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Maybe you’ve heard it, maybe you’ve said it: “I want to get better, I just don’t want to gain weight!” Unfortunately, there is no magic wand to make that possible – especially when weight restoration is recommended by your team. Decades of research all boils down to an undeniable fact: emotional and mental recovery happen when physical health is reestablished through weight restoration. Body and mind really are inextricably intertwined.

The silver lining is that once you get to the other side of weight restoration, the emotional and psychological healing that is likely to occur can make weight changes more manageable. Many people even come to appreciate their healthy bodies and have trouble remembering why weight ever mattered so much! I know that might be hard to believe right now, but it’s true, and it’s worth it, so I invite you to take the leap of faith. Here are 5 strategies that might help:

1) Focus on Your Values and Motivators

It’s normal to feel uncertain or ambivalent about recovery in general – especially the weight piece. That’s why it’s important to figure out right at the beginning of treatment why recovery matters to you. These things are going to be harder to remember when you’re having a tough day, so write them down on an index card and use it as a bookmark so that you can keep looking back at it when you need a reminder.

To come up with your list, here are some questions to ask yourself.

• What things do you want to do that the eating disorder gets in the way of? For example, going out for dinner, getting a degree or having a family.

• How has the eating disorder interfered with your values or who you want to be? For example, many people find themselves being less honest or isolating from family and friends, even though they value honesty and relationships.

• What do you dislike about the eating disorder? For example, you might dislike thinking about food all the time, the fact that you’re numb to positive emotions or that you lack energy or motivation for things you used to enjoy.

2) Learn about the Process

When you know that weight restoration is part of your treatment plan, you might focus so much on possible body changes that you start to see almost everything as a sign that your weight is skyrocketing. For example, it is very normal to experience fluid shifts and digestive discomfort that make you feel bloated and uncomfortable. These sensations happen regardless of whether or not weight is changing. It’s also common to believe that, since you are eating more, you must be gaining weight. However, your body is often using the added nutrition to make repairs rather than to restore weight.

The bottom line is, when living with an eating disorder, predictions about your weight are usually skewed. Even if your prediction is somewhat accurate, it’s probably not as dire as you might think. Did you know that weight continues to redistribute itself for 6-12 months after restoration? Knowledge is often power, so in this case, I would recommend talking to your team and asking them to explain what is happening to your body and what to expect during the course of treatment. And do your best to trust what they tell you – they’ve witnessed this process many times before!

3) Turn Your Attention Outward

The more we fixate on something, the more distorted our thoughts and perceptions get. For example, have you ever stared at your computer screen for so long that the words and images become blurry? Similarly, when we focus on our bodies for too long – including its appearance and sensations– our perception can become distorted, thus increasing distress.

Break the cycle by purposefully directing your attention outward, away from your body (but not onto other people’s bodies!). Focus on something in your environment, like the view out the window. Make a list of as many dog breeds as you can think of. Call a friend and ask them how their day is going (rather than talking about what’s upsetting you). Color. Listen to music. Read. Anything that pushes body awareness to the back of your mind.

4) Talk Back to the Eating Disorder

Sometimes, it’s hard to shift your attention away from negative thoughts about your body, fears about weight change and body checking behaviors. When this happens, use your values, motivators and what you’ve learned about the recovery process to challenge the eating disorder thoughts or “voice.” Practice disagreeing with it assertively and repeatedly. The more you do it, the easier it will get.

5) Practice Self-Compassion

Compassion is an alternative to judgment that recognizes difficulties as a universal part of what it means to be human. We experience compassion for each other when we notice that someone is having a tough time, feel emotionally moved by their pain, and therefore respond with kindness, warmth and a desire to help. Do the same for yourself: recognize that you are having a tough time and respond with kindness and warmth. Speak to yourself in a gentle and understanding way, like you might speak to a friend. Try putting your hands over your heart or giving yourself a gentle squeeze (corny, but scientifically proven!). If it’s too daunting to give yourself kind encouragement, you might imagine an inner ally, a positive persona who voices kind and encouraging things to you, drowning out or talking back to the eating disorder’s negative voice.

Of course, none of these strategies is going to guarantee you smooth sailing (that magic wand still doesn’t exist). Recovery is hard work, but that hard work is part of what leads to lasting health and happiness. If you let your team and support system help, and if you draw on these strategies for inner support, you will get through it. And yes, it will be worth it!

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Natalie Hill, LICSW, M.Div., is a clinician in Walden’s residential program. Ms. Hill’s professional interests include Narrative Therapy and innovations in Eating Disorder treatment. 

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Avoidant Restrictive Food Intake Disorder (ARFID) is a relatively new feeding disorder diagnosis that was added to the newest version of the Diagnostic and Statistical Manual. This condition can look a lot like picky eating, but has some very important differentiating characteristics. Amanda Smith, LICSW, Assistant Program Director for Walden Behavioral Care’s Peabody clinic highlights some things that you might not know about this condition.

5 Things You Might Not Know About Avoidant Restrictive Food Intake Disorder (ARFID) - YouTube

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Amanda Smith, LICSW, is the Assistant Program Director at Walden Behavioral Care’s Peabody clinic. In this role she oversees the day-to-day care of adolescents in the partial hospitalization and intensive outpatient programs. She works closely with staff, providers, families and clients to help foster a recovery-focused environment. Her career at Walden began in 2010 when she served as a clinical case manager on the inpatient unit for eating disorders. Prior to her current role, she spent time as a clinical case manager in residential and the partial hospitalization and intensive outpatient programs in Waltham. She received her masters of social science administration from Case Western Reserve University.

