The COVID-19 pandemic has posed unique challenges for those with eating disorders , particularly for those seeking support, and for providers who have had to adapt treatment delivery (e.g. virtual, hybrid; telehealth) to attend to barriers to treatment access associated with the pandemic. Most treatment centers responded to the pandemic by moving services either fully or partially online. However, we do not have a lot of science behind this transition. So we sought to change that.
 
Members of our team at the EAT Lab recently published an article in partnership with the Louisville Center for Eating Disorders (LCED1) Intensive Outpatient Program (IOP) evaluating outcomes for in-person versus telehealth treatment formats prior to and during the pandemic. In other words, we wanted to know, does telehealth intensive treatment (3 hours a day, 5 days a week) for eating disorders work? We expect that a lot of treatment moving forward will be delivered over telehealth, so it’s a very important question to answer!
 
Read the full article here. 
 
​​To make these important telehealth vs. in-person IOP treatment findings from LCED accessible and understandable, this blog post replaces highly scientific language with a plain language summary of the findings below. We also provide additional comments about why these findings are important and what they show us about the ability of the eating disorder field to increase access to eating disorder treatment through the use of telehealth.

​​Background: COVID-19 led to BOTH 1) more eating disorder symptoms and diagnoses in the general public and 2) worsening eating disorder symptoms for those who had already had an eating disorder (Phillipou et al., 2020; Schlegl et al., 2020). Further, the pandemic also led to increased barriers to accessing treatment, such that in-person treatment delivery became harder to implement while following public health guidelines, and posed a potentially higher risk of contracting COVID-19 for patients with EDs. Lastly, not a whole lot is known about delivering intensive ED treatment (particularly IOP) virtually!
 
Purpose: We were interested in finding out whether moving the traditionally in-person IOP program to virtual in response to the COVID-19 pandemic would affect treatment outcomes. In other words, we were interested in the following questions: 1) Will eating disorder, depression, and anxiety symptoms decrease from admission to the IOP program to discharge, and 2) Will they decrease similarly regardless of if the treatment is in-person or fully online (telehealth)?
 
Method: 
Participants (Who): Overall we had 93 participants with eating disorders go through the IOP program. About 60 patients received in-person (traditional) IOP treatment prior to COVID-19 and about 33 patients received virtual IOP treatment during COVID-19. These patients completed outcome measures of eating disorder symptoms, anxiety, and depression before and after treatment and agreed that we could use their data for research purposes. This sample of patients included individuals with Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED), Otherwise Specified Feeding or Eating Disorder (OSFED), and Avoidant/Restrictive Food Intake Disorder (ARFID). In other words, patients with a wide variety of ED diagnoses participated in the research reported in this paper! Patients also reported a variety of other psychiatric diagnoses (in addition to ED diagnoses). Check out the article for figures and tables showing the breakdown of diagnoses!
 
Procedure (How): Treatment for those enrolled in the IOP program prior to the COVID-19 pandemic participated in treatment on average for 10 weeks. All treatment was in-person. For those who enrolled during COVID-19, the same exact treatment format was implemented, but the delivery was completely online and virtual. 
 
Measures (What): For this study, we included measures of body mass index (BMI), and eating disorder, depression, and perfectionism symptoms as outcomes. You can read more about the specific scales we used in the full paper, but these were chosen because they are all important features of eating disorder treatment outcomes. For example, perfectionism has been shown to be intimately involved in eating disorders (Bardone-Cone et al., 2007). 
 
Analytic Approach: We also ran statistics to determine if there were any major differences in our outcome measures at the start of treatment (reminder: BMI & eating disorder symptoms, depression, or perfectionism symptoms) between those who started treatment prior to COVID-19, or after COVID-19 (there were a few - see below). Repeated Measures ANOVAS (Click to learn more) were used to assess if there were significant differences in outcomes for those who received virtual (during COVID-19) or in-person (prior to COVID-19) IOP treatment. This means- we tested are there differences in how well the IOP treatment works that depends on format (in-person or telehealth)?
 
Results: The only significant differences between the virtual vs. in-person groups at the start of treatment were that the in-person group was more concerned than the virtual group was with two aspects of perfectionism that we measured: parental expectations and criticism. This result does not really mean much, but we always test for differences between groups when doing this type of research.
 
Here are the important findings:
 
BMI (weight): BMI increased overall and increased in both groups. See the Figure! The gray line are all the participants; the orange line are participants who did treatment via telehealth, and the blue is in-person. All the lines increase, which is what we want (for BMI specifically)! And, there were no differences between groups.

This is important because weight gain is a good sign that ED treatment is going well.
 
Eating Disorder Symptoms: Eating disorder symptoms went down overall and went down in both the in-person and telehealth groups. Again, there were no differences between groups. This means that both treatment formats make eating disorder symptoms better! See Figure below, remember, the gray line are all the participants; the orange line are participants who did treatment via telehealth, and the blue is in-person.

​We won’t bore you with the additional figures, but you can find them in the full paper! We did find the same pattern for the rest of our outcomes: depression and perfectionism decreased similarly across treatment, regardless of whether patients received in-person or telehealth treatment. This is what we want to see!
 
Conclusions: Eating disorder symptoms decreased. BMI increased. Depression and perfectionism decreased. This is what we want! And importantly , all outcomes were comparable across both groups. This means that telehealth team-based eating disorder intensive outpatient programming (IOP)is not only possible, but also may be equally as effective as traditional in-person team-based IOP treatment for eating disorders. At least, that is what we found in our sample in Kentucky. We hope to see more of this research throughout the U.S. in the future! 
 
There are a few limitations to consider regarding this research. Firstly, most of our sample was composed of white women, which, while representative of those who are most likely to access treatment, seriously limits the generalizability of our findings to truly representative and diverse populations of those with EDs. In other words, people of all races and genders can (and do) have eating disorders (Burke et al., 2020; Feldman & Meyer, 2007; Smolak & Striegel-Moore, 2001), and we have no way of knowing based on this study if our findings would apply to them, too. This is especially concerning given that those with marginalized identities, such as Black, Indiginous, and People of Color (BIPOC), and queer individuals, are frequently underserved in the eating disorder field. A few other important limitations include that we had a relatively small sample size (meaning having more people in the study would have increased our confidence in the findings), and that this wasn’t a randomized control trial (so we weren’t able to randomly select who got which type of treatment delivery, since we obviously did not predict the onset of the pandemic or offer any in-person treatment during COVID-19). 
 
