed. The ED risk reduction results were not as strong which may be due to the fact that participants could go through this program faster, meaning that there was less time submerged in the messaging. This had less impact on reduction of thin-ideal internalization.7
“Dying To Be Thin”:
This is a 55-minute documentary (McPhee, 2000). Widely-available at no-cost, this video covers body image, pressures to be thin, eating disorders, treatment, recovery, and consequences of eating disorders.1
This is a two-page brochure (National Eating Disorders Association, 2002) covering negative and positive body image and how negative body image may lead to eating disorders. The brochure lists ten steps to positive body image.1, 11
Quality of Studies:
The studies were inconsistent in quality. Though the majority (8 of 12) were randomized control trials (RCT), the criteria and methods left many of them lacking, with five of the twelve receiving a negative (-) grade. Four were well organized and received a positive (+) rating. Most of the studies had a strong conclusion, but due to lack of generalizability (homogeneity) or sample size, most (8 of 12) were categorized as a grade II, with only one study deserving of a grade I. Overall, the grade of research is: II, neutral.
All of the studies focused solely on females, with relatively homogeneous populations. Demographically, studies were representative of female students at American universities, but not the population at large.1, 3, 4, 5, 7, 11 Additionally, all of the studies had sample sizes of less than 1000 participants, the majority having less than 200.
There was a great likelihood of selection bias in all of the studies, as participants could voluntarily opt-in to the study or opt-out at any time. Several researchers noted that the participants who stayed in the studies may have had more interest in the topic of body image. Therefore, it is difficult to draw conclusions on how effective the interventions would be with a more universal population. Furthermore, as the study assessments were self-reported surveys, there was potential for error in interpretation of questions, or in answering questions how they think the researchers want to hear.
In conclusion, based on the studies reviewed, cognitive dissonance-based prevention programs in group settings (such as the Body Project) created the greatest reduction in ED risk factors, even at 3 years-post intervention, compared to control interventions. These CD-based programs have a greater likelihood of success in settings such as schools, especially Colleges/Universities. This is because of the unique setting schools offer in which it is often easier to deliver prevention programs. Although trained counseling clinicians were most effective, several studies noted that training peer leaders or other endogenous staff (such as teachers or school nurses) led to a statistically significant reduction of ED risk factors compared to control groups.
The one study that had participants go to a medical clinic, rather than having programming done at school, had high dropout rates.4 The authors explained that this was due to the greater time and effort needed to go to an off-campus clinic. This further shows how much more effective campus settings can be for prevention programs. With over 11.5 million female college students in 2017 in the U.S.13 (meaning approximately 1.15 million of which will develop a diagnosable eating disorder, given a 10% prevalence) this is utterly important.11
Universal programs (inclusive of all genders):
It was stated in one paper that there was research showing that programs targeting high-risk participants led to greater effects than programs that were “universal.”9 However, none of the studies evaluated for this review were universal, in that they were aimed at only females with body image concerns who did not have a diagnosed eating disorder. We believe that further studies could be done to assess whether or not cognitive dissonance-based prevention programs would be effective for males or those of the LGBTQ community. Due to body image differences among genders/gender identity, there would likely have to be different content for the CD programming to make it effective.
Programs for those with active EDs:
Potential participants with diagnosable EDs were excluded from all of the studies reviewed. This leads us to believe there is a gap in the research for programs that will reduce ED risk factors in those with clinical levels of EDs. This may be because at the point of having a diagnosable ED, it is not “prevention” anymore, but rather treatment. The disheartening piece is that according to background research in two studies (Linville, Cobb, Lenee-Bluhm, et. al; and Muller and Stice) over two-thirds of people who have EDs do not get diagnosed or receive treatment.4,6 Further research in programming that can help those with active EDs (who have not yet been identified as such) would help bridge the treatment gap.
Using this information in practice, we believe that all colleges should offer cognitive dissonance-based group programming (the Body Project). Ideally these groups would be led by trained counselors, but training peer leaders was also proven to reduce ED risk factors, and in remote areas (distance-learning / places where they cannot recruit leaders) internet versions of the Body Project can be offered. Challenging what people believe about body image and eating habits changes their behaviors to remain consistent with new beliefs. By inviting them to publically (in a group setting) denounce the thin-ideal (or other body image fads) they set themselves up for creating positive changes.