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Conversations around weight are hard. Being a dietitian – especially a dietitian that works with the eating disorder population – weight comes up in nearly every conversation that I have. While it is a common assumption to think that eating disorders are about food, they are not always. The same can be said about weight, as not everyone who experiences an eating disorder assigns the same value to weight, shape and appearance.

As providers, we are caught in this paradox of closely monitoring the caloric intake and weight trends of our clients while at the same time helping our clients to not do this. Believe me, as a registered dietitian on a treatment team, this is not lost on me. In many cases, my treatment recommendations are directly related to the weight trends of my clients. I’d like to argue that weight is one of the topics clients feel most vulnerable discussing—yet the topic almost always comes up in my sessions.

So, for those that DO believe that their worth depends on weight, how can we best support them?

Don’t assume – always ask:  Eating disorders are super complex and will present differently – and serve different functions – for each individual. This is why I recommend never assuming that you know how a person feels about their weight. In other words, just because he or she is seeking eating disorder treatment, doesn’t necessarily mean that they are preoccupied by what they weigh or what they look like. As weight is very personal and our clients can be especially sensitive to this topic, I recommend approaching the subject compassionately, without judgement and certainly supported with psycho-education around appropriate nutrition and its importance in recovery.

Weight loss is contraindicated in eating disorder treatment: There are only two weight recommendations for those in treatment for eating disorders—weight restoration and weight stabilization. Never weight loss. We now know that diets aren’t effective long-term, and that everyone has a different recommended weight range for optimum health.  I’ve seen the approach of ‘Let’s focus on the eating disorder now and worry about the weight later,’ but I would caution that this approach closes the door to conversations about weight concerns and opportunities to challenge societal “norms” that can contribute to the development of identities and body image.

The  body knows best: How do we actually determine our weight recommendations for an individual? Sure, we can calculate their BMI and see where it falls on the BMI chart. I’m less interested in that. I’m MUCH more interested in a person’s weight history/growth charts and overall wellbeing. I tell every client, ‘Our task is to listen to what your body is telling us and respond appropriately to its needs.’ For some this will involve weight restoration and others stabilization. My clients who need to restore weight usually know (and will tell me) what weight will support their overall health.

Remember anyone can be malnourished at any size. Bodies come in all shapes and sizes—so do eating disorders. You cannot ‘look’ like you have an eating disorder. Keep this in mind when treating clients. The cognitive work required in mental health treatment is hard enough—let alone with a malnourished brain!

If your client undergoes treatment at Walden, they will experience an emphasis on empowerment with regard to scales and weighing. We do our best to personalize treatment to help individuals to feel less vulnerable when it comes to weight and its importance in life. Remember, when determining ideal body weight ranges and treatment goals, it is always best to collaborate with a multidisciplinary team of eating disorder specialists.

If you have questions regarding the topic of weight – we’re here to consult with. Call your nearest clinic or contact our admissions department at 888-791-0004.

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Danielle Sommers MS, RD, LDN is the program dietitian for Walden’s adult and adolescent PHP as well as the Free to Be program in Braintree, MA. She earned her bachelor’s degree in Human Biology, Health, and Society from Cornell University and completed her Dietetic Internship with a Master’s Degree in Clinical Nutrition at the University at Buffalo. She is passionate about eating disorders and helping others foster positive relationships with food through individual counseling, psychoeducation, group nutrition therapy, and meal planning. She implements Motivational Interviewing and Medical Nutrition Therapy in her work with patients and families. In her spare time, you can find her cake decorating or catching up on some reading.

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It is a Thursday morning around 8:30 AM. This is the time that you always have breakfast; no earlier, no later. You prepare the same meal that you have every day at 8:30 AM. You feel comfort in this meal. It is “pure,” it is “clean” and it is “perfect.” The rest of the meals and snacks that you have planned for the day are just the same – they are also “pure, clean and perfect.”

While eating non-processed foods and being cognizant of where your food is coming from is by no means disordered eating (in and of itself), there can certainly come a point where an individual can indeed become “too healthy.”

The term Orthorexia Nervosa (ON) was first coined by Bratman and Knight in the late 1990’s in an article in Yoga Journal and is defined as an obsession with “healthy” eating choices, or the thought that eating certain foods will have harmful effects (1). There is a marked concern with the quality of food—including the source, processing, and packaging of foods to be consumed. This type of rigid thinking with regard to food choices, can lead to nutritional deficiencies, impacted relationships, decreased quality of life and other medical complications such as weight loss and malnutrition. Individuals with orthorexia typically do not have a primary focus on weight (unlike many individuals with other eating disorder diagnoses), rather, the quality and value of the food itself takes precedence. Though ON is not yet recognized as a psychiatric disorder in the DSM-5, significant research around diagnostic criteria has been reviewed by Bratman and fellow researcher Thomas Dunn, (3) and is described below:

Criterion A: Obsessive focus on “healthy food” as evidenced by:
• Preoccupation with dietary restrictions
• Violation of restrictions causes anxiety and distress with fear of disease or other negative impacts
• Dietary restrictions increase over time

Criterion B: Compulsive behavior causes clinical impairments:
• Malnutrition, weight loss, or other medical complications
• Impairment of social or academic functioning due to beliefs about dietary restrictions
• Body image concerns, self-worth and confidence are contingent on meeting “healthy” eating guidelines

Do any of the above criterion sound familiar? Do you think that you might have ON? Ask yourself these few questions, (4).

Do you choose foods based on your health status? Are you choosing foods based on the thought that it will improve your health and wellbeing? Does the thought of eating something that does not necessarily have this immediate effect make you apprehensive?