Limitations considered, there are still HUGE implications for increasing treatment access to those who otherwise might not be able to receive in-person eating disorder treatment. If we can do eating disorder IOP as well virtually as in-person, then there is no reason that those who a) cannot afford transportation to treatment, b) live in rural areas, or c) simply live too far away from specialized treatment to commute, should be denied the opportunity. In this way, COVID-19 may precipitate long-overdue efforts to increase ED treatment access for underserved communities. 

Get Involved! Treatment Access Resource & Study: If you or someone you know has struggled to access high-quality eating disorder treatment for any reason at all, please consider checking out one of our EAT Lab partners, Project HEAL, for treatment access resources. Additionally, we are currently hosting a short, confidential online study (5-10 minutes long) in partnership with Project HEAL, to help the field understand the overlap and impact of various treatment access barriers for those with eating disorders. Please consider participating if you meet eligibility criteria outlined at the beginning of the survey and want to help. 
 
If you have questions about the plain language study summary (or the original article, linked above), please reach out to us via the comment board below on this page, and we would be delighted to correspond with you (or clarify anything better). And, if you’d like to see more content on the blog like this, let us know! 
 
Thank you! 
 
1LCED is the only program in the state of Kentucky offering specialized IOP treatment for eating disorders. The center uses a multidisciplinary team-based approach to intensive eating disorder treatment, wherein psychologists, therapists, dieticians, and prescribers come together to treat each patient in an evidence-based and personalized manner. 

Citation: 
Levinson, C.A., Spoor, S.P., Keshishian, A.C., & Pruitt, A. (in press). Pilot outcomes from a multidisciplinary telehealth vs in-person intensive outpatient program for eating disorders during vs before the Covid-19 Pandemic. International Journal of Eating Disorders. 
 
References 
Bardone-Cone, A. M., Wonderlich, S. A., Frost, R. O., Bulik, C. M., Mitchell, J. E., Uppala, S., & Simonich, H. (2007). Perfectionism and eating disorders: Current status and future directions. Clinical psychology review, 27(3), 384-405.
 
Burke, N. L., Schaefer, L. M., Hazzard, V. M., & Rodgers, R. F. (2020). Where identities converge: The importance of intersectionality in eating disorders research. International Journal of Eating Disorders, 53(10), 1605-1609.
 
Feldman, M. B., & Meyer, I. H. (2007). Eating disorders in diverse lesbian, gay, and bisexual populations. International journal of eating disorders, 40(3), 218-226.
 
Phillipou, A., Meyer, D., Neill, E., Tan, E. J., Toh, W. L., Van Rheenen, T. E., & Rossell, S. L. (2020). Eating and exercise behaviors in eating disorders and the general population during the COVID-19 pandemic in Australia: Initial results from the COLLATE project. International Journal of Eating Disorders, 53, 1158– 1165. https://doi.org/10.1002/eat.23317
 
Schlegl, A., Maier, J., Meule, A., & Voderholzer, U. (2020). Eating disorders in times of the COVID-19 pandemic results from an online survey of patients with anorexia nervosa. International Journal of Eating Disorders, 53, 1791– 1800. https://doi-org.echo.louisville.edu/10.1002/eat.23374
 
Smolak, L., & Striegel-Moore, R. H. (2001). Challenging the myth of the golden girl: Ethnicity and eating disorders. In R. H. Striegel-Moore & L. Smolak (Eds.), Eating disorders: Innovative directions in research and practice (pp. 111–132). American Psychological Association. https://doi.org/10.1037/10403-006
​

Written by Brenna M. Williams, M.S., Fourth Year Graduate Student

​I have a confession to make. I love animation. I’m talking Disney, Pixar, Cartoon Network, Japanese anime. All of it. I have loved animation since I was a little kid, and today as a 25-year-old PhD student, I continue to browse for the latest popular animated television shows on Netflix and HBO Max. I couldn’t tell you exactly why I love animation so much, but as an adult, I think it has a lot to do with the characters. I relate to and admire many of the characters as they develop. However, it is a privilege to relate to these characters, and I am privileged to have grown up with characters that share many of my identities and reflect my appearance and my beliefs.
 
The world of animation is growing more and more diverse, with incredible animators from all backgrounds designing characters that reflect the variety of human beings in the world. This representation is important for children and adults alike. Positive representation (that is, portrayal of people in a positive and uplifting light) of individuals from marginalized communities, including people of color, women, LGBTQ+ individuals, and fat people can lead to increased self-esteem and decreased bias. Given how influential media is, positive representation in animation can have an impact on society. Shows like She-Ra and the Princesses of Power and Kipo and the Age of Wonderbeasts, with their diverse characters and cast, have already started making an impact. Given my specialty in eating disorders, I also think it’s important that animators design characters of all different body types. It’s also important that these characters’ bodies are portrayed positively, especially those in larger bodies. By showcasing characters of all body shapes and sizes, we can increase the representation of diverse bodies and challenge weight stigma and fatphobia.
 
Throughout my adventures through animated shows, I have found some shows and movies that represent individuals with a variety of body types in a positive light. In this blog post, I share three of my favorites.

​Steven Universe (2013-2019; ~10+ years old)
Steven Universe is an animated television show that originally aired on Cartoon Network and is now available on Hulu or HBO Max. Steven Universe is a coming-of-age story about a young boy named Steven Universe who lives with the Crystal Gems in Beach City. The Crystal Gems are magical, humanoid aliens with special powers. This show explores themes of love, family, and relationships, and it features characters of all colors, genders, sexualities, and shapes and sizes. This series was created by Rebecca Sugar (she/they), who is both the first woman and non-binary person to independently create a series for Cartoon Network. The voice cast is also diverse, with women of color making up the majority of the main cast. Steven Universe is known for paving the way for many more recent LGBTQ+ series, and it focused on many LGBTQ+ themes prior to the SCOTUS ruling making same-sex marriage legal throughout the United States. Steven Universe was nominated for five Emmy Awards and is a beloved series by many. In 2019, a movie was also released, and a spin-off series, Steven Universe Future, was streamed from 2019-2020. I recently just started watching this series for the first time, and I am in love. Steven is a character unlike any other I have seen, and the mysteries of his family and the Crystal Gems has kept me watching for hours on end. This is definitely a series worth watching! 