*Key to abbreviations:
AIM = Affect Intensity Measure (Larsen, 1984)
BDI = Beck Depression Inventory (Beck, Steer, & Garbin, 1988)
BMI = Body Mass Index
BSQ = Body Shape Questionnaire (Cooper, Taylor, Cooper, & Fairburn, 1987).
CDI-SF = Child Depression Inventory - Short Form (Kovacs, 1992)
CES-D = Center for Epidemiologic Studies - Depression Scale (Radloff, 1977)
DERS = Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004)
DRES = Dutch Restrained Eating Scale (van Strien, Frijters, Van Stavern, Defares, & Deurenberg, 1986)
DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. (American Psychiatric Association, 1994)
DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, Fifth edition. (American Psychiatric Association, 2013)
EAT-26 = Eating Attitudes Test (Garner, Olmstead, Bohr, & Garfinkel, 1982)
ED = Eating Disorder
EDDI = Eating Disorder Diagnostic Interview (Stice, Burton, & Shaw, 2004)
EDE = Eating Disorders Examination (Fairburn & cooper, 1993).
EDE-Q = Eating Disorder Examination-Questionnaire (Fairburn & Beglin, 1994).
EDDS = Eating Disorder Diagnostic Screen (Stice, Fisher, & Martinez, 2004)
EDI = Eating Disorder Inventory (Garner et al., 1983)
HWI = Healthy Weight Intervention (program) (Stice, Chase, Stormer, Appel, 2001; Stice, Shaw, Burton, & Wade 2006)
IBSS-R = Ideal Body Stereotype Scale-Revised (Stice, Ziemba, Margolis, & Flick, 1996).
PANAS-X = Positive Affect and Negative Affect Scale-Revised (Watson & Clark, 1992)
PSPS = Perceived Sociocultural Pressure Scale (Stice, Presnell & Spangler, 2002)
PSPS^ = Perceived Sociocultural Pressure Scale (Stice, Ziemba, Margolis, & Flick, 1996)
SATAQ-3 = (Sociocultural Attitudes Towards Appearance Questionnaire - 3 (Thompson et al., 2004)
SD-BPS = Satisfaction and Dissatisfaction with Body Parts Scale (Berscheid, Walster, & Bohrnstedt, 1973)
TOSCA-3 = Test of Self-Conscious Affect-3 Scale (Tangney, Dearing, Wagner, & Gramzow, 2000)
1. Stice E, Rohde P, Durant S, Shaw H. A Preliminary Trial of a Prototype Internet Dissonance-Based Eating Disorder Prevention Program for Young Women with Body Image Concerns. Journal of Consulting and Clinical Psychology. 2012;80(5):907-916. doi:10.1037/a0028016.
2. Black Becker, C, Bull, S, Smith, L, Ciao, A. (2008). Effects of Being a Peer-Leader in an Eating Disorder Prevention Program: Can We Further Reduce Eating Disorder Risk Factors? Eating Disorders.16(5), pp.444-459.
3. Stice E, Rohde P, Shaw H, Gau J. An Effectiveness Trial of a Selected Dissonance-Based Eating Disorder Prevention Program for Female High School Students: Long-Term Effects. Journal of Consulting and Clinical Psychology. 2011;79(4):500-508. doi:10.1037/a0024351.
4. Linville D, Cobb E, Lenee-Bluhm T, López-Zerón G, Gau JM, Stice E. Effectiveness of an Eating Disorder Preventative Intervention in Primary Care Medical Settings. Behaviour Research and Therapy. 2015;75:32-39. doi:10.1016/j.brat.2015.10.004.
5. Levitt DH. Participation in Athletic Activities and Eating Disordered Behavior. Eating Disorders. 2008;16(5):393-404. doi:10.1080/10640260802370556.
6. Müller S, Stice E. Moderators of the Intervention Effects for a Dissonance-Based Eating Disorder Prevention Program; Results from an Amalgam of Three Randomized Trials. Behavior Research Therapy. 2013;51(3):128-133. doi:10.1016/j.brat.2012.12.001.
7. Stice E, Durant, S, Rohde P, Shaw H. Effects of a Prototype Internet Dissonance-Based Eating Disorder Prevention Program at 1- and 2-year Follow-up. Health Psychology. 2012:77-86. doi:10.1093/med:psych/9780199859245.003.0007.