Do your thoughts about food preoccupy more than three hours of your day? You may be finding yourself thinking of things such as: planning your next meal, timing out meals, researching restaurant menus, thinking of ways to avoid eating with others, etc.

Does eating a certain way impact your typical lifestyle? Have you been isolating around meal times? Ask yourself, what does it look like when going out to eat with family or friends– are you having trouble tolerating the menu or maybe even attending? Are the obsessive thoughts about food quality impacting your day-to-day functioning and concentration?

Do you allow yourself to eat food items that are outside of categories that you’ve deemed as “healthy?” This may include foods that you once used to enjoy. It may seem like the list of these foods has decreased quite a bit recently.

Does the quality of food take precedent over taste preferences? When picking out food at the grocery store, wonder to yourself – are you choosing intuitively? Intuitive Eating: the philosophy of listening to one’s natural body cues, (hunger, fullness, cravings) rather than solely focusing on the nutrient contents, (i.e. macronutrients and micronutrients) in foods.

How do we get from “pure,” “clean” and “perfect” to “balance,” “variety” and “intuitive?” This process is not easy. To help stabilize these intrusive thoughts, clinical complications and related behaviors, adequate support from experienced professionals is the first step. If you or a loved one answered yes to one or more of these questions listed, please seek help and support through Walden Behavioral Care.

References:
1. Koven NS, Abry AW. The clinical basis of orthorexia nervosa: emerging perspectives. Neuropsychiatr Dis Treat. 2015;11:385-394.
2. Moroze RM, Dunn TM, Craig Holland J, Yager J, Weintraub Psychosomatics. 2015 Jul-Aug; 56(4):397-403.
3. T.M. Dunn, S. Bratman / Eating Behaviors 21 (2016) 11–17
4. Donini, L.M., et al. “Orthorexia Nervosa: Validation of a Diagnosis Questionnaire.” Eating Weight Disorders, vol. 10, 2005. “Homepage.” Intuitive Eating, www.intuitiveeating.org/.

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Emily Schwarz, RD, LDN is the adolescent dietitian for the Walden’s residential eating disorders program and began her career with Walden Behavioral Care in October, 2017. Emily earned her Bachelor’s degree in Nutrition and Dietetics at the University of Massachusetts Amherst and completed her dietetic internship at Hunter College City University of New York in May 2017, where she worked at multiple sites to address the unique health needs of New York City. During her internship, Emily began her interest in eating disorders while completing an extensive rotation at the Renfrew Center of New York. She can be reached at eschwarz@waldenbehavioralcare.com or at 781-693-9970.

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Ever wonder if your child’s picky eating is more than just picky eating? While the majority of toddlers and young children experience some type of picky eating as a normal part of their childhood development, there is a line where normal picky eating can become dangerous – and where medical and psychological intervention may be necessary.

Avoidant/Restrictive Food Intake Disorder (ARFID) is characterized by an eating or feeding disturbance that manifests as a failure to meet nutritional or energy needs. It can look much like picky eating – as both those with ARFID and those who are picky eaters have a limited range of food they like or are willing to eat – but there are several important differences to note. Here are some important differentiators between normal childhood picky eating and ARFID.

  1. An individual with ARFID may demonstrate sudden or significant weight loss. This could be a result of sensory sensitivities and/or aversions to food (most often caused by an adverse event or effect of eating that could include vomiting, choking or a real or feared allergic reaction) that cause restrictive eating.. Developmentally appropriate picky eaters are generally able to maintain weight despite limited food selection and do not typically experience weight loss due to a fear of vomiting or choking.
  2. Another characteristic of ARFID, specifically children diagnosed with this condition, can be a failure to achieve expected weight gains. This means that a child has fallen off their expected growth trajectory or might experience a failure to thrive or grow from an early age. Adults with ARFID may fail to maintain a weight that is appropriate for their unique nutritional needs. Picky eaters are generally still able to get enough nutrition and calories to maintain growth within their expected ranges on growth charts, or maintain a healthy weight.
  3. Someone with ARFID may be reliant on feeding tubes or nutritional supplements such as Ensure in order to obtain appropriate nutrition. Picky eater are generally able to eat enough foods and enough variety that they do not require supplementation to meet caloric needs.
  4. People with ARFID may have interference with psychosocial functioning. They may find it difficult to be around certain foods and thus are unable to be in social situations, eat in cafeterias, attend parties etc. They may also experience intense anxiety around anticipating what food might be available for them at social events, and may even avoid these events in response to their anxiety. A picky eater is generally able to attend social activities with little to no distress about the food that will be present.
  5. At times, ARFID can be triggered by a specific event or fear that arises, such as a fear of vomiting or choking. At times this will have been triggered by a specific choking or vomiting incident, but it can also arise when someone sees a person vomit and becomes intensely anxious about this happening to them. This fear then results in restriction of food intake to prevent vomiting or choking. A picky eater does not respond to fears as something that drives their eating and food choices.
  6. Lastly, a lack of interest in food or eating can be a sign of ARFID. Often, people with ARFID will say they are not hungry, do not think about food, and can even forget to eat because food is not a priority for them. In contrast, picky eaters do often feel hungry, are interested in eating the foods they enjoy and do not have the same lack of interest in food and eating.

While there are many differences between an actual diagnosis of ARFID and picky eating, the line can often be blurred. If you have concerns that you or your child’s picky eating may have become a problem, further assessment may be helpful. I invite you to contact Walden’s admissions department at 888-791-0004 to get the assessment and help that you deserve.

