Elizabeth Jarrard, MS, RD, LDN is a fellow blogger, with Guiltless and Don’t White Sugar Coat It, and a registered dietitian, practicing with Marci RD Nutrition Consulting in Harvard Square. Elizabeth specializes in eating disorders, as well as medical, sports, and plant-based nutrition. She is known for her ability to challenge eating disorder beliefs with a well placed ‘So?” I have asked Elizabeth to explore with us how eating disorders are maintained and treated from the perspective of a dietitian.
Thank you so much for joining us, Elizabeth. As recovery professionals, we frequently talk about changing a relationship with food. What does that mean from your end of a treatment team?
Active eating disorders distort your relationship with food. Food is in many ways throughout an eating disorder–as a means of control, as a way to cause pain, as a way to numb feelings, and many other ways. Food is transformed from something that is nourishing and life-giving into a tool of destruction. It becomes an abusive relationship that is hard to quit. As a nutrition therapist I work with my clients to remove the shame, fear, and guilt associated with food, and bring them into a healthier relationship with both food and their bodies.
In both your blog and in work with clients, you advocate for variety in what a person eats. How does variety contribute to ED recovery?
Variety is the spice of life! First, variety is important in eating disorder recovery just so we can ensure we are getting enough macro and micronutrients to support health–especially brain health during the recovery process. Second, variety helps to move clients out of the narrow constraints and ruts that eating disorders love–that false sense of control.
How does variety relate to balance? How do you know whether your day was balanced in relation to food?
Great question. Variety ensures that we are not feeding into the confines and constraints of an eating disorder. Balance is another goal of eating disorder nutrition therapy. I believe there are no “good” or “bad” foods, and it really comes down to moderation. Saying that we can never have a pastry again, sets us up for failure. Balance is having a pastry when we are hungry for one, and able to mindfully eat it and assess how it makes us feel. When you eat in a balanced way, you should have consistent energy levels throughout the day–avoiding huge slumps and feeling well nourished. At the beginning of eating disorder recovery meal plans can be an effective way to start to find balance. In working with a dietitian that specializing in eating disorders, you can find a meal plan that works with your life, and helps to find balance.
Clients often say they are afraid or even terrified to feel hunger. What are your thoughts on dealing with it?
Depending on where you fall in the eating disorder spectrum, hunger can be a very scary feeling. It may come as a surprise if it is something that you have tried to actively suppressed. Or it may be something you are used to numbing and soothing during a binge. Hunger can feel uncontrollable. It is important to pay attention and relearn your hunger cues. i often work with clients on learning to identify their hunger using a hunger scale (one like this http://medweb.mit.edu/pdf/hunger_scale.pdf). This requires tuning into your body and noticing how you uniquely experience hunger. Our goal is to avoid being at either end of the hunger scale spectrum. We can do this by nourishing our bodies, and becoming more in tune with what our bodies need.
We often come across clients who are athletes or need special diets for medical reasons. Unfortunately, we also see things like over-exercising or being overly focused on “allowed foods” that fall into the ED category. How do you help clients find that middle ground? To keep things, like exercise, that are important to overall health, but also back away from obsessive behaviors?
No one said the middle ground was ever easy. If a client is able to, I recommend switching exercise types while decreasing overall duration and intensity. For example, if they have been overexercise by running, we’ll start to decrease their mileage, while incorporating different types of exercise like yoga, or light cross-training, to begin to move away from obsession on one track. Exercise can be useful for both health and recovery, but not when done excessively. Yoga can be very therapeutic in the recovery from eating disorders.
For clients with medically required special diets, we work on incorporating more fear foods and expanding variety within their constraints. Even if a client has food allergies, there is usually still a lot of variety we can work in.
Thank you so much Elizabeth! It’s always so interesting and helpful to hear about recovery from your perspective. For more information, please contact Elizabeth at firstname.lastname@example.org or c: 307.349.0503. You can also check out her blogs at Guiltless and Don’t White Sugar Coat it.
Hi everyone! I’d like to introduce Tetyana, founder of the critically acclaimed blog Science of Eating Disorders. She has made it her aim to “facilitate knowledge synthesis, translation, and dissemination” of the peer-reviewed literature relating to eating disorders. Awesome goal, no? I asked Tetyana to be interviewed because she has become such an important resource for me in keeping up-to-date on all aspects of EDs, not just treatment. Trainings and classes are great, but there’s nothing like a good blog to keep you in touch.
Tetyana, thank you so much for agreeing to this interview! I’ll be honest. Narrowing down my questions was difficult, but I’d like to start with the origin of EDs. When trying to understand the origin of EDs, phrases like “perfect storm” are thrown around. Can you tell us what that really means?
