Caroline Christian, Ph.D. Student in the EAT Lab
 
​Every parent wants to help their child lead a happy and healthy life. For parents of children in larger bodies, this can feel like a difficult challenge. Many parents are left scrambling, without much guidance, to find answers.
 
The question, “How do I help my child be healthy?” may lead to a google search, with search terms like, “diets for kids” and “child weight loss.” This quick search can then lead to a rabbit hole of ads and articles about dieting and weight loss products for kids, most of which are aimed at “helping” parents and kids in larger bodies. However, lurking behind the guise of health are pages of products selling thin- (rather than health-) focused weight loss programs to hopeful parents, and even some targeted directly to young children.
 
What is not reflected in these ads, however, is the immense short- and long-term harm of dieting in children, specifically diets that involve restricting calories or nutrients to promote weight loss. We live in a diet culture, which means we live in a society that values thinness and equates thinness to health, morality, and beauty. Diet culture promotes losing weight at all costs, even health. Diet culture messages about weight loss are not limited to google; they are all around us, and all around our kids. Now, more than ever, parents must critically consume information about dieting and weight loss and consider how we share these messages with our children. 

A recent scientific review suggests that children’s negative beliefs about larger bodies are influenced by many sources, including peers, parents, teachers, and media use.(1) Such harmful beliefs about weight can begin by around age 3, and dislike of one’s own body often begins around ages 5-7.(2) As young children are exposed to negative messaging and stereotypes about larger bodies, restrictive dieting behaviors become more prevalent. In one study, approximately 60% of 6-13 years old have engaged in restrictive dieting and in a national epidemiological study, approximately 20% of middle school children have used extreme weight-control behaviors, such as skipping meals.(3)

​Importantly, dieting is associated with many negative short- and long-term health outcomes. First, although it may sound counterintuitive, research shows that dieting for weight loss in children predicts overeating and weight gain.(3,4) This is because restrictive diets trick the body into thinking there is limited access to food. In order to protect against starvation, the body lowers metabolism, redirects energy, and stores as much energy as possible to try to gain weight.(5) Cycles of restrictive dieting, especially from a young age, raises the body’s natural healthy weight and increase risk for serious health issues, including heart disease and type II diabetes.(6)
 
All bodies respond to dieting this way; however, children are still developing physically and cognitively, which adds additional dieting risks. For example, if a child is not receiving adequate nutrition due to restrictive dieting, the body will start redirecting nutrients to the vital organs, which leaves limited energy for growth, puberty, and brain functioning. Children who are on diets, even children in larger bodies, may experience stunted growth and delayed puberty.(7) Additionally, children who are on restrictive diets may have difficulty with learning, memory, and attention, due to the brain not receiving the nutrients needed for proper functioning and development, leading to challenges at school and socially.(8)
 
Beyond these physical and cognitive effects, dieting and diet culture messages can take a great toll on children’s and teens’ mental health. Studies suggest that dieting during childhood or adolescence is one of the most important predictors of the onset of eating disorders during this stage.(9) Additionally, experiencing and internalizing diet culture messages is associated with high levels of depression and anxiety and low self-esteem.(1) As children start receiving messages that thin = healthy, good, or beautiful, they often start to view their own body more critically. Children and adolescents who do not meet this thin appearance ideal may feel as though they are the opposite – unhealthy, bad, or ugly – leading to higher depression and anxiety symptoms. In fact, children who have experienced weight-based discrimination are almost twice as likely to engage in self-harm or suicidal behaviors compared to their peers.(10)

Given the risks associated with dieting and diet culture for children in larger bodies, it is especially important for parents, caregivers, and teachers to take an active role in helping promote healthy behaviors in children, without the negative consequences of dieting. Below are some strategies supported by science:
 
1. Remove value labels on foods. One of the most prevalent diet culture beliefs is the idea that some foods are “good” and other foods are “bad.” Most restrictive diets and weight loss plans, including those designed for children, classify some foods, like pizza, ice cream, and pasta, as
“bad.” These messages are quickly internalized by children, who may begin to avoid many “bad” foods, greatly limiting their food variety, and leading to feelings of shame and guilt if they do eat these foods. It is natural for children to enjoy sweets. Incorporating sweets in moderation into a child’s diet can help reduce cravings for and overeating on these kinds of foods. Discussing how different foods make the body feel can also help children build intuition about how to best fuel their body. For example, a child may quickly recognize that a donut for breakfast everyday may not give them the lasting energy to pay attention at school. Listening to their body’s needs is a helpful way for children to start making decisions about food, compared to making decisions based on what the scale says.
 