She-Ra and the Princesses of Power (2018-2020; ~8+ years old)
She-Ra and the Princesses of Power is a reboot of the 1985 series She-Ra: Princes of Power. Available on Netflix, She-Ra and the Princesses of Power follows Adora, a teenager who finds out she can transform into the legendary heroine She-Ra, and her friends as they work to build the Princess Alliance and defeat the evil Horde. This series showcases characters of all shapes, sizes, colors, sexualities, and genders. Importantly, it includes a diverse cast as well. She-Ra and the Princesses of Power explores a variety of themes, including family, justice, and relationships and is best known for its exploration of LGBTQ+ themes. This one of my absolute favorites because of its character building and sense of humor. I shared this with my boyfriend and my roommate (who both loved it), and I recommend it to pretty much anyone who lets me. 

​Bee and PuppyCat (2013-Present; ~13+ years old)
Bee and PuppyCat is an animated web series that follows Bee, an unemployed young woman, and PuppyCat, a mysterious creature that appears to be a cat-dog hybrid, as they work various temporary jobs together. The art style of this show is beautiful, and it has been compared to the work of Hayao Miyazaki. The characters are designed in a way that represents a variety of body types, and I especially love how Bee looks like an average woman in her 20s. The first season is available on YouTube, and season 2 is scheduled to stream on Netflix in 2022. There is still a great deal to learn about the characters and their backstories, but this storyline has become one of my favorites. I especially love PuppyCat, who is voiced by Oliver, a Vocaloid. I’m looking forward to watching the second season on Netflix, but in the meantime, I’ll keep watching the first season on repeat.
 
I love animation. I love the art and the characters, and I especially love when the character design and development is focused on diversity. There are so many incredible series and movies out there that include main characters who represent many different backgrounds. I am looking forward to seeing more of these characters, and I hope that animators will continue to design characters that positively represent individuals of all body sizes. 

By Claire Cusack, M.A., Lab Manager, Incoming 1st year graduate student
 
Ew. Gross. Ick. Yuck.
 
People describe an array of things as gross, repulsive, or disgusting.

But what is disgust, and what does it have to do with eating disorders?
 
At its base, disgust means “bad taste.” Disgust is a tool that may keep us alive by helping us to reject, spit out, and avoid food and substances may cause us disease and death (1). Disgust is a basic emotion characterized by a facial reaction (for instance, scrunching the nose), physiological sensation (e.g., nausea), and a visceral feeling of revulsion. As you’d expect, or have perhaps experienced, it is typically followed by avoidant behavior, such as moving backward, covering your nose, spitting something out, or closing your eyes.  With this understanding, disgust may help us. For example, if you spit out poisoned food because it tastes bad, it may save your life!

How does disgust run amok?
 
Though disgust may serve as a protective function for our bodies, things can go awry in eating disorders (2,3) That is, your brain sends a false alarm that there is a threat, when in actuality there is none. Similar to anxiety, you may interpret a food as disgusting and overestimate the harm caused by it (4). Over time, your brain may pair a certain food with the feelings of disgust, and you may avoid foods that are not harmful but necessary for your survival. This pathway is difficult to change for a couple reasons:
 
1) Your brain’s resources are dedicated to prioritizing “safety,” and
2) Avoidance feels good (5).

What sets off the false alarm?

This likely varies person to person, but there are some common triggers that may signal disgust. First, disgust is culturally bound (6) and tied to related ideas of morality (4). As a society, we decide what is “disgusting,” and when we engage in behaviors that elicit disgust, we then attach a good or bad value judgment to it. While fat is important for our survival, we may falsely learn that fat is bad or disgusting. So we may learn to believe that certain food or certain body sizes and shapes are good or bad due to us learning that fatness is disgusting (incorrectly; 7).

It can be challenging to integrate physical feelings, emotions, and thoughts. It’s especially difficult when you don’t trust your body (13). It makes sense to evaluate food as disgusting if you don’t believe your body will take care of you. However, food is only one aspect of disgust and eating disorders. Individuals with eating disorders find an array of things disgusting, such as food, weight gain, their body, but disgust can generalize beyond eating disorder content (14). The line between body and self can become blurred (15). In other words, individuals with eating disorders may also feel disgusted by who they are (8, 16). It’s so tempting to accept these thoughts and feelings at face value, but not all thoughts are true, in fact most are not. The bottom line: your body is not disgusting, and neither are you.
 
Ways to work through false alarm disgust:
 
1.) Identify what’s disgusting. Work with your therapist to identify and rank what is disgusting from least to most disgusting (17).You may work together to plan exposures to work through feelings of disgust.
 
2.) Learn your values. What are your values? Family, friends, school or work, spiritual growth, social justice, kindness, or maybe something else? You can write these down. Now, when you look at the disgusting list, do you believe the things on the disgust list above are disgusting or does your eating disorder? With this awareness, you may be able to make decisions that could still feel gross, but actually align with your values (18).
 
3.) Create opportunities for new learning. This suggestion builds on #1 and #2. If physical sensations such as drinking water, following your meal plan, eating foods that feel heavy in your stomach, or something else feels disgusting to you, and if they are a false alarm disgust, then press through and approach them. One way to approach false alarms is through interoceptive exposures. An interoceptive exposure is where you intentionally engage in activity that causes you to feel a particular sensation in your body. These exposures may help distress associated with your eating disorder (8,9,19). Let’s say feeling full disgusts you because you think that the sensation of fullness means you are gaining weight. You could drink water and sit with the bodily and emotional sensations that arise (or work with your therapist to do this).
 