I don’t actually hear that term very frequently, but it refers to the fact that eating disorders – like most other mental and physical disorders – are the result of a complex interaction between our genes and the environment. A phrase I like more is: “Genetics loads the gun, environment pulls the trigger.” (I do dislike that both refer to violent events or violence.) There is a range of genetic and environmental factors that can predispose an individual to develop an eating disorder; it is not a “perfect” storm as much as it is a range of conditions, on the genetic and environmental spectrums, that predispose someone to develop an eating disorder. I think it is important to emphasize that genes code for proteins, not complete behavioural traits, but in concert, our genetic makeup plays a big role in how we process information and respond to it — how we feel, think, and/or behave. Differences in various genes can affect these processes – sometimes in subtle and sometimes in not so subtle ways. The environment – and that includes the environment in utero and early childhood experiences – can interact with and modulate the way our genes are turned “on” or “off” and further shape how we feel, think, and/or behave. These complex interactions, which we do not fully understand, predispose some individuals to, for example, develop an eating disorder. But it is important to stress that when we talk about genetic predispositions, environmental stressors, or the effects these have on the brain, we are not talking about things that are permanent and unchangeable; they are not.
People with eating disorders suffer quite a few consequences, but continue to engage in the behaviors. Can you speak to the factors that maintain an eating disorder.
With respect to maintaining factors, I can only really speak about restricting and bingeing/purging behaviours mostly because that’s what I experienced and what I tend to read about. I think the behaviours (restricting, bingeing/purging) become negatively reinforcing, by which I mean that they remove a negative or unpleasant state. The removal of an unwanted state (anxiety, for example) ultimately leads the individual to become compelled to engage in those behaviours, especially when they find themselves in those states (and of course that state could be constant, too). That’s just a component of what maintains it – there are others, of course. After a while some things become habits and environmental associations (bingeing/purging whenever in a particular setting) also form. Moreover, restriction alters the way we think and process information, and all sorts of other things. But I think the power of the behaviours to remove a negative state – even if just momentarily – is one of the biggest factors that maintain the disorder. In some ways the behaviours mirror addiction, I feel, though I wouldn’t extend that analogy further than it can go.
If you could change two things about the way eating disorders are treated, what would they be and why?
I think the biggest problem in eating disorder treatment is not the way they are treated but the fact that many sufferers (a) do not get the treatment they need and/or (b) do not get treatment quickly enough. Appropriate, sufficient, and timely treatment needs to be available to more people. People should not have to wait two years to get a spot in a treatment program. People who are struggling should not be made to feel that they are “not sick enough” to warrant the treatment they need. We cannot control our genetic makeup, we cannot control our family history, and we often cannot really control our environment and the events that happen to us, but as a society, we really can make treatment more accessible and more widely available.
Any given paper on eating disorders points to a “significant gap” in the literature around the origin, maintenance and treatment of EDs. What would you say is the biggest gap and where is the most need, in terms of research?
I do not actually think there are as many gaps as often portrayed – not as many as people sometimes think there are, anyway. And I guess it comes down to a question of priorities: Do we know a lot about the causes of eating disorders on a genetic and neurobiological level? No. Do we need to know those things in order to effectively treat eating disorders? Well, not really. People have recovered and will continue to recover without this knowledge. We know enough to make sufficient strides in the most important thing, at least on a clinical level: making full remission a real possibility for a lot more people. I am very interested in eating disorder causes and maintain factors, but when it comes to improving treatment outcomes we already know enough to make an impact. We know that one of the main predictors of recovery (that is within our control) is illness duration. The shorter someone has been sick, the more likely they are to fully remit from the disorder. We know that much, and that’s enough, right now, to really make a big dent in pushing long-term recovery rates up.
And I want to be really clear here: I do NOT, in any way, want to suggest that we shouldn’t be funding basic research nor do I mean to imply that we should stop trying to find treatment tools that will help individuals who have been sick for a significant amount of time recover. I love basic research, and I love good research. It excites me a lot. I think it is incredibly important and it shouldn’t be an either/or thing: either money for basic (or clinical) research or money for treatment programs. But I don’t buy the idea that we need more research in order to see full remission rates go up.
In terms of gaps in basic research, it is hard for me to say where it is needed the most because that depends on the end goal. I can talk about what I think would be really interesting to explore, though. I am interested in genetics and neurobiology, but I don’t think the tools (at least neuroimaging tools) we have right now are sufficient to untangle things at the level that interests me, personally. Something that’s more interesting to me personally and, arguably more doable, are questions surrounding diagnostic crossover: Why do some individuals crossover and others don’t? Can we predict who will and who won’t experience crossover at an early time point, and can we use that knowledge to help in treatment? What happens during diagnostic crossover OR during rapid shifts in behaviours (restricting for a few weeks, then bingeing/purging for a few weeks, or even changes throughout the day)? What do these shifts mean for personality and temperament traits (rigidity versus impulsivity, for example)? Mainly: How do we connect the dots and explain the differences we see between AN patients and BN patients in personality and temperament and in the prevalence of various psychiatric comorbidities with the fact that so many AN patients eventually crossover to BN? What does that mean in terms of ED causes, maintain factors, and eventual outcome? These questions really interest me personally.