2. Model healthy eating and body image behaviors. It is no secret that children learn from their parents. Disordered eating in children is directly related to parents’ disordered eating and conversations with parents about eating.(12) When children hear adults saying things like, “Oh, I get to eat this because I worked out this morning,” “I’m so hungry, but I can’t eat because I am already at my points for today,” and “I shouldn’t wear this, it makes me look fat,” it is natural for them to start believing the same things about themselves. These statements put children in a box of feeling like they need to earn their food, restrict their food, and shrink their body. Even if parents are doing everything to feed their child a balanced and nourishing diet, children can still develop unhealthy beliefs about food and their body if parents’ model restrictive eating or negative body talk about themself.
 
3. Teach effective emotion regulation skills. One major cause of unhealthy eating patterns is using food to cope with emotions. While emotions are a natural part of eating, if over- or undereating are one of the only coping skills that a child has, it can lead to a dependence on food to feel good. Parents and teachers have a unique opportunity to help children respond to emotions effectively from a young age. Rather than responding to children’s emotions with food-related rewards or consequences, like “You can get a lollipop if you stop crying,” other strategies may be more helpful and sustainable. For example, parents may help children with taking deep breaths, communicating about their emotions, and practicing basic mindfulness. You can read more about emotion regulation for kids here.
 
4. Diversify experiences around food. Diet culture thrives on the belief that food can be used and manipulated to change one’s weight or body shape. However, the reality and complexity of nutrition is much richer and more enjoyable. By involving children in various parts of the process around food, like taking them to the grocery store or local farms, watching programs like Waffles & Mochi, and letting them help cook dinner, children can begin to see food as more than calories. These experiences also help kids learn about and understand how nutrition can be rewarding.   
 
If you are interested in reading more about the empty promises of dieting and diet culture or how to better support children with developing healthy eating and body image, below are resources for continued reading and learning.
 
Health At Every Size: The Surprising Truth About Your Weight
How to Raise a Mindful Eater: 8 Powerful Principles for Transforming Your Child's Relationship with Food
Why Diets Make Us Fat: The Unintended Consequences of Our Obsession With Weight Loss
Kids, Carrots, and Candy: A Practical, Positive Approach to Raising Children Free of Food and Weight Problems
Your Dieting Daughter...Is She Dying for Attention?

References:

1. Puhl RM, Lessard LM. Weight Stigma in Youth: Prevalence, Consequences, and Considerations for Clinical Practice. Curr Obes Rep. 2020;9(4):402-411. doi:10.1007/s13679-020-00408-8

2. Jensen M. Body Dissatisfaction and Weight Bias in Children. Undergraduate Honors Capstone Projects. Published online May 1, 2019. doi:https://doi.org/10.26076/a9d6-14f6

3. Tanofsky-Kraff M, Faden D, Yanovski SZ, Wilfley DE, Yanovski JA. The perceived onset of dieting and loss of control eating behaviors in overweight children. International Journal of Eating Disorders. 2005;38(2):112-122. doi:10.1002/eat.20158

4. Field AE, Austin SB, Taylor CB, et al. Relation Between Dieting and Weight Change Among Preadolescents and Adolescents. Pediatrics. 2003;112(4):900-906. doi:10.1542/peds.112.4.900

5. Rose KL, Evans EW, Sonneville KR, Richmond T. The set point: weight destiny established before adulthood? Current Opinion in Pediatrics. 2021;33(4):368-372. doi:10.1097/MOP.0000000000001024

6. Roybal D. Is “Yo-Yo” Dieting or Weight Cycling Harmful to One’s Health? Nutrition Noteworthy. 2005;7(1). Accessed August 31, 2021. https://escholarship.org/uc/item/1zz4r4qk

7. Campbell K, Peebles R. Eating Disorders in Children and Adolescents: State of the Art Review. PEDIATRICS. 2014;134(3):582-592. doi:10.1542/peds.2014-0194

8. Datta N, Bidopia T, Datta S, et al. Meal skipping and cognition along a spectrum of restrictive eating. Eating Behaviors. 2020;39:101431. doi:10.1016/j.eatbeh.2020.101431