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Jenna Montanez, LCSW, is an Assistant Program Director, providing supervision and clinical support within Walden’s partial hospital and intensive outpatient levels of care at the South Windsor CT clinic. Jenna received her master’s degree in social work from Washington University in St. Louis, and following graduation began working in clinical day schools. Jenna also has experience in residential and group home care with adolescents with serious mental health and trauma histories. Jenna has been with Walden Behavioral Care since August of 2016. Jenna’s current interests include supervision and training, as well as community based outreach to enhance the education of other professionals, such as educators and primary care physicians, in the area of eating disorders.

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As a yoga therapist and someone who has a close personal connection with eating disorders, I am a strong advocate for the appropriate use of yoga in the treatment and recovery of eating disorders.

Yoga is a process of awakening awareness. The more awareness, the more choice and freedom we have. The more we can explore our choices and freedoms, the more confident we can be in trusting ourselves and creating appropriate boundaries. With that trust, a new or renewed sense of “Self” can awaken.

Time and again, after a guided meditation, a student will look at me with grateful tears in their eyes and a calm, deep understanding in their voice saying: “Thank you, I forgot” or “I feel like I just remembered a part of myself.” I believe what they are describing is the experience of their “Self” being moved. While I have not come across studies on this idea of “Self,” I do believe it is the most powerful gift yoga has to offer – especially for those in eating disorder recovery. I also believe that if we can cultivate our relationships with this part, we are better positioning ourselves to thrive.

What is Yoga?

Most of us associate yoga with the physical postures that we have either seen or practiced. Some know that breath is an important part of practice. What many do not know, is that breath and poses are only two of the 8-limbed path of yoga.

The full 8 limbs include mindfulness practices (the Yamas and Niyamas) that can be observed on the mat and in life – non-harming, truthfulness and surrender are just a few. With the physical and breathing practices, there are a series of steps towards meditation and ultimately enlightenment. These include turning inward, deepening focus and finding effortlessness and bliss.

As important as the actual practices of yoga is the understanding of who we are as humans through the lens of yoga. “Pancha Maya Koshas” refers to the five layers of illusion that are part of being human. The “True Self” in yoga is seen as pure energy and consciousness that we all have the power to connect with at any time (though it may take practice). The five layers include the physical body, the energetic body, the mental body, the witness and the bliss body.

Why Yoga for Eating Disorders?

Teaching those who are in conflict with their physical selves – that there are other aspects of self they can identify with (an energetic body, a witness body and even the pure consciousness of their True Self) – is exceptionally healing. It is often the first step to feeling at home in our physical bodies, and the first step in trusting our feelings and our own unique experiences in the world.

Physically, yoga can be tailored to support digestion, relieve constipation and reduce reactivity around the painful process of refeeding. Emotionally, yoga supports a connection with internal resources so that feelings, needs and longings are grounded. With a design that first “opens” the body through stretching and ends with relaxation, stressful thought patterns that perpetuate eating disorders can often fade (at least temporarily). Sometimes, emotions that have burdened us for years are able to be released during or after a yoga practice.

For some, yoga might feel confrontational. We are asking people to sit in direct experience with their body and breath. For those living with eating disorders, this simple process can feel extremely uncomfortable. For so long, these individuals have experienced turmoil and disconnect between body and mind. For this reason this connection has been altogether avoided. What I encourage to my students during practice, is to push through the discomfort and do their best to stay in this experience. What they will often find a deeper sense of being present (noticing what is happening now as opposed to ruminating thoughts about the past or the future). They may also even find pleasure and acceptance in the body and eventually find the ability to listen to and respect their body’s unique needs or come to feel that their body is whole and capable.

Ultimately, yoga teaches self-compassion and resilience.

What does the research tell us?

Today more and more inpatient and outpatient eating disorder recovery centers are finding qualified yoga teachers to lead specialized classes for their populations. Research has shown the following benefits without negative affect on weight:
• a significant decrease in depression, anxiety and body image disturbance[1]
• lower negative affect before meal times [2]
• Increased use of coping skills and self soothing, feeling of calm, awareness of internal cues and negative self talk, and positive body image [3]

One study compared traditional therapy to traditional therapy combined with yoga. Eating Disorder Examination (EDE) scores decreased over time in the yoga group, whereas the group without yoga showed initial decline but then returned to baseline EDE scores by week 12. [4]
3 things to keep in mind if developing a yoga for eating disorders program[5]
• The participant has to be engaged with the process in order to benefit. They should always have choices within the practice and the practice should be optional.
• There are many styles of yoga; mindful-based restorative programs tend to be the most effective across studies.
• Yoga interventions are most effective when combined with therapy and should not replace traditional treatment and support.

Conclusion:

Perhaps one of the most healing elements of yoga is that it does not abide by the outcome-based focus of the western world. Yoga cares little about success – it cares little about your caloric intake, the number on the scale or how others perceive you. Yoga cares about what you are cultivating right now through action and intention. For those struggling with eating disorders, the ability to connect with right now can actually mean freedom!

If you are interested adding yoga to your recovery process, be sure to discuss with your physician and treatment team. Look for specialized yoga therapists or yoga teachers who have been trained in trauma-sensitive or restorative yoga. Remember that recovery is not a straight path no matter what tools you are using. I encourage you to trust yourself, stay focused and find the supports that work best for you. Recovery is possible.