8. Gupta S, Rosenthal MZ, Mancini AD, Cheavens JS, Lynch TR. Emotion Regulation Skills Mediate the Effects of Shame on Eating Disorder Symptoms in Women. Eating Disorders. 2008;16(5):405-417. doi:10.1080/10640260802370572.
9. Stice E, Rohde P, Durant S, Shaw H, Wade E. Effectiveness of Peer-Led Dissonance-Based Eating Disorder Prevention Groups: Results from Two Randomized Pilot Trials. Behaviour Research and Therapy. 2013;51(4-5):197-206. doi:10.1016/j.brat.2013.01.004.
10. Becker CB, Mcdaniel L, Bull S, Powell M, Mcintyre K. Can We Reduce Eating Disorder Risk Factors in Female College Athletes? A Randomized Exploratory Investigation of Two Peer-Led Interventions. Body Image. 2012;9(1):31-42. doi:10.1016/j.bodyim.2011.09.005.
11. Stice E, Rohde P, Butryn ML, Shaw H, Marti CN. Effectiveness Trial of a Selective Dissonance-Based Eating Disorder Prevention Program with Female College Students: Effects at 2- and 3-year Follow-Up. Behaviour Research and Therapy. 2015;71:20-26. doi:10.1016/j.brat.2015.05.012.
12. Greif R, Becker CB, Hildebrandt T. Reducing Eating Disorder Risk Factors: A Pilot Effectiveness Trial of a Train-the-Trainer Approach to Dissemination and Implementation. International Journal of Eating Disorders. 2015;48(8):1122-1131. doi:10.1002/eat.v48.8.
13. Back To School Statistics. National Center for Education Statistics Website. https://nces.ed.gov/fastfacts/display.asp?id=372 Published 2017. Accessed November 11, 2017.
I have been working on this for a while, and now can share that my first YouTube video has been posted!!!!
This first video is a shorter version of my free course on the different types of eating disorders.
Other videos are coming soon on debunking popular fad diets (starting with the "keto" diet) and medical complications of eating disorders.
Please go check out my channel, and subscribe to the channel to be notified when a new video comes out. Here is the link: www.youtube.com/channel/UCfmXodqj-5iWPqLYOVQI67Q
....and the video!
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By: Lauren Goette
Lauren Goette received her B.S. in Psychology from Cal Poly, San Luis Obispo June 2017, and plans to become a licensed professional counselor in the future. Having personally struggled with anorexia, Lauren has become an advocate for mental health, working as a Peer Health Educator at Cal Poly and speaking out against the stigma surrounding mental illness. This was a paper she wrote her senior year (published with permission).
The deadliest mental disorder in existence, Anorexia Nervosa (AN) threatens the lives of millions of US citizens each year. According to Arcelus, Mitchell, Wales, and Nielsen (2011), anorexia has the highest mortality rate of any mental disorder. In fact, it has been estimated that anywhere from five to twenty percent of individuals with AN will die from the disorder (“Anorexia Nervosa,” n.d.). This exceptionally high mortality rate is largely the result of anorexics’ self-induced starvation, which can be achieved through methods such as calorie restriction and excessive exercise (“Feeding and Eating Disorders,” 2013). As a result of these behaviors, anorexia can lead to serious physical problems, such as slow heart rate, low blood pressure, reduced bone density, severe dehydration, fatigue, hair loss, and a plethora of other physiological issues (“Health Consequences of Eating Disorders,” n.d.). And while there are numerous physical complications that result from this disorder, a significant amount of damage is also inflicted on the cognitive level. A variety of studies conducted in the past two decades have shed light on the devastating cognitive impacts of anorexia, as well as the promising positive effects of refeeding. Current evidence shows, as a result of semi starvation, individuals struggling with anorexia can experience drastic structural brain changes, inhibited cognitive abilities, and memory impairments, which may be improved with weight restoration.
Structural Brain Changes
One of the most severe physical and psychological costs of anorexia is structural brain changes, which can cause significant harm to the cognitive functioning and overall mental health of anorexia sufferers. In the short term, a diet deficient in calories and nutrients, often coupled with excessive exercising, can lead to loss of both white and gray matter (Sidiropoulos, 2007). Prolonged caloric restriction promotes “abnormal reward responses to food and a deviation from a healthy feeling/perception of the body when eating.” These structural changes may, in part, explain why anorexics continually avoid food consumption, as the act itself appears to elicit a negative perception and/or sensation of the body. Additionally, this reduction of gray matter in may also contribute to the disturbance of the brain’s typical reward responses which encourage food consumption.