9. Neumark-Sztainer D, Wall M, Guo J, Story M, Haines J, Eisenberg M. Obesity, Disordered Eating, and Eating Disorders in a Longitudinal Study of Adolescents: How Do Dieters Fare 5 Years Later? Journal of the American Dietetic Association. 2006;106(4):559-568. doi:10.1016/j.jada.2006.01.003

10. Sutin AR, Robinson E, Daly M, Terracciano A. Perceived Body Discrimination and Intentional Self-Harm and Suicidal Behavior in Adolescence. Childhood Obesity. 2018;14(8):528-536. doi:10.1089/chi.2018.0096

11. Robinson E, Sutin AR. Parents’ Perceptions of Their Children as Overweight and Children’s Weight Concerns and Weight Gain. Psychol Sci. 2017;28(3):320-329. doi:10.1177/0956797616682027

12. Berge JM, MacLehose R, Loth KA, Eisenberg M, Bucchianeri MM, Neumark-Sztainer D. Parent Conversations About Healthful Eating and Weight: Associations With Adolescent Disordered Eating Behaviors. JAMA Pediatr. 2013;167(8):746. doi:10.1001/jamapediatrics.2013.78

​

​Written by Sara Clark

​If you have heard any of these comments during pregnancy, you are not alone. As a mom of 3, I have been there and heard all these things multiple times throughout every single one of my pregnancies, and I hated it every time. Every comment left me feeling incredibly self-conscious and embarrassed; like there was something wrong with me or how I was choosing to manage my pregnancy. Everyone seemed so excited to appraise my pregnant body for changes, and no one really bothered to pay attention to the person, and their feelings, behind the bump. The more comments I got, the more it stung. While these comments are often meant to be a way to ask about your pregnancy, and most of it is intended to be lighthearted, sometimes it can be really insensitive! Managing your own conflicting feelings about your changing body and pregnancy can be difficult enough without the added stress of heading into a social event knowing you will hear these things over and over again. So, what are we supposed to do about the frustrating, confusing, wonderful, and sometimes anxiety inducing feelings we have over our changing body in pregnancy and on top of that, handle navigating social situations with them?  

First of all, take a deep breath and know that you are not alone in these feelings, studies show that pregnancy is a time for increased anxiety especially over all of the physical changes that are experienced. What you are feeling is totally normal.

Something that has been shown to help manage any new or old anxious feelings is to practice mindful self-compassion. Mindful self-compassion is learning to view yourself, your experiences, and your feelings with a more open and forgiving heart. This might be something that you are familiar with; the idea of mindfulness is not exactly a new concept. This philosophy has been used in Buddhism for thousands of years. However, more recently researchers are taking these philosophies and making them much more accessible in daily-life practices and formal meditations.  According to Dr. Kristin Neff there are 3 main components to engaging in self-compassion; they are self-kindness, common humanity, and mindfulness. By introducing these into your everyday life and activities, you are giving yourself skills to learn to manage any emotions that come up when people comment on your changing, pregnant body and increase your wellbeing.

Imagine you’re enjoying yourself at a party and someone says to you,
 
                                                “Oh wow! Haven’t you had that baby yet!”
 
And suddenly you feel really angry, and then you immediately feel guilty for feeling angry at this person for simply trying to make conversation. What do you do?!

First, good job using mindfulness and acknowledging how you feel! Now is a good time to practice some self-kindness.

 Self-kindness implores us to treat ourselves with the kindness and understanding that we would a close friend or family member. While that might seem simple enough, sometimes it can be really difficult! Take a moment to think about the last time you made a big mistake, were the comments you made to yourself very kind, or were they critical? Would you say those same things to a friend if they made a mistake? Contrary to popular belief, we tend to treat others with more kindness than we do ourselves. Imagine a friend is retelling this story to you from their point of view, would you criticize them for feeling angry in the moment? Probably not, as a friend you would most likely offer a kind, sympathetic ear and comfort your friend.