Mirror exposures may be useful for working through the body parts you find disgusting (20). This involves looking at the parts of your body that bring up feelings of disgust for you. These exposures can be practiced in therapy sessions and between therapy sessions. The goal is not to feel less disgusting but learn that you can handle this feeling.
 
“You can be still and still moving. Content even in your discontent.”
– Ram Dass
 
4.) Notice when the disgust alarm is false. Mindfulness exercises and meditation to increase awareness and accuracy of body signal interpretation (21, 22). For example, breathing exercises, progressive muscle relaxation, or 5-4-3-2-1 (5 things you can see, 4 things you can touch, 3 things you can hear, 2 things you can taste, and 1 thing you can smell) can bring you to the present moment. Then, you may be better able to answer questions like, “Is this actually disgusting? Am I safe? Should I avoid this? Does that match my values?”
 
5.) You are more than your body. You may feel disgust in or about your body or body areas. This does not mean you are disgusting, because feelings are not always accurate. The feeling of disgust may be a false alarm, but it is felt as very real. Two truths can exist at once. A feeling (and/or a thought) is not a fact, so challenge these feelings/thoughts by asking yourself questions rather than accepting feelings as absolute truths. Is there evidence to suggest you are not disgusting? For example, did you help a friend? Or maybe you were kind to a coworker or peer?
 
6.) Fight fatphobia. Create new culture that values and celebrates all body sizes and shapes, including yours. Ask yourself, “Where did I learn this was disgusting?” If you’re interested in fighting fatphobia and learning more about diet culture, let us know by emailing canceldietculture@gmail.com – We have a new treatment study coming soon focused on this very issue!
 
References
[1]        P. Rozin and A. E. Fallon, “A perspective on disgust,” Psychol. Rev., vol. 94, no. 1, pp. 23–41, 1987, doi: 10.1037/0033-295X.94.1.23.
[2]        T. Harvey, N. A. Troop, J. L. Treasure, and T. Murphy, “Fear, disgust, and abnormal eating attitudes: A preliminary study,” Int. J. Eat. Disord., vol. 32, no. 2, pp. 213–218, 2002, doi: https://doi.org/10.1002/eat.10069.
[3]        B. O. Olatunji and D. McKay, Disgust and its disorders: Theory, assessment, and treatment implications. Washington, DC, US: American Psychological Association, 2009, pp. xvii, 324. doi: 10.1037/11856-000.
[4]        J. M. Tybur, D. Lieberman, R. Kurzban, and P. DeScioli, “Disgust: Evolved function and structure,” Psychol. Rev., vol. 120, no. 1, pp. 65–84, 2013, doi: 10.1037/a0030778.
[5]        T. Hildebrandt et al., “Testing the disgust conditioning theory of food-avoidance in adolescents with recent onset anorexia nervosa,” Behav. Res. Ther., vol. 71, pp. 131–138, Aug. 2015, doi: 10.1016/j.brat.2015.06.008.
[6]        P. Rozin and J. Haidt, “The domains of disgust and their origins: contrasting biological and cultural evolutionary accounts,” Trends Cogn. Sci., vol. 17, no. 8, pp. 367–368, Aug. 2013, doi: 10.1016/j.tics.2013.06.001.
[7]        B. O. Olatunji and C. N. Sawchuk, “Disgust: Characteristic Features, Social Manifestations, and Clinical Implications,” J. Soc. Clin. Psychol., vol. 24, no. 7, pp. 932–962, Nov. 2005, doi: 10.1521/jscp.2005.24.7.932.
[8]        K. Bell, H. Coulthard, and D. Wildbur, “Self-Disgust within Eating Disordered Groups: Associations with Anxiety, Disgust Sensitivity and Sensory Processing,” Eur. Eat. Disord. Rev. J. Eat. Disord. Assoc., vol. 25, no. 5, pp. 373–380, Sep. 2017, doi: 10.1002/erv.2529.
[9]        J. F. Boswell, L. M. Anderson, and D. A. Anderson, “Integration of interoceptive exposure in eating disorder treatment,” Clin. Psychol. Sci. Pract., vol. 22, no. 2, pp. 194–210, 2015, doi: https://doi.org/10.1111/cpsp.12103.
[10]      M. Plasencia, R. Sysko, K. Fink, and T. Hildebrandt, “Applying the disgust conditioning model of food avoidance: A case study of acceptance-based interoceptive exposure,” Int. J. Eat. Disord., vol. 52, no. 4, pp. 473–477, 2019, doi: 10.1002/eat.23045.
[11]      O. G. Cameron, “Interoception: The Inside Story—A Model for Psychosomatic Processes,” Psychosom. Med., vol. 63, no. 5, pp. 697–710, Oct. 2001.
[12]      S. S. Khalsa et al., “Interoception and mental health: A roadmap,” Biol. Psychiatry Cogn. Neurosci. Neuroimaging, vol. 3, no. 6, pp. 501–513, Jun. 2018, doi: 10.1016/j.bpsc.2017.12.004.
[13]      T. A. Brown et al., “Body mistrust bridges interoceptive awareness and eating disorder symptoms,” J. Abnorm. Psychol., vol. 129, no. 5, pp. 445–456, Jul. 2020, doi: 10.1037/abn0000516.
[14]      L. M. Anderson, H. Berg, T. A. Brown, J. Menzel, and E. E. Reilly, “The Role of Disgust in Eating Disorders,” Curr. Psychiatry Rep., vol. 23, no. 2, p. 4, Jan. 2021, doi: 10.1007/s11920-020-01217-5.
[15]      J. Moncrieff-Boyd, S. Byrne, and K. Nunn, “Disgust and Anorexia Nervosa: confusion between self and non-self,” Adv. Eat. Disord., vol. 2, no. 1, pp. 4–18, Jan. 2014, doi: 10.1080/21662630.2013.820376.
[16]      J. R. Fox, N. Grange, and M. J. Power, “Self-disgust in eating disorders: A review of the literature and clinical implications,” in The Revolting Self: Perspectives on the Psychological, Social, and Clinical Implications of Self-Directed Disgust, P. A. Powell, P. G. Overton, and J. Simpson, Eds. London: Karnac Books, 2015, pp. 167–186.
[17]      R. M. Butler and R. G. Heimberg, “Exposure therapy for eating disorders: A systematic review,” Clin. Psychol. Rev., vol. 78, p. 101851, Jun. 2020, doi: 10.1016/j.cpr.2020.101851.
[18]      C.-Q. Zhang, E. Leeming, P. Smith, P.-K. Chung, M. S. Hagger, and S. C. Hayes, “Acceptance and Commitment Therapy for Health Behavior Change: A Contextually-Driven Approach,” Front. Psychol., vol. 8, 2018, doi: 10.3389/fpsyg.2017.02350.
[19]      E. E. Reilly, L. M. Anderson, S. Gorrell, K. Schaumberg, and D. A. Anderson, “Expanding exposure-based interventions for eating disorders,” Int. J. Eat. Disord., vol. 50, no. 10, pp. 1137–1141, Oct. 2017, doi: 10.1002/eat.22761.
[20]      T. C. Griffen, E. Naumann, and T. Hildebrandt, “Mirror exposure therapy for body image disturbances and eating disorders: A review,” Clin. Psychol. Rev., vol. 65, pp. 163–174, Nov. 2018, doi: 10.1016/j.cpr.2018.08.006.
[21]      J. Gibson, “Mindfulness, Interoception, and the Body: A Contemporary Perspective,” Front. Psychol., vol. 10, 2019, doi: 10.3389/fpsyg.2019.02012.
[22]      P. Lattimore, B. R. Mead, L. Irwin, L. Grice, R. Carson, and P. Malinowski, “‘I can’t accept that feeling’: Relationships between interoceptive awareness, mindfulness and eating disorder symptoms in females with, and at-risk of an eating disorder,” Psychiatry Res., vol. 247, pp. 163–171, Jan. 2017, doi: 10.1016/j.psychres.2016.11.022.