I also have a hypothesis that I’m waiting for someone to test, which is as follows: I suspect that the onset of bingeing behaviours in an AN patient who has been ill for, say, 3-5 years with AN, is predictive of a better outcome (eventually, like 10-20+ years down the road) than for someone who, 5 years after becoming ill, does not develop bingeing behaviours. I’m waiting for someone to test this. (Always important to stress that I’m talking about general trends in large sample groups, not any individual person per se.)
Finally, Tetyana, I’d like to ask a personal question, if you do not mind. You have shared that you are recovering yourself and you’ve personally experienced different levels of care. Would you explain the role your passion for science and your blog has played in your recovery?
I am passionate about science because I am a firm believer that the scientific method is the best tool we have to uncover truths about the world. I try to hold onto my Sagan-esque passion for science. I think having a passion is always helpful in recovery; it can help keep someone keep being in recovery.
With respect to the blog, it is hard to say how it impacted on my recovery – it probably played a neutral to slightly positive role. The experience in general has been hugely positive, and being involved with something that is so fulfilling and so rewarding is, of course, good for anyone’s self-esteem and mental health! But in that sense, it played the same role as doing other things I find really fulfilling.
It is part of the package of how I’d like my life – both day-to-day and in the long-term – to proceed. I’ve made a lot of conscious choices about how I want my life to be structured (and I’m particularly lucky to have the privilege and ability to do so), and doing science blogging is part of that picture, but not a major part. I started the blog when I was particularly frustrated with graduate school. I just wanted to have something I can work on after a week of failed experiments that amounted to me feeling very unproductive and generally low. I thought of it as my little project and if it went well, I’d continue, if not, then, oh well. I got way more positive feedback than I ever expected, and so in that sense it is been amazing. I especially love that the comments on the blog posts are intelligent and interesting, and the diversity of readers — from those personally affected with eating disorders, to carers, clinicians, and researchers — it is amazing. I love criticizing papers (I always loved journal club), I enjoy coding/playing around with PHP and HTML, making figures in Illustrator, and obviously I like editing, so it is a nice mix of all of these things I like.
In terms of recovery, I don’t have any secrets. I don’t consider myself recovered; I am not. I just don’t find my eating disorder really gets in the way of things. It doesn’t get in the way of my social life, or anything. I am not overwhelmed with thoughts of food. I love my body. I maintain my weight, and eat what I want. But I’m not free every behaviour, and I do need to make sure I eat enough otherwise I easily slip into eating less, just by accident/habit. Being mindful of my mental state helped me a lot, doing things I find really rewarding also helped me a lot, and being in an amazing relationship also helped — a lot of things in tandem, really. No magic bullets.
I’d like to thank you Tetyana for sharing your thoughts with us today! Your honestly and blunt style is much appreciated. Also, You do a remarkable job and the ED community is very lucky to have you to keep us informed!For more information, please visit Tetyana’s blog Science of Eating Disorders, where she and other contributing bloggers explore the research around eating disorders.
**Trigger and language warning. This post uses words and phrases that may trigger those who have struggled with an eating disorder, so please do what’s best for you. Also, I am genuine in my response to the media buzz. Be aware that my choice of words is not censored.
In the past few month, I’ve heard about the thigh gap diet and a series of asinine comments from the CEO of Lulelemon about women’s thighs being a problem for his clothes. My gut response has ranged from “Fuck you! Who do you think you are?” to “Please, God! Don’t let this be happening again.” But, generally, I just stay angry about the ridiculousness of the situation.
It may seem silly. Who cares what some idiot said in an interview, right? Well, I wish that is all it was, but let me explain. There are those of us who suffer from an eating disorder, have recovered from an eating disorder, treat those with eating disorders or some combination there of. In our world, the “thigh gap” as a measure of thinness is not new. It has been around for decades now, especially among the “pro-ana” set. (Pro-ana refers to those who promote anorexia as a lifestyle.) It has been one of the many “body checks” that people with eating disorders use to determine if they are thin enough that day.
To set an eating disorder behavior as a standard of beauty? It’s beyond unacceptable! Do they not understand what they are asking of women?
First, they are setting up half the population to continually fail at being acceptable to society. The thigh gap is nearly impossible to achieve, regardless of weight. The real kicker is that it requires that a woman’s hips be wider than average! We are screwed either way! Either our hips are too wider or our thighs touch? What the hell? We can’t win!!