Self-kindness can look different for different people in this situation. It might look like simply getting through the conversation as cordially as possible and then taking a moment to yourself. Something that helped me move through these events was to have a few phrases that helped empower me, while creating my own self kindness support and boundaries with others.
​
Some of my favorite phrases that I liked to use were;

​“I know! Isn’t it amazing, I’m growing a whole human being!”
“Thanks for your concern but my body is no one’s business but my own”
“My doctor tells me that we are fine and perfectly healthy”
“I don’t know what you mean? I’m not pregnant?!” but only if you are feeling extra, ;-)

The final pillar of mindful self-compassion is Common humanity. Common humanity is taking a moment to realize you are not alone. For example, you are not alone in your feelings, and you are not the only pregnant person to ever have these feelings.  Sometimes, being human can be incredibly isolating. We can trick ourselves into thinking that no one could possibly understand us. That’s not true! As someone who has experienced pregnancy, I can absolutely relate to all these frustrating confusing feelings. The next time you’re at your Obstetrics office take a moment to look around the waiting room. I guarantee at least one (most likely all) of those other expecting parents have heard or thought negative comments about their changing pregnant body. Odds are they felt exactly like you did when you heard intrusive comments about your pregnant body. You might be the only pregnant person in your family or friend group and so finding common humanity might feel difficult. To help build common humanity, try to seek out positive pregnant parent groups. These groups can be found on social media, “preparing for baby” classes at your hospital, local Le Leche League chapters, or even local prenatal exercise classes. The most important thing is that you find a place where you feel most comfortable, supported, and can find common humanity with other pregnant families.
 
Just like you are practicing ways to respond to your new baby’s needs through learning things like diapering, feeding, and soothing skills, mindful self-compassion skills are essential for learning how to take care and support yourself. So, when you find yourself on the receiving end of any of these “intrusive pregnancy comments” take a moment to remember we tend to treat others with more kindness and understanding than we treat ourselves. Rather than becoming frustrated with yourself for not loving every part of pregnancy and feeling personally attacked or resentful about the comment, remember that you are human and what you are feeling is normal and valid. Finally, we are worthy of kindness, even if in the moment it is only coming from ourselves, taking a minute to reflect on this can ease some of the most stressful moments in pregnancy.   
 
If you are interested in more mindful practices, please visit Dr. Kristin Neff’s website, they have many free and wonderful resources, to help you practice mindful self-compassion during and after your pregnancy.
 
https://self-compassion.org/
 
Resources for local pregnancy support in Kentuckiana:
 
https://uoflhealth.org/services/womens-health/center-for-women-infants/
 
https://nortonhealthcare.com/services-and-conditions/obstetrics-and-gynecology/services/pregnancy/during-pregnancy/parent-classes/
 
https://www.baptisthealth.com/louisville/patients-and-visitors/community-classes-and-support-groups/classes-and-programs/maternity-classes/
 
https://www.mamatomama.us/programs
 
https://louisville.momcollective.com/pregnancy/pregnancy-infant-support/

Rowan Hunt, MS and Hannah Fitterman-Harris, PhD
 
Despite their depiction in media, we know that eating disorders are about more than food, weight, and bodies. Often, it’s easier to talk about these things than what is underlying the eating disorder: emotions. Emotions are so human; everyone experiences them. However, sometimes feeling emotions (especially emotions like anger, sadness, and anxiety) can be uncomfortable. In the face of this discomfort, it’s easy to get caught up in trying to avoid the emotions. This also seems to be true in the case of eating disorders. Individuals sometimes use eating disorder behaviors to try to reduce or avoid negative feelings.(1) Research has shown that people who had difficulty recognizing and regulating emotions were also more likely to have eating disorder symptoms.(2) Additionally, those with eating disorder symptoms were less likely to use helpful coping strategies to manage their emotions – like accepting their emotions, thinking differently about a situation to decrease negative emotions, or problem-solving – and were also more likely to use unhelpful strategies such as rumination (continuously focusing on a negative thought or situation), avoiding emotions, and suppressing emotions.(2)
​
To summarize, individuals with eating disorders tend to feel more negative emotions, less positive emotions, and tend to have a harder time sitting with those emotions or using helpful coping strategies. This tendency towards emotions like sadness, anger, and anxiety can prompt individuals with eating disorders to turn to eating disorder behaviors to distract from or relieve unpleasant emotions. However, we know that emotions are like signals – and when you ignore the message that they are trying to send to you, the alarm just gets louder. As a result, these unpleasant emotions can rebound and come back stronger – thus driving an unfortunate cycle of more eating disorder behaviors. 