By Ani C. Keshishian
2nd Year Graduate Student
​
The COVID-19 pandemic has changed daily life as we know it and has had an enormous toll on mental health. Stresses related to the pandemic and increased isolation have led to a rise in depression, anxiety, and other mental health problems. Eating disorders are also on the rise. In 2020, the National Eating Disorders Association (NEDA) reported a 70% increase in calls and inquiries compared to 2019. Studies show that many with eating disorders are experiencing a worsening in symptoms. There are several factors that have contributed to the increase in and worsening of eating disorders. Pandemic related stressors leave many struggling to cope. Don’t despair! There are small things you can do to make sure you stay on track with eating disorder recovery! Here are steps you can take to maintain your mental health and manage your eating disorder.

1. Eat regularly. Make sure you are eating at regular intervals (approximately every 3-4 hours). Unemployment, working and schooling from home, and quarantining have left many lacking structure and feeling stressed. However, it is important to maintain the nourishment your body needs to survive and thrive, especially during stressful times. Eating regularly can also improve awareness of body cues, such as hunger and fullness.
2. Sleep regularly. Good sleep hygiene can improve your energy level and mood, while reducing feelings of depression. The National Sleep Foundation recommends adults need between 7 and 9 hours of sleep per night. Too little or too much sleep can have negative impacts on your well-being, contributing to depression, anxiety, and fatigue. Develop a consistent sleep schedule. Go to bed and get up at the same times each day, even on the weekends. Being consistent with your sleep times can help you maintain daily routine and structure.
3. Engage in enjoyable activities. COVID-19 has left many with a lot of free time spent alone. You don’t need to spend the extra time learning a new language, writing a novel, or re-organizing your closet. Spend time doing the things that bring you joy, whether that is reading a book, playing a game, building a puzzle, listening to music, taking a short walk, or sitting outside. Find the activities that make you happy and commit time to engaging in them, even or especially when you are feeling stressed.
4. Limit social media usage. Social media usage has also been associated with anxiety, depression, poor sleep, and low self-esteem. Being confined to your home can leave you vulnerable to increasing your social media usage. Social media can create a climate of social comparison and preoccupation with appearance. Especially during the pandemic, fatphobic messages – such as the growing usage of terms like the “quarantine 15” – can contribute to fear of weight gain. Limiting your social media usage, taking a social media break, removing triggering content, and following body positive content can help promote your mental health.
5. Practice gratitude. Take time to recognize and appreciate the things you are grateful for every day. It can be simple ordinary things such as noticing the sun shining, sensing the breeze on your face, watching a child play, listening to a bird sing, or taking note of a stranger’s kindness. There are many negative things we can focus on during these stressful times. But focusing on the positive things you are thankful for can reduce your stress levels and make you feel more connected to others.
6. Stay connected. Social distancing and quarantine have led to increases in social isolation and loneliness. It is important to take active steps to stay connected with the ones you love and care about. Positive social supports have been shown to be a powerful resource on the road to recovery. Communicate with your family, friends, coworkers, or classmates. Even though in-person contact is limited, you can still connect with a text, phone call, facetime, skype, or zoom. Feeling connected to others can reduce loneliness and improve your overall well-being.
7. Reach out for professional help. It is important to maintain both your physical and mental health. If you are experiencing symptoms of an eating disorder, it is vital that you seek professional support. If you are already in treatment, make sure you stay connected with your treatment team and ask for additional support if you need it. If you need more support, there are eating disorder organizations that can help you navigate the process of finding help, such as NEDA, the National Association of Anorexia Nervosa and Associated Disorders (ANAD), and Project Heal. Don’t hesitate to reach out for help.

 
It is undeniable that COVID-19 has changed our way of life. But it is important to remember that this is temporary. This too shall pass!

By: Cheri A. Levinson, PhD | EAT Lab Director

1. Food will not hurt you. In fact, food is your route to healing. 

2. Your anxiety, fear, guilt and other emotions will not hurt you. Embrace your emotions and you will start to break free.

3. Your size does not matter. It does not matter. It does not matter. Size does not define who you are or what you can do with your life.

4. Becoming thinner will not make you happy. Running more will not make you happy. Restricting more will not make you happy. Letting go of your eating disorder is the only pathway to happiness.