References:

[1]: Hall, Allison; et al. Use of yoga in outpatient eating disorder treatment: a pilot study. J Eat Disorders. 2016; 4:38
[2]Carly R. Pacanowski, Lisa Diers, Ross D. Crosby & Dianne Neumark-Sztainer (2016): Yoga in the treatment of eating disorders within a residential program: A randomized controlled trial, Eating Disorders, DOI: 10.1080/10640266.2016.1237810
[3] https://www.emilyprogram.com/blog/discovering-the-role-of-yoga-in-eating-disorder-treatment
[4] J Adolesc Health. 2010 Apr;46(4):346-51. doi: 10.1016/j.jadohealth.2009.08.007. Epub 2009 Nov 3.
[5]McMahon, Jennifer E., “The Use of Yoga in Eating Disorder Treatment: Practitioners’ Perspectives” (2014). Master of Social Work Clinical Research Papers. Paper 361.

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Erin LoPorto, Certified Yoga Therapist, E-RYT 500, holds advanced training in yoga and yoga therapy. She completed a two-year internship at Kripalu Center for Yoga and Health where she was able to study with world leaders in the fields of yoga, Ayurveda, energy healing, meditation and the mind-body connection. She is certified teacher of Kripalu Yoga, PranaFlow and TriYoga Therapy. She has collected over 1000 hours of training in Yoga Therapy. She is also a talented bodyworker; she holds certifications in Reiki I and II, Multi-Dimensional Transformational Healing, Access Bars and Lotus Palm Thai Yoga Massage. Additionally, Erin studied somatic expressive therapy through the Leven Institute and has taken a particular interest in trauma treatment and eating disorder recovery. She has been teaching yoga at Walden Behavioral Care for Eating Disorders since 2013 and Revolution Community Yoga since it first opened in 2012. She also has a private practice at www.erinloporto.com.

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It’s a question I get frequently as a nurse in an eating disorder Residential treatment program, almost unanimously among those new to treatment: “Why do I get so dizzy when I stand up.”

No doubt, it’s a frightening sensation: feeling as though you are going to pass out and fall over after standing up from a sitting position. It’s doubly unnerving when you don’t know why it’s happening.

The condition is called orthostatic hypotension (OH) and it’s the reason for the dizziness and lightheadedness experienced when one rises from a lying to sitting or sitting to standing position. More specifically, orthostatic hypotension is a drop of more than 20 mm Hg (millimeters of mercury, a unit of pressure) in systolic blood pressure (the pressure in your arteries when your heart contracts, also known as the “top” number) or more than 10 mm Hg in diastolic blood pressure (when the heart relaxes between beats or the “bottom” number).

OH is a common problem in eating disorder treatment and is often caused by acute or chronic malnutrition/dehydration. Dehydration is an overall lack of water in the body that results when a person loses more fluids than they take in and is a common occurrence in those suffering from Anorexia Nervosa (AN) or Bulimia Nervosa (BN).

There are times when dehydration can happen quickly (e.g. cases of excessive sweating due to intense exercise/extremely hot weather or in instances of excessive vomiting of diarrhea). Dehydration can also be a recurring problem (as is often the case with AN or BN) when there is chronic inadequate intake of fluids. Thus, those suffering from AN or BN who are struggling to drink enough fluids are at risk for dehydration, which heightens the risk for OH.

Before we talk more about what exactly OH is, why it happens and why it can be so dangerous, let’s discuss what blood pressure is, what the top (systolic) and bottom (diastolic) numbers mean and what are considered “good” and “bad” numbers when it comes to blood pressure.

First, the heart is a muscle and it acts like a pump, contracting to push blood to all parts of the body – also known as perfusion – to ensure they function properly. When the heart contracts (think of a squeezed fist) it pumps blood through the blood vessels to the rest of the body. The pressure in your blood vessels when the heart contracts is called the systolic blood pressure (SBP). For the most part in impatient or ED treatment, nurses and doctors prefer an SBP of at least 90 (ideal is 115 mm Hg).

When the heart relaxes between beats (unsqueeze your fist now), the pressure in your arteries is the diastolic blood pressure (DBP), which should be at least 60 mm Hg – ideal is 75 mm Hg – to adequately perfuse all parts of the body.

So now that we know what blood pressure is and what the specific numbers mean, we can better explain orthostatic hypotension. When a person is lying or sitting, the blood in their body pools in the blood vessels of the legs and feet, meaning less blood is returned to the heart. Upon rising from a lying or sitting position, your heart should beat slightly faster and the blood vessels should constrict (tighten) to keep blood pressure high enough to ensure blood is adequately being pumped to all parts of the body.

When the blood vessels do not constrict quickly enough – often because of dehydration (low fluid volume) – the BP can drop suddenly, meaning certain parts of the body are not getting the blood flow they need. This is orthostatic hypotension and symptoms can include weakness, fatigue, blurred vision, sweating, nausea, pale skin, clammy skin and feeling “shaky.” And if the brain is not getting enough blood, symptom can include dizziness, lightheadedness or fainting.

Orthostatic hypotension (OH) can have a number of causes (medications, alcohol use, postpartum complications, neurological and connective tissue disorders, diabetes) but the most common reason for OH in Residential and Inpatient eating disorder treatment is dehydration. As discussed before, dehydration occurs when the body has an inadequate amount of water. If there is not enough fluid volume in your blood vessels, there will not be enough pressure created to force the blood to all parts of the body (notably the brain), causing the some of the symptoms listed in the last paragraph. The heart will beat faster to compensate for the lack of fluid volume in the body in an attempt to raise the blood pressure but if the dehydration is too severe, the heart will be unable to do so.

To visualize it more easily, think of a water pipe. If there is a small amount of water in the pipe with no force applied to pump it through, the water will just sit still. But if a pump applies force, the water will move through the pipe. And the more water there is and the more force applied by the pump, the faster the water will move the pipe. In this analogy, the pump is the heart and the water is blood. This is why it’s so important to be sufficiently hydrated because adequate blood pressure requires adequate water and fluid intake.