Often the direct result of structural brain changes, AN sufferers can experience a wide range of cognitive difficulties. Higgs (2009) explored the impact of interference from diet-related thoughts on anorexics’ cognitive abilities. On a cognitive task, restrained eaters’ reaction times when imagining eating cake were significantly slower compared to when they imagined drinking water. On the other hand, unrestrained eaters' reaction times did not significantly differ between the cake or the water conditions. Higgs maintained that the cognitive impairments displayed by restrained eaters were the direct result of a “reduction in processing capacity due to interference from diet-related thoughts.” With this reduction in processing capacity, dieters’ ability to perform basic cognitive tasks was drastically diminished, highlighting how impactful caloric restriction can be on AN individual's thoughts and on their execution of simple cognitive tasks.
In addition to these milder cognitive issues, AN sufferers can also develop chronic cognitive deficits. Specifically, Gillberg et al. (2010) found, eighteen years after AN onset, anorexics had more attention, executive function, and mentalizing problems. Anorexia was found to be associated with “a range of neuropsychological problems that are present long after the eating disorder… is no longer an important feature.” Even after starvation has ceased, weight-restored anorexia survivors can experience lingering cognitive issues. Gillberg et al. suggested that this is the result of severe structural damage which can leave important cognitive facilities critically damaged. Moreover, Fowler et al. (2006) found that even “relatively severe” neurocognitive impairments have the potential to adversely affect AN sufferers’ daily social and occupational functioning in the long term. These impairments can have a substantially negative effect on recovered individuals’ quality of life, making typically simple cognitive tasks exceptionally difficult to accomplish.
Along with cognitive difficulties, AN can also cause notable memory impairment. Kemps, Tiggeman, Wade, Ben-Tovim, and Breyer (2006) found that anorexic individuals’ frequent obsessive eating-disordered thoughts actively prevent their working memory from operating effectively, which can lead to various issues with basic memory functions such as recall. Chan et al. (2013) also found anorexic’s impairment in memory functions to be positively correlated with BMI. In other words, the lower an AN sufferer’s BMI, the worse their memory functions were, and vice versa. Kingston, Szmukler, Andrewes, Tress, and Desmond (1996) also discovered an association between anorexics’ lower weight and poorer performance on memory tasks. Kingston et al. maintained that this poor performance was directly related to anorexics’ degree of weight loss, concluding that anorexics’ memory performance declines with their decrease in weight. Chan et al. proposed that this correlation between BMI and memory impairment indicates that anorexics’ memory deficits may, in part, be associated with malnutrition, however current research remains inconclusive.
Having focused largely on the starvation-induced structural, cognitive, and memory impairments of AN, it is also imperative to recognize the simplest yet most effective treatment for such damage: weight restoration. Though not a “cure-all,” weight restoration, accomplished through the refeeding of the anorexic patient, has the potential to reverse much of the structural and cognitive damage caused by the disorder. In terms of brain matter recovery, Sidiropoulos (2007) demonstrated how weight restoration resulted in the return of white matter to premorbid levels. Simply by increasing caloric intake, anorexic patients were able to recover all of the white matter they had lost throughout the course of their disorder. Similarly, Wagner et al. (2006) found that weight restoration in long-term recovered anorexic individuals resulted in the reversal of structural brain abnormalities. These results imply that weight restoration has the power to reverse structural brain damage, and restore any and all white matter lost to anorexia.
Focusing on the psychological implications of structural brain recovery, Bernardoni et al. (2016) found a strong association between partial weight restoration and improvements in affect and eating disorder symptoms. With even minor increases in weight, recovering anorexics experienced significant improvements to their psychological wellbeing. On the cognitive side, Hatch et al. (2009) discovered that weight-restored individuals were notably faster on cognitive tasks, and exhibited superior verbal fluency and working memory. Hatch et al. concluded that, with refeeding and weight gain, cognitive impairments in weight-restored AN sufferers appeared to normalize.