5. You can and will survive if someone judges you. When it comes down to what matters, people do not care about how big, thin, fat etc. you are. People worry more about themselves than other people. And if they do judge you on how you look, first, it won’t impact your life and second, you probably don’t want to be around them anyway.

6. The more you eat the more energy you will have. The more energy you have the more you can actually enjoy life.

7. You are a unique and special person who does enough and is enough just by being you.

8. Everyone deserves to eat. That voice in the back of your head telling you otherwise is wrong.
​
9. Diet culture is an illusion steeped in patriarchy. It’s society’s way of holding you back. It profits large corporations and a corrupt wellness industry. Don’t let it win.  Fight back.

By Caroline Christian, M.S. 
3rd Year Graduate Student 

In our society, there are codes for how we treat one another. Imagine you are watching as someone walks up to a stranger and says, “Oh my gosh, you are so fat, there is no way anyone will ever love you.” What would your reaction be? Shock? Horror? Disbelief? You may even feel the need to walk up to the person and let them know that is not acceptable, or to comfort the other person. Or imagine saying to a friend, “Ew, your body looks gross today. You shouldn’t leave the house.” Or imagine if a friend said to you, “You need to lose weight, let’s not eat today.” What would your response be? These are examples of statements you would likely never say, or probably even think, about another person, because it would be rude, hostile, and may even end relationships. So why do we accept these statements when they are said to us by an eating disorder?

Individuals with eating disorders experience urges to engage in maladaptive behaviors, which are often driven by eating disorder thoughts. As discussed in the book, “Life without Ed”, by Jenni Schaefer, eating disorder thoughts often feel like another voice or entity (Ed) living in your head, chiming in on how you eat, socialize, and view your body (if unfamiliar with the eating disorder voice, you can read more here). The examples, “you are so fat,” “you shouldn’t leave the house today,” and “you need to lose weight” are just a few Ed thoughts that individuals with eating disorders may feel constantly bombarded with, especially around meal times, social gatherings, or situations involving seeing one’s body. Even if you don’t have an eating disorder, you likely still hear thoughts like this from time to time when looking in the mirror, trying on clothes, comparing yourself to friends, or eating at a restaurant. Although not typically accepted towards others, having critical thoughts about one’s own body and eating habits is so engrained in our society. We are taught that these self-critical thoughts are there for a reason: to motivate us to be “healthy,” to be the best version of ourselves, to be liked, and to have the most friends. These myths leading to shame, unhealthy weight-loss behaviors, and the impossible pursuit of perfection can hold us back from self-love and living life to the fullest. We are told we need to hate ourselves in order to motivate positive change, but in reality, the best motivator to want to take care of yourself is to love and accept yourself exactly as you are.
​
Below are tips from evidence-based therapies for eating disorders, anxiety, and obsessive-compulsive disorder that may help you respond to these intrusive eating disorder thoughts that people of all backgrounds experience. The severity of these thoughts may widely differ for all people, but these tips can be helpful for folks that are young and old, men, women, and gender minorities, and people with and without eating disorders. For individuals at various stages of eating disorder recovery, we hope this is a helpful supplement or refresher, but strongly recommend working with an eating disorder specialist to practice responding to Ed thoughts. Resources for seeking treatment are included the very bottom of this page.
 
1. Practice logging thoughts to notice when Ed thoughts come up. The first step in responding to unhelpful thoughts is to notice when they arise. Starting a log or diary of thoughts can help identify when thoughts come up, if there are patterns in what triggered the thought, and how these thoughts impact your day. For example, you may notice you have self-critical thoughts about your body when you look in the mirror, and that these thoughts contribute to shame and make it harder to focus at work. Even just building this awareness can help you reclaim your life from Ed thoughts. It can also help you decide if and when it may be most helpful to use the other skills below.  
 
2. Telling Ed “maybe, maybe not.” One quick response to Ed thoughts is, “Maybe, maybe not.” This skill comes from acceptance-based and exposure-based therapies, and stems from the idea that you can accept uncertainty without having to respond to it with anxiety or unhealthy behaviors. For example, if Ed says, “Nobody will like you because you look fat,” you can say “Maybe nobody will ever like me, but maybe they will.” This dismission of Ed prevents the thought from spiraling and can help you become comfortable with the discomfort of uncertainty. For example, in reality, there may be people in society who judge others based on weight, but ruminative thoughts about the past and worried thoughts about the future don’t have to dictate how you feel in the current moment.
 
3. Treat yourself like you would treat a friend who heard Ed thoughts. Treating yourself like you would treat a loved one is the primary tenant of self-compassion. As exemplified in the first paragraph, many of us would never say the things Ed tell us to a friend or accept such comments from a stranger. Self-compassion is a great tool to use all the time, but especially when 1) you’re going through a hard time or 2) you feel like you’ve made a mistake. Self-critical thoughts about food and body can be especially loud during these times, so when you hear those thoughts (e.g., “you aren’t good enough”; “you shouldn’t have eaten that”), try to respond to yourself like you would a friend going through that same tough time. For example, if your friend is having Ed thoughts about her body after looking in the mirror, you may compliment her, remind her of other things you like about her, give her a hug, or invite her to do something fun or relaxing. Many people rarely afford the same compassion to themselves. Start to practice directing this kindness inward and see how it may change your outlook.
 
4. Challenge Ed thoughts. Another tool for responding to these thoughts comes from cognitive-behavioral therapy. Most self-critical thoughts have logical fallacies in them, like assuming something is black-or-white, exaggerating possible negatives, trying to predict the future, or assuming you know what another person may think. If you notice you have a thought that is based on a myth or misconception (try noticing them in the examples above!), you can challenge the thought and replace it with a rational alternative. You can challenge a thought by putting it on trial, and listing evidence (facts, not feelings) that support the statement is true, as well as evidence that contradicts the thought. For example, there probably isn’t much evidence that your friends think you are fat, but a lot of evidence that your friends like you for who you are! Writing out this evidence can help you see the reality of the situation; not just what Ed sees.
 