So, how do we get out of this cycle? Research suggests that teaching individuals to use more helpful (and less unhelpful) ways of regulating their emotions could help to improve eating disorder symptoms.(2) One place to start is by learning the purpose of your emotions. It may feel like our emotions (again – especially emotions like anger, sadness, and anxiety) don’t serve any purpose but to make us feel bad. However, we know that all emotions (even the “bad” ones) do something for us. By learning the purpose of our emotions, it can be easier to accept them (or at least tolerate them).

​In summary, emotions communicate important information. When we use our emotions as signals and respond to them with curiosity rather than fear or avoidance, they can tell us a lot about what’s going on in the world and what we need in any given moment. The next time you’re feeling sad, angry, or fearful, instead of trying to stuff down the emotion try thinking about what that emotion is trying to tell you!

References
 

1. Heatherton & Baumeister (1991). Binge eating as escape from self-awareness. Psychological Bulletin, 110(1), 86-108. https://doi.org/10.1037/0033-2909.110.1.86
2. Prefit, A., Candea, D. M., & Szentagotai-Tatar, A. (2019). Emotion regulation across eating pathology: A meta-analysis. Appetite, 143(1), 1-10. https://doi.org/10.1016/j.appet.2019.104438
3. Lazarus, R. S. (1991). Cognition and motivation in emotion. American Psychologist, 46(4), 352-367. https://doi.org/10.1037/0003-066X.46.4.352
4. Fanselow, M. S. (2018). Emotion, motivation and function. Current Opinion in Behavioral Sciences, 19, 105-109. https://doi.org/10.1016/j.cobeha.2017.12.013
5. de Gelder, B. (2006). Towards the neurobiology of emotional body language. Nature Reviews Neuroscience, 7(1), 242-249. https://doi.org/10.1038/nrn1872

 

By Abigail McCarthy, EAT Lab Research Coordinator

Learning or noticing that a friend or family member is struggling with an eating disorder can be devastating. The signs might be blatantly obvious– your loved one could:

• look emaciated or have lost a lot of weight recently               
• be losing hair 
• have lost the spark in their personality
• have become isolated 
• be hiding their body with layers of clothes

 
Or, especially at first, the signs might be more subtle– you could’ve noticed that your loved one is:

• getting obsessive about exercise
• fearful about fat and weight gain
• using the bathroom immediately after a meal
• thinking or moving more slowly
• Maybe are even gaining compliments about losing weight! 

 
It’s important to remember that 90% of people with an ED have normal body mass index, so often it is hard to visually tell if someone has an eating disorder.
 
They might need more rest than usual to support their new “healthy” habits or could’ve finally reached their goal weight or shape. You might notice the distress on their face when they look in the mirror, but you think they look amazing. Dealing with an ED is a hard battle that nobody should have to fight alone. Here are ways you can actually make a difference:
 
1. Do your research and find a professional for support.

It’s important to have education regarding eating disorders, but remember you are NOT their dietician, therapist, psychologist, or psychiatrist. Provide yourself with the knowledge to recognize the signs of an ED or a medical emergency as directed to by professionals.
Here is some helpful and trustworthy information with a help hotline: 
https://www.nationaleatingdisorders.org/what-are-eating-disorders​

2. Encourage your loved one to seek help.

This could look like starting with a licensed counselor or seeking specialized eating disorder treatment. For more information, visit:
What is ED treatment?: https://www.nationaleatingdisorders.org/treatment
Treatment near you: https://map.nationaleatingdisorders.org
 
3. Try not to take things personally.

If your loved one seems defensive or angry while denying that they are putting themselves at risk, remember that this is the ED talking– not your child, friend, sibling, parent, or cousin. Find a different outlet to express the anger you have towards their ED. Respond with love, empathy, and “I” statements. Do NOT confirm their ED behaviors to avoid conflict, remove yourself from the situation if you feel yourself doing so.

More information on “I” statements: www.nationaleatingdisorders.org
 
4. Remember to take care of yourself too.

Use self-care if you feel yourself becoming stressed or overwhelmed. Your mental health can be affected if you only prioritize another person.
Self-Care information: https://www.nimh.nih.gov/health/topics/caring-for-your-mental-health

5. Remember they need to choose recovery for themselves.

Avoid drawing attention to their disordered eating behaviors in front of others, keep these conversations private. Avoid forcing them to eat or face feared foods or asking them why they just “can’t” eat, these will likely make things worse.