As for diagnosis of OH, it’s done by taking your blood pressure both sitting and standing (or lying, sitting and standing) and seeing if there is more of a 20 mm Hg drop in SBP or a 10 mm Hg drop in DBP. In addition to changes in blood pressure, your heart rate will increase when changing positions. If your heart rate increase by more than 20 beats per minute from lying to sitting or sitting to standing, that is known as being orthostatic by pulse.

The treatment for OH is to administer fluids (usually water or Gatorade), whether it is orally, via nasogastric tube (in inpatient settings) or, in severe cases of dehydration, intravenously. Mild OH is common and can generally be treated easily and safely with oral fluids. But if you – or someone close to you – frequently experiences any of the symptoms listed in this blog or feel you may be suffering from an eating disorder, please seek help.

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Sean Jacquet joined Walden in February 2016 as a Registered Nurse in Walden’s Eating Disorder Residential Program. He received his Bachelor of Arts in Journalism from UMASS Amherst (2003) and started his career with GateHouse Media as a sports staff writer for MetroWest Daily News (Framingham, MA) and Daily News Tribune (Waltham, MA) before going back to school and receiving his Bachelor of Science in Nursing from Massachusetts College of Pharmacy and Health Sciences in Worcester, MA (2012). Prior to joining Walden, he was a staff nurse and a Nursing Supervisor at Westwood Lodge. He can be reached at sjacquet@waldenbehavioralcare.com.

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Bulimia is a life-threatening eating disorder and psychological illness characterized by eating unusually large amounts of food in a short period of time, followed by purging. Purging can take the form of self-induced vomiting, use of laxatives and/or diuretics, and/or extended periods of compensatory exercise and/or caloric restriction. Research estimates that 1.5% of women and 0.5% of men in the United States have bulimia. This equates to approximately 4.7 million females and 1.5 million males. Although both men and women can experience eating disorders, here are four things you might not know about men and bulimia.

  1. Men have body image challenges which can contribute to the development of eating disorders, including bulimia.

In the United States, body image concerns and eating disorders are often mistakenly considered “women’s issues.” Research, however, indicates that body image can be challenging for a lot of men, and prevalence seems to be increasing annually. Teenage boys, for example, are now three times more likely to suffer from Body Dysmorphic Disorder, with numbers of male body dissatisfaction increasing from 15% to 45% over the past 25 years.[i] Research published in the Journal of Psychology of Men and Masculinity in 2013 reported that approximately 95% of the 153 college age men surveyed were dissatisfied with their bodies on some level.[ii]  A 2014 study in the Journal of Body Image, analyzed four studies of undergraduate men, and found that over 90% of the men in the studies, struggle in some way with body dissatisfaction and negative emotions, thoughts or opinions towards their body.[iii] Although women’s struggles with body image regularly make headlines, the data clearly indicates that male body image dissatisfaction is a significant emerging problem that cannot be ignored.

Male body image dissatisfaction is complex, but many researchers identify social media, Western cultural values, video games, movies, toys, and celebrities as important contributors. These sources of influence often emphasize various body image ideals, such as the muscular ideal perpetuated by the fitness industry and Hollywood. Attempts to attain unrealistic body ideal standards often increase susceptibility to disordered eating or eating disorders. Bulimia is one of the many possible potential consequences. Unfortunately, men tend to rarely discuss body negativity, as they have few opportunities to process what they experience or deal with the related negative emotions. Men seek treatment for body image distress or eating disorders far less frequently than women do, or they may delay seeking treatment until much later in the course of the illness, due to shame, stigma or other stereotypes that make it difficult for men to ask for help. Furthermore, eating disorders and male mental health challenges are often shrouded in secrecy, which increases barriers for those seeking treatment and indicates that research may actually significantly underrepresent the number of men who struggle in silence.

  1. Bulimia isn’t always about body image. There are many other factors involved.

Bulimia is a blend of a psychiatric illness and a maladaptive coping skill. Sometimes men develop bulimia as a way to cope with trauma, anxiety, depression, stress or other uncomfortable thoughts, feelings, sensations or experiences. Men and women alike often report bulimia and restrictive eating disorder behaviors as providing a temporary sense of relief from life’s stressors, but eventually these behaviors become entrenched, habitual and chronic, and can lead to a variety of physical and mental health consequences. While individuals with eating disorders that do not involve body image dissatisfaction may not be in pursuit of dramatic changes to body weight, shape or size – they are serious nonetheless.  This is due to the negative impact on growth and development of adolescent boys and on bone and theheart and endocrine (hormonal) systems for adult men. Regardless of the triggers, bulimia requires treatment for a complete recovery where patients can develop the functional coping strategies and positive mindset needed for long-term success.

  1. Eating disorders can change overtime and transition to forms of bulimia.

Contrary to popular belief, it is not uncommon for eating disorders to change over time. Chronic restriction might transition to the development of binge eating disorder which can then transition to bulimic behaviors. Binge eating disorder, for example, is the most common eating disorder affecting males. It is estimated that 40% of those with binge eating disorder are men. Men who struggle with binge eating disorder may go on to develop bulimia if purging is used to cope with the fear of weight gain associated with the binge eating behavior. Due to diet culture and social media biases, people often commonly associate bodyweight, shape and size with particular eating disorders and frequently fail to notice eating disorder behaviors and/or excessive exercise in larger – bodied individuals and/or athletes. Regardless of body shape and size, any attempt to manage bodyweight concerns by purging through excessive exercise, self-induced vomiting, fasting, laxatives, or diuretics can facilitate the development of bulimia and related negative consequences.