Despite the existing support for weight restoration, it has noteworthy limitations. First and foremost, complete structural brain repair is not entirely possible through weight restoration While Sidiropoulos (2007) did find significant improvements in the quantity of white matter recovered in weight-restored individuals, in truth, some gray matter loss persisted. In spite of the recovery of white matter to premorbid levels, previously anorexic individuals sustained irreversible gray matter loss, which remained unaffected by their increased weight. Secondly, weight restoration fails to improve distorted cognitions about body image. Even after weight restoration, Bernardoni et al. (2016) revealed that patients remained dissatisfied with their bodies. Lastly, weight restoration fails to recover weight-restored individuals’ memory abilities. Nikendei et al. (2010), discovered that deficits in immediate and delayed story recall in currently ill AN patients persisted even after these patients were weight-restored. Nikendei et al. suggested that this was the result of a so-called “scar effect” on the brain caused by chronic starvation. They maintained that this scar effect may play an important role in the etiology and/or persistence of AN, and might also explain why memory impairments sustained during AN are seemingly irreparable.
The vast body of anorexia research available today highlights both the extensive damage AN can cause to anorexics’ brain structure, cognitive abilities, and memory, in addition to the reparative power of weight restoration. Tragically, for individuals struggling with AN, the damage sustained throughout the course of the disorder can inhibit their brains’ basic cognitive functions. The structural brain changes caused by AN can lead to an irreversible loss of brain matter, as well as serious complications with cognitive and memory functioning. Anorexia nervosa can make simple cognitive and memory tasks, such as attention and recall, exceedingly difficult to accomplish. These cognitive and memory impairments, which can be caused by both structural brain damage and cognitive interference, can make everyday functioning a challenge. Not to mention, the irreversible nature of some of this damage can cause long-term impairment, even in weight-restored individuals. Despite the seemingly endless list of structural, cognitive, and memory complications caused by AN, weight restoration may hold the key to the recovery of both brain matter and cognitive abilities. In spite of its shortcomings, weight restoration has the ability to effectively repair the structural brain damage and cognitive impairment caused by anorexia nervosa.
As a RD, I have gotten so many questions about the fad diet du jour: the "Keto" or "Ketogenic" diet. I finally decided to just write down the research in a reader-friendly version. Additional video on the history and use of the ketogenic diet at the bottom of this post. Here you go-
The ketogenic (or “keto”) diet is just another fad diet.
The Keto diet is an amped-up Atkin’s diet (that we all know now was/is terrible for your cardiovascular system, and not a sustainable way to keep weight off) where the majority of what you eat comes from fat, and carbohydrates are extremely limited (In contrast, a healthy diet should be a much more balanced macronutrient distribution of 20-35% protein, 45-65% carbohydrate, and only 10-35% fat). This skewed macronutrient distribution is actually very dangerous for the human body for several reasons -
#1, We use carbohydrate as fuel for our brain. Glucose is needed for cognitive function, and many people on the Ketogenic diet experience brain fog and difficulty focusing. Ketone bodies (specifically: beta-hydroxybutyrate (built up in blood serum), acetoacetate (found in urine), and acetone (responsible for that bad breath)), which are created when carbohydrates are not present, are not as effective (or healthy) for our brain. This may also cause metabolic acidosis which is characterized by a reduced pCO2 and/or lower pH (we need to stay in balance!).
#2, On a ketogenic diet, your intake of fruits and vegetables is extremely limited (if eaten at all) and we all know how important the fiber, vitamins, minerals, and other compounds in fruits/veggies are. On that note…
#3, The keto diet is extremely low in fiber! Fiber is not only protective against many gastrointestinal cancers, it is also a big factor in fullness and weight loss. Furthermore, constipation is very common on low-fiber diets like the Keto diet.
#4, Ketosis/ketoacidosis is what is happening in the body/brain on a chemical level – this is the body making fat into something the brain can use when carbohydrates are not available. It's a lot of work for the the body to produce, not as efficient as carbohydrate, and can be incredibly dangerous for diabetics. Additionally, we have some cells with few-to-no mitochondria. These cells are carbohydrate-dependant and must be fueled by glucose. These cells include certain cells with no mitochondria in our blood (erythrocytes), eyes (cornea, lens, and retina); cells with few mitochondria include renal medulla, testis, and leukocytes. (https://link.springer.com/article/10.1007/s11883-003-0038-6)
#5, “Keto breath.” Halitosis (bad breath) from (acetone) ketone bodies makes for an acetone-like smell on your breath that no amount of brushing/mouthwash can fix. Medical professionals look for (smell for?) this in malnourished patients.