6. If you and your loved one are minors, tell someone.

If you worry your friend has a hard home life, and could be unsafe if you notified their parent, reach out to a school psychologist, guidance counselor, or other trusted adult. You can also reach out to the helpline on the National Eating Disorder Association website. You can’t handle this on your own, and neither can your loved one.

Eating Disorder Helpline: https://www.nationaleatingdisorders.org/help

By Kimberly Osborn, Lab Manager in the EAT lab

When considering whether you should seek help for your eating disorder, do you have thoughts like:

Maybe you believe that your suffering is less valid because you are not at a certain weight or don’t engage in certain behaviors.  

Despite the extraordinary physical and psychological suffering caused by these deadly illnesses, many people have trouble believing their struggles are valid regardless of the severity of their eating behaviors. [1,2]  These beliefs often discourage people from reaching out, which prolongs suffering and causes further physical and psychological harm. 
 
Although these thoughts are very common among people with eating disorders, research shows that weight is often not associated with the severity of a person’s eating disorder or the level of impairment they are experiencing. [3,4]
 
The fact is that severity of your eating disorder cannot be measured simply by the number on a scale or body mass index because it is a mental disorder.
 
This means that you cannot tell how much a person is struggling or how malnourished they are just by looking at them. Did you know that people in larger bodies can have severe and serious restrictive eating disorders? This is because weight is impacted by many factors outside of food intake and exercise behaviors, such as genetics, hormones, age, etc. In fact, most people with eating disorders are not in the “underweight” category.[5]

This is also a misconception! Lab results provide a snapshot of some aspects of your health in that moment, but they do not show the full story about the negative impacts the eating disorder has on your physical and mental functioning. Studies show that people with severe and life-threatening eating disorders can have “normal” lab results for various reasons including the person’s genetics, the type of test run, time of day, and more.[6,7]
 
A leading eating disorder physician, Dr. Gaudiani, [6] discusses how our bodies are very skilled at trying to keep our physical functioning stable in crisis. Some people’s bodies can maintain this stability longer than others, which could produce “normal” lab results even while long term damage to the body is occurring. Additionally, even within the same person, lab results can change very drastically in a very short amount of time, meaning that your labs can go from “normal” to life-threatening within the same day. 

FALSE! Even if your eating disorder symptoms “could be worse”, you still deserve help!
Waiting to get treatment for your eating disorder often decreases your chances for a full recovery and leads to worsening physical and mental outcomes. I once heard a therapist illustrate this concept well: “If you break a finger, you wouldn’t need to break the other nine fingers to deserve help! You would likely immediately try to fix it”. Your eating disorder is the same!
 
At the end of the day, feeling that you are not “sick enough” to get treatment for your eating disorder is a sign that you are sick enough.
People without disordered relationships with food or their bodies do not experience beliefs that being thinner or more malnourished makes you “better” at the illness or more deserving of help. These thoughts are often a part of the illness and an indication that you should reach out for help.
 
Your experiences are valid, and you are deserving of support and recovery regardless of how much you weigh, how long you have had an eating disorder, or your medical lab results. 

Ready for the support and recovery you deserve? Here are some great resources:
 
National Eating Disorders Association: https://www.nationaleatingdisorders.org/where-do-i-start-0
National Eating Disorders Association Helpline: https://www.nationaleatingdisorders.org/help-support/contact-helpline
Free eating disorder support groups: https://anad.org/
Eating Disorder Hope’s Treatment Finder: https://www.eatingdisorderhope.com/
Association for Size Diversity and Health: https://asdah.org/
The Food Psych Podcast by Christy Harrison: https://christyharrison.com/foodpsych

​References
 
[1] Eiring, K., Wiig Hage, T., & Reas, D. L. (2021). Exploring the experience of being viewed as “not sick enough”: A qualitative study of women recovered from anorexia nervosa or atypical anorexia nervosa. Journal of Eating Disorders, 9(1), 1-10. https://doi.org/10.1186/s40337-021-00495-5
[2] LaMarre, A., & Rice, C. (2016). Normal eating is counter‐cultural: Embodied experiences of eating disorder recovery. Journal of community & applied social psychology, 