  1. Many male athletes have bulimia.

Research indicates that athletes are 2-3 times more likely than non-athletes to experience eating disorders, with as many as 70% of athletes in weight class sports engaging in dieting or disordered eating behaviors. Many athletes consider their disciplined eating habits, rigorous training strategies, and weight control behaviors to be signs of their commitment to sport. Given the secretive nature, stigma, and denial surrounding eating disorders, particularly in competitive sports, male athletes are predisposed to hiding their behaviors and justifying their actions using a “win at all cost” mindset. In fact, many eating disordered behaviors exhibited by male athletes easily fly under the radar of concern because they are perceived as within the social norms of the sports culture with which they live.  In contrast to women and female athletes who are often motivated by the thin ideal, men and male athletes may be more likely to engage in behaviors to achieve a particular physique associated with a perceived performance and/or health benefit. Although male athletes might not engage in self-induced vomiting, purging through excessive exercise, overtraining in the gym, and chronic caloric restriction or macronutrient manipulation coupled with over-reliance on nutritional supplements and protein powders can severely harm the body over time. Other components of bulimia, such as binge-eating, could are often rationalized away in the context of sport. For instance, a “big male appetite,” or “eating big to bulk up for sport,” are both seemingly normalized for boys and for men in our culture. Nevertheless, despite an outward healthy appearance and in spite of one’s participation in sports, these behaviors eventually threaten athletic performance, predispose athletes to injury, have significant consequences to physical and mental health, and require professional treatment.

Concluding thoughts:

Even though there are variations of bulimia and associated disordered eating practices, one fact remains: bulimia and eating disorders do not discriminate according to shape, size, age, sex, gender, sexual orientation, race, ethnicity, income or educational level. Anyone can develop an eating disorder. Men and male athletes are not immune; nor are they alone. Unfortunately, eating disorders in men are typically under-diagnosed, under-treated, and poorly understood. It is time to break the silence and identify where to go for help!

If you or someone you know requires help with bulimia, another eating disorder, or compulsive exercise, please consider our treatment programs at Walden Behavioral Care. The Walden GOALS program offers a treatment program specifically for competitive athletes.

[i] Pope HG, Phillips KA, Olivardia R. The Adonis complex: the secret crisis of male body obsession. New York: Free Press; 2000.

[ii] Daniel, S., & Bridges, S. K. (2013). The relationships among body image, masculinity, and sexual satisfaction in men. Psychology of Men & Masculinity, 14(4), 345-351.

[iii] Frederick D. A., Buchanan G. M., Sadehgi-Azar L., Peplau L. A., Haselton M. G., Berezovskaya A., Lipinski R. E. (2007). Deserting the muscular ideal: Men’s body satisfaction in the United States, Ukraine, and Ghana. Psychology of Men & Masculinity, 8, 103-117.

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Matt Stranberg, MS, RDN, CSCS, LDN is a licensed registered dietitian nutritionist and certified strength and conditioning specialist. He is a nutritionist and exercise science advisor for the Walden GOALS program. Matt devoted the early part of his career to refining the art of training elite collegiate and professional athletes. In graduate school, he developed expertise in nutrition, behavior change and eating disorders. Matt now devotes his practice to translating nutrition and exercise science into practical solutions. As a lead member of the GOALS team, Matt is known for his dedication to educating and empowering athletes of all backgrounds to facilitate a full and meaningful recovery from disordered eating. Matt holds a B.S. degree in Kinesiology from the Honors College at The University of Massachusetts Amherst, a master’s degree in Applied Exercise Physiology and Nutrition from Columbia University and was a dietetic intern at Boston’s Brigham and Women’s Hospital.

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Orthorexia is a fairly recent term that is used to describe a disordered eating pattern classified by the restriction of any foods that are subjectively deemed “unhealthy.” One’s definition of healthy foods can vary, however this disorder typically involves solely consuming foods that are organic, clean and unadulterated. This would include raw, whole and limited – ingredient foods. While individuals should spend SOME time thinking about making healthy food choices, allowing oneself to only consume foods that meet optimal standards – which is a pattern indicative of someone with orthorexia – feels depriving and unattainable, which can ultimately result in feelings of guilt and/or shame.

Often, we see orthorexia occurring co-morbidly with obsessive compulsive disorder (OCD). Just as individuals with OCD set standards for how they must perform rituals or compulsions, we are seeing individuals with orthorexia setting very high standards with regards to diet and food consumption. If foods considered “unhealthy” are consumed, thoughts can often become so distressing that individuals feel the need to perform a compulsion (which can often include over-exercising and/or fasting in order to relieve anxiety). Just as those with OCD experience impairment to psycho-social functioning, individuals with orthorexia often become isolated as day-to-day tasks can feel overwhelming. Navigating grocery shopping, dining halls/buffets, going to the mall or movies, going out to eat or simply enjoying time at a friend’s or family member’s home can be stressors for those with orthorexia, and so they are often avoided.

Here are some actual examples of orthorexia cases that I have seen in my work. You will be able to see how it mirrors thoughts and behaviors that are also associated with OCD. Please note: names and specific details have been changed as to protect confidentiality.