5. Let Ed thoughts come and go without changing behaviors. Importantly, self-critical thoughts are usually accompanied with something you should do or change, including unhealthy weight loss behaviors. It can be hard not to let these thoughts motivate you to do things that may be harmful or hurtful. However, there are several skills you can use to let these thoughts go, without giving them power or feeling like you must engage in behaviors. One example is the “leaves on a stream” meditation. In this meditation, you picture yourself in a wooded area by a stream. You picture the leaves from the trees around you as they fall from the trees, land on the stream, and slowly get swept away. When doing this meditation, as thoughts come up, especially unhelpful Ed thoughts, you can acknowledge the thought, place it on a leaf, and slowly watch it float away. There are also versions of this meditation where you put your thoughts on clouds, or a conveyor belt – whatever is best for you! The idea behind this meditation is that you can experience thoughts without valuing or buying into them, and that the thought does not have to continue to stay in your mind. Practicing this meditation can help you get better at letting go and saying no to Ed thoughts.   
 
6. Model these skills for loved ones. It is important to note that most people have self-critical thoughts and varying levels of practice responding to them. When interacting with friends and loved ones, it can be helpful to spread positive messages about food and body image and be mindful of saying things that enhance other’s Ed thoughts. Even saying critical thoughts about yourself, like “Do I look fat in this dress?” is a form of fat talk that can influence other’s perceptions of themselves. Instead, try to be self-compassionate, present-focused, and nonjudgmental of thoughts even when you are around others. By doing this, you may help others that have similar struggles with self-criticism or intrusive Ed thoughts. You can read more about how to spread positive food and body messages in this blog!
 
Responding to these self-critical thoughts about food and body image is not easy at first, whether you have an eating disorder or not. However, being aware of and responding to these thoughts can give them less power in your life, opening you up to a fuller life with self-compassion, self-acceptance, and present-focused awareness. As thoughts like, “I should lose weight so people think I am attractive,” or “I look so bloated and gross right now” come up in real life, let yourself replace these thoughts with rational thoughts, like, “My loved ones care about me, not my weight” and “It is normal that my body shape fluctuates.” Even though it may feel difficult at first, I encourage you to practice these responses and find the ones that are most helpful for you.
 
Resources for seeking treatment:
https://www.edreferral.com/
https://www.nationaleatingdisorders.org/help-support/contact-helpline
https://map.nationaleatingdisorders.org/
(for those in Louisville or Kentucky) https://www.louisvillecenterforeatingdisorders.com/

By Claire Cusack, B.A., Lab Manager
 
“If you would only stop thinking, you would be much happier”
―Pavilion of Women, Pearl S. Buck
 
Individuals with eating disorders are often bombarded with negative thoughts, both eating disorder specific and general. Some thoughts may resemble worry and others rumination. Yes, there is a difference between worry and rumination! Though worry and rumination are similar negative thinking patterns (Fresco et al., 2002),
 

• Worry refers to an uncontrollable, sequence of negative thoughts, whereas
• Rumination refers to brooding about negative thoughts and feelings (Ellis & Hudson, 2010; Papagerogiou, 2006).

 
Worry is usually repetitive negative thoughts about the future, and rumination is usually repetitive negative thoughts about the past.  In other words, worry is characterized by “What if’s” and rumination is characterized by “Why’s.”
 
What if I fail? Why did I say that?
What if I gain weight? Why can’t I eat normally?
 
At some level, everyone worries and ruminates, even those without eating disorders, and worry and rumination may be adaptive! For instance, concern about an upcoming test may motivate you to study, to reflect on a time that things didn’t go as well as you hoped, or may help you do things differently next time. However, for individuals with eating disorders who also show anxious and depressive symptoms, the thoughts may become unhelpful (Smith et al., 2018). This is where you may get stuck. Have you ever kept circling over an event and have gotten nowhere?
 
Have you asked yourself things like:
​

​Repeating these thoughts may make them seem true or like your fears are inevitable. The good news is that 93% of worries do not come true (LaFreniere & Newman, 2020). When worries do come true, it’s often because we make them come true or what happens turns out to not be as bad as we thought it would.
 
For example, before you know it, you’ve spent so much time thinking that you haven’t checked in with your friend about how they actually interpreted what you said. Or, you’ve spent so much time worrying about failing, that you didn’t study for the test. These sorts of behaviors in response to thoughts may actually cause a rift in the friendship or a low grade. Indeed, it is easy to get trapped in these cyclical negative thought patterns and believe them. These thoughts may make it more difficult to concentrate, do daily activities, or focus on the present (Paperogiou, 2006). Moreover, you may believe that these thoughts are valuable (Behar et al., 2009) and help you (Ellis & Hudson, 2010), such as by avoiding weight gain, or make you feel better (Schmidt & Treasure, 2006). What makes rumination even more insidious is it doesn’t always appear like “negative” or brooding thoughts. Reflecting on food, weight, and shape can lead to eating disorder symptoms just like brooding does (Cowdrey & Park, 2012). An example may be writing down food intake, thinking about it, and analyzing it (Cowdrey & Park, 2011). Though not obviously problematic, this type of behavior encourages repetitive (and unrealistic) negative thinking that takes you out of the present moment.
 
How do I know if my thoughts are helpful or not?

“Yes” to these questions may suggest your thinking patterns are not serving you. When worry and rumination become unmanageable, people often engage in corrective responses (Rawal et al., 2011). These responses may look like seeking reassurance (e.g., weighing or body checking) and attempting to avoid the negative thoughts (Cowdrey & Park, 2012), which ultimately increases eating disorder symptoms (Rawal et al., 2011). The reverse may be true too, where eating disorder symptoms trigger worry and rumination, thus circling back to more eating disorder behaviors (Smith et al., 2018). The repetitive negative thoughts, eating disorder behaviors, and management of both are exhausting.

​So, what can you do about it?
 