#6, High blood lipids/cholesterol/blood pressure. It’s a high fat diet- you didn’t see this coming? The body can only break nutrients down at a certain rate, and high levels of fat in the diet may lead to high levels of blood lipids are responsible for blockages (atherosclerosis), and other cardiovascular complications up to death. While you can reverse the numbers, the plaque buildup in arteries is almost impossible to reverse. Not worth it! (note: some people do see lowered blood lipid profiles on this diet).
#7, Following this diet is often a form of disordered eating or may lead to an eating disorder (just as with any restrictive diet). Cutting out whole food groups is not healthy. We need all 3 macronutrients in appropriate proportions (majority coming from carbohydrates) to have a healthy body. Our body needs a variety of foods for best health. The reason this diet “works” for weight loss is that it restricts the types of foods that people tend to over-do-it-on like chips, candy, pastries, etc. Any diet that cuts out your favorite foods will cause weight loss, but at what cost (physically and mentally?)
#8, Not all fats are created equal. Most people starting a Keto diet are not differentiating between saturated (solid at room temp, and not something we want in large quantities) and unsaturated fats (liquid at room temp, and “healthier”). Getting this wrong also increases complications from the diet. Additionally, many people who followed a diet high in medium-chain-triglycerides (MCT) experienced undesirable digestive issues.
#9, It may mess with your thyroid and other hormones – lowering your metabolism (isn’t the point of this diet weight loss? That’s counter-intuitive…), energy, and fertility. Every time we lower our metabolism through dieting it lowers the “set-point” of our metabolism, making it harder and harder to lose weight. This is an adaptive response for mammals in famine, but not what the average person wants nowadays.
Who it the Keto diet appropriate for?
The only population that the ketogenic diet is scientifically proven to be beneficial (and safe) for is a select group of people with epilepsy (seizure disorders). This is the position of the Academy of Nutrition and Dietetics.
The Keto diet especially sucks for athletes (and people working out to lose weight)
Since our preferred fuel source is glucose (carbohydrate) from either blood glucose or glycogen (fancy term for carbohydrate stores in the liver and muscle cells), running exclusively on fat slows athletic performance as the body works much harder to break down fat (dietary and adipose storage).
Additionally, the lower protein intake and change in hormones in the body with a keto diet lower the ability to build and maintain muscle mass. If “mirror muscles” like biceps are not motivating enough to keep you off it- remember that our organs like the heart are also muscle tissue that would be broken down by this diet, causing organ damage or failure.
It’ll get you, mentally and emotionally
Ketogenic diets cause headaches, brain fog, and often irritability and obsession with food. This type of diet will very likely make you think about food an unnecessarily large amount of time, and make it difficult to be social (not being able to eat at the same places as your friends; oh, and that bad breath!).
You may feel more depressed (especially if you are already prone to depression and/or taking antidepressants) as serotonin (the “happy” neurochemical) is produced from carbohydrates. If you take an SSRI know that this class of medications work directly on serotonin that is present, and the diet requires a minimum about of carbohydrate (as we learned from the works of Ancel Keys in his starvation study) to allow the SSRI medication to work.
So, what’s the verdict?
In case you didn’t get it from the above – the Keto diet sucks. Not only is it a fad-diet (aka – not suitable for long-term weight loss/lifestyle), it can be very dangerous.
If you need help figuring out what to eat, contact a Registered Dietitian. In the meantime, if you do need some structure, balanced eating like the Mediterranean diet or DASH diet is a better way to go.
For a YouTube video with more information on this diet: click the image below
Don’t give up the foods you love. There is room for all foods in a healthy diet. We just need to keep proportions and variety in mind to fuel our body optimally.
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It's National Nutrition Month and I have a treat for you!!!
For National Nutrition Month all of my current online courses are on sale for 50% off as my treat for you! You can learn the info that I teach my private clients in the comfort of your home - for a steep discount! Use the code SAVE50MARCH at checkout.
Do you overeat? Check out: "Stop Binge Eating Without Giving Up The Foods You Love"
Are you a performer (dance, acting, musician)? Check out: "Whole Health for Performers"
I'm super excited to share the education I give my private clients with a wider audience that are not able to come to nutrition counseling or cannot afford counseling, or who want a refresher to keep the motivation up between sessions with me or other professionals.
Libby is a Registered Dietitian focusing on eating disorder treatment and prevention. She is working on the central coast to create wellness in individuals and the community.
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