People with eating disorders routinely set themselves up to fail. I know. I’ve recovered from one. Part of the belief system is that you can never be good enough, so you just play out the failure over and over again, affirming those negative beliefs. Now, in a very targeted and specific way, our own culture has told us that we are not good enough, ever.
And second, this nonsense is delegitimizing the terror and horror that comes with eating disorders, and creating an environment that further supports eating disorders. Great job…Those of us who have or have recovered from eating disorders can attest to how time consuming, depressing, and overwhelming body checking can be. As I said before, with an eating disorder, you fail again and again. And every single time you fail, it feels like the worst thing that has ever happened to you. It’s every disappointment, every loss, every bad thing in your life is played out in that moment.
I wish I had a better way to explain what happens for someone with an ED. All the behaviors, from restricting to purging to everything is between, are designed to relieve a paralyzing anxiety; but in the end, it only makes it worse.
Now, the media and clothing line CEOs want to set one of those behaviors up as”normal”? Well, fuck them. They have no right to take advantage of the insecurities and vulnerabilities of women, as a whole.
I can only hope that the women of American will see this nonsense for what it is and tell the media and anyone else promoting it to fuck off too.
Hi everyone! I recently had the great privilege of interviewing Dr. David Brendel. I have known David for almost two years now and I just adore his style and approach to clinical work. He is, in the truest sense, a humanist scientist. He brings a flexibility and creativity to the science of clinical work.
On top of that, David has a scary impressive resume. David has a private psychiatry practice in Belmont and a is a Certified Executive Coach with a practice in Boston called Leading Minds Personal and Executive Coaching. He is the Medical Director of Psychiatry at Walden Behavioral Care, an treatment facility that offers a continuum of care for eating disorder and psychiatric patients. David earned his M.D. from Harvard Medical and his Ph.D. in philosophy from the University of Chicago. He has a dozen or so peer reviewed articles, multiple book chapters, and is the author of MIT press book Healing Psychiatry. And because he does not have enough to do, he also host a radio “Leading Minds with Dr. David Brendel” and consults for several major TV networks.
You can see David is a bit of a psychology renaissance man, making him the perfect person with whom to explore the complex nature of eating disorders.
Below is the audio for the interview. There are also a few moments where there is a leaf blower in the background. I did my best to take it out but I’m sorry for any problems it cause!
As we move into the fourth and final way to understand why people stay stuck, psychologically speaking, we have to consider the totality of the human experience, as that is what spirituality is all about. We have moved from the biological aspects up through the interpersonal. Now we are moving onto the spiritual.
Spirituality is difficult concept to process and define, but I shall do my best. Please do not confuse the spiritual with the religious. Religion isn’t really suited for a discussion based in science. How does spirituality fit into the picture, then? “Casey,” you might be thinking, “I thought spirituality and science were antagonistic to each other.” Well, inherently, no, they are not antagonistic and most of us in the mental health field understand that spiritual health is an important facet of psychological health.
But let me back up. Let me see if I can define spirituality and how it relates to the idea of being stuck. Social scientists have come to see spirituality as the way a person sees herself and her experience in a broader ontological context. In other words, how do you believe your life fits into humanity and history as a whole. Victor Frankl, a Holocaust survivor and founder of logostherapy (“Meaning therapy”) wrote a book called “Man’s Search for Meaning,”1 and in it, describes how finding meaning in your life can allow you to live happily and move forward psychologically, even if your body is physically stuck. Meaning and purpose allow you to have hope, to see the positive aspects of a painful situation, and see the best in yourself.
When we find ourselves “stuck”, in the spiritual sense, we have lost our meaning in life or our understanding of our purpose has become distorted. Maybe cannot connect our personal experience to the whole of humanity or what there is a conflict in our values and what we think our purpose is. For example, if a person believes she does not matter as a person or that what she is doing with her life hurts others, she will have a difficult time being psychologically healthy. She may start to feel trapped in her own life. She may find herself stuck.
I think we’ve all had moments of being stuck in the spiritual sense. It’s certainly easy to see the trickle down effect on the rest of levels. Your relationships, thoughts and even your brain will suffer when you don’t feel like your life is worthwhile.
Hopefully, through these brief discussions on why we stay stuck, you can see how we find ourselves locked in depressed and anxious states. Maybe it’s because our brain have changed. Maybe it’s because we’re in a cycle. Or maybe it’s because we lack meaning and purpose in our lives.
The next question, of course, is how do we get out? How do we unstick ourselves and finally feel better. Well, stay tuned for the next post! We’ll cover the different ways you can intervene at all the different levels.
1 Frankl, V.E. (1985). Man’s search for meaning. New York City: Simon and Schuster, Inc.