While you may currently be in the throes of an endless loop of worry, depression, and symptoms, you can put a pin it and break the cycle. It may seem counter-intuitive, yet approaching and accepting your thoughts can help you find a way out. This means inviting curiosity into your thoughts. When a thought (or series of thoughts) pops into your head, instead of accepting them as fact, notice them, acknowledge them, and try saying “Maybe, maybe not.” This lessens their power. You might wonder, “Why do I need to approach my thoughts and emotions when I am already constantly thinking?” Certainly, worry and rumination can be near constant and thus, may not seem like avoidance. Ironically, they are forms of avoidance. So, how do you approach a thought or feeling when you feel like you’re already doing that, and in fact, can’t avoid thinking? Surprisingly, this does not involve changing the content of your thoughts, but rather changing the thought processes (Ellis & Hudson, 2010; Watkins et al., 2007). Simply put, you don’t have to change what you’re thinking about, but how you’re thinking about it. Here are some suggestions when encountering repetitive negative thoughts:
 

• Acknowledge and Accept. Try noticing the thought and emotions; acknowledge them; and watch them pass without engaging in an eating disorder behavior. For instance, if the thought is “What if I get fat?” Acknowledge the feeling: “I feel scared.” Reframe how you are thinking: “I notice that I am scared.” Instead of avoiding food, approach food by eating the meal or snack anyway. Cycling through a litany of “What if’s” is a strategy to avoid the fear of weight gain.

 

• Take a step back from the thoughts, take a step into the feelings. Entertaining an endless list of “What if’s” or pondering an equally exhaustive list of “Why’s,” may lead you to get lost in the details and forget the purpose. It’s challenging to see the big picture with that level of scrutiny. Taking a step back may provide you with room to acknowledge the feelings. For example:

 
When giving a presentation at school or at work, you might slip on your words. If you catch yourself wondering “Why did I do that? Did they notice? Everyone must think I’m incompetent,” you can take a step back from the thoughts by acknowledging them. “I think that others think less of me because I made a mistake.” Taking a step into the feelings may look like, “I feel embarrassed.” Remembering the big picture could look like, “Even though I messed up a few words, the audience was still able to follow my presentation. Everyone makes mistakes.”
 

• Tune in to your body. This does not mean evaluate and judge your body, but instead to listen to your body (Park et al., 2011). It may be helpful to consider this as a shift from “doing” (e.g., ruminating and worrying) to “being” (e.g., how do you feel in this moment). As worry is typically future driven and rumination is typically past-driven, it can be helpful to focus on the present moment. Taking an inventory of the five senses may be a place to start. What can you see, hear, feel, taste, smell right now? Other activities that have been found helpful for worries include relaxation skills (Hoyer et al., 2009), meditation (Course-Choi et al., 2017; Eberth & Sedlmeier, 2012), and yoga (Zoogman et al., 2019).

 
Here are three take-aways: 
 

1. Not all of your thoughts are facts.
2. Most of your worries are not likely to come true.
3. You can create peace with your thoughts.

 
This doesn’t mean you won’t think negative thoughts or experience uncomfortable emotions. This is a hope that by shifting the way you think, you can not only face uncomfortable emotions, but you create room to feel the happier ones, too.

​Brenna Williams, B.A.
 
“To be beautiful means to be yourself. You don’t need to be accepted by others. You need to accept yourself.” – Thich Nhat Hanh
 
When you look in the mirror, what do you think about your body? How do you picture yourself in your mind? Do you feel comfortable with your body shape, or do you feel self-conscious about the way your body looks? Do you think you have a realistic perception of your body, or is the way you see your body distorted? The way you answer these questions represents your body image.
 
Body image is formally defined as how we feel about our own bodies and our physical appearance. People with a positive body image have realistic perceptions about their bodies. They also accept their bodies or feel comfortable in their own bodies. On the other hand, people with a negative body image have distorted perceptions of their bodies, and they feel shameful, anxious, or self-conscious about their bodies. In other words, people with a negative body image do not see their bodies realistically and they are dissatisfied with their bodies. If you have a negative body image, you’re not alone! Most people have a negative body image, with up to 72% of women and 61% of men report being unsatisfied with their bodies (Fiske et al., 2014). Having a negative body image can impact our mental health. For instance, body dissatisfaction is related to lower self-esteem (Tiggeman, 2005), depression (Keel et al., 2001), and disordered eating (Goldfield et al., 2010).
 
The good news is that body dissatisfaction and negative body image do not have to be permanent, and we do not have to change our bodies to like them. Furthermore, you don’t have to like or love your body to have a positive body image! Having a positive body image can involve simply accepting our bodies as they are in the present moment and not letting how we feel about our bodies get in the way of doing the things we enjoy. We can learn to accept and appreciate our bodies as they are right now. Loving or liking our bodies is not necessary. By changing our behaviors and our perspectives we can promote a positive body image in both ourselves and society.
 
Promoting a Positive Body Image in OURSELVES:

• Focus on the healthy ideal, rather than the appearance ideal. The healthy ideal is how your body looks when all of your health needs are met, including physical, mental, emotional, social, spiritual, and intellectual health.
• Focus on your body’s functions. Remind yourself of all the things your body does that you are grateful for, such as “I like my hands because they help me draw.”
• Practice self-compassion. When you notice you are feeling badly, instead of criticizing yourself, practice self-kindness. Try saying to yourself, “I accept myself as I am today” when you don’t feel good about your body.
• Notice when you are comparing yourself to others. We usually compare ourselves to others who we perceive as “better” than us (i.e., taller, thinner, more muscular), rather than those we are “better” than.
• Focus on the positives. Remind yourself of the physical characteristics that you do like. List them out, “I like my eyes. I like the color of my hair. I like my legs.”

 
Promoting a Positive Body Image in SOCIETY:

• Listen for and challenge body shame talk. When you hear other people talking badly about their own body, or other’s bodies, try calling out their behavior.
• Notice any of your own negative body talk. Make a pact with a friend or family member to stop talking negatively about your own or other’s bodies, and become aware of how you may talk about your own and other’s bodies.
• Start a “body acceptance” campaign or project. Put up positive body image quotes on Post-It notes in your home, school, campus, workplace, or town.
• Raise awareness. Read and share resources about media literacy, body diversity, body positivity, and Health at Every Size (HAES).

 
Positive Body Image Resources

• Health at Every Size
• National Eating Disorder Association
• The Body Project
• The Body: A Home for Love

 
Please share your own ideas of how to promote a positive body image in both ourselves and society in the comments. We would love to hear your suggestions!