• Susan needs to eat at the same exact time every day (not 5 minutes before or after) or else calories will be absorbed differently and therefore contribute to diabetes, heart disease and weight gain
• Joe must have vegetables at every eating episode as they are the “epitome of health”
• Ann will only shop at Whole Foods or farmer’s markets; other grocery stores are not an option
• John specifically plans out the time he showers in the evening as a shower will help digest dinner. The shower needs to be between dinner and evening snack in order to aid in feelings of fullness/eating too close together

These are common signs and symptoms of orthorexia1 that have OCD characteristics:

• Compulsive checking of ingredient lists and nutritional labels
• An increase in concern about the health of ingredients
• Cutting out an increasing number of food groups (all sugar, all carbohydrates, all dairy, all meat, all animal products, etc.)
• An inability to eat anything but a narrow group of foods that are deemed “healthy” or “pure”
• Unusual interest in the health of what others are eating
• Spending hours per day thinking about what food might be served at upcoming events
• Showing high levels of distress when “safe” or “healthy” foods aren’t available
• Obsessive following of food and “healthy lifestyle” blogs on Twitter and Instagram
• Body image concerns may or may not be present
Both orthorexia and OCD are serious conditions that can severely impede upon day-to-day functioning. I would recommend that anyone who is experiencing either or both of these conditions seek treatment from an OCD and eating disorder specialist or find providers that have experience with both. Remember, if you are experiencing any of these symptoms, you are not alone. Let us help!

References:

1. https://www.nationaleatingdisorders.org/learn/by-eating-disorder/other/orthorexia

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Bridget Komosky MS, RD, CD-N is a Registered Dietitian Nutritionist. She completed her Bachelor of Science degree in Nutrition at Ithaca College and her Master of Science degree in Clinical Nutrition at New York University. She completed her dietetic internship at NewYork-Presbyterian Hospital in New York, NY. Her work in eating disorders includes a six-month fellowship at NewYork- Presbyterian Hospital and New York Psychiatric Institute, employment as a dietitian on the inpatient eating disorder unit at NewYork-Presbyterian Hospital, and now as a dietitian at Walden Behavioral Care since October 2013. Currently, Bridget is the Nutrition Coordinator for Walden Behavioral Care’s CT Region adult and adolescent Partial Hospitalization Programs and the Binge Eating Disorder Intensive Outpatient Program.

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I am sure that most of us know someone who is so dissatisfied with their body shape, weight and/or size that they have – at one point or another – struggled in the conflicting ideals of pathological dieting and nourishing themselves enough to sustain daily activities. Many people even begin to engage in disordered eating behaviors such as abusing diet pills, powders, and other supplements or using unhealthy purging behaviors all in pursuit of the “perfect” body..

While we know that eating disorders can develop from interplay of biological, psychological and environmental factors that are often beyond our control, there are many risk factors that we can actively work to minimize – and even prevent – including body dissatisfaction. We can embody prevention by practicing strategies -not just with children and adolescents in mind -but in our daily encounters with people of all ages.

Here are three ways to embody prevention:

1. Become media literate, and help others to do so, too. We all need to practice thinking critically about the messages advertisers are pressing upon us. Remember these things:
a. The images we see are often manipulated and manufactured for maximum appeal -they are designed to make us feel that we need to improve ourselves. After all, their aim is to sell us the remedy!
b. We need to be skeptical about the claims they make about their product. Ads are founded on false claims (read the fine print!), but packaged to us in a way that capitalizes on our insecurities.
c. It is acceptable, and sometimes necessary, to turn away from the screen and make your own decisions about what you need to be happy and “enough.”

2. Become aware of weight and size prejudice, and work to decrease and eliminate it.
a. Intervene on bullying and teasing. Resist engaging in weight-based jokes.
b. Take steps to insure individuals of all sizes and shapes are accommodated in the spaces you inhabit (i.e. chairs appropriate for larger bodies and exercise classes for all abilities. (For more information and ideas, visit their website)
c. Know that health and illness occur at every size. Try not to make assumptions about wellness based on size and shape (for more information, click here)

3. Honor yourself and others.
a. Try not to complain about your body or its parts (or the body or parts of others). It’s hard to feel good when surrounded by negativity and judgement.
b. Dress your body in clothing that fits your body, your style and makes you feel good. Resist the urge to fit yourself into trends. Celebrating yourself paves the way for others to do so, too.
c. Avoid talking about diets and categorizing foods or behavior related to food as being “good” or “bad.” Food being granted moral qualities and discussions about restrictive diets can increase physical and emotional struggles for yourself and others. Be very aware of what you say – even to yourself.

By embodying prevention, we take steps to decrease body dissatisfaction in ourselves and in others. Thank you in advance for the part you play in making the world a more welcoming place for all of us!

For more information on how you can get involved in preventing eating disorders, check out our non-profit affiliate Foundation for Research and Education in Eating Disorders (FREED) here!

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Stephanie Haines, M.Ed., CHES, is the prevention education specialist at FREED. Her role is to provide prevention education to school communities including students, teachers and administrators regarding eating disorders, body image and related topics. Before joining FREED, Stephanie was a Senior Prevention Specialist at FCD: Prevention Works!, part of the Hazelden Betty Ford Foundation located in Newton, MA. Here, she provided substance abuse prevention education to students on 5 continents. She continues her work with FCD by training school personnel in prevention strategies. Earlier in her career she was a licensed certified occupational therapy assistant in New Hampshire. Stephanie is a member of the National Wellness Institute and is a member of a number of training and prevention-focused committees.

Stephanie earned her master’s degree from Plymouth State University in New Hampshire, where she served as a graduate assistant to Margaret Burckes-Miller, founder and director of the university’s Eating Disorders Institute. She earned her bachelor’s degree from Granite State College and an associate’s degree from New Hampshire Technical College.[/fusion_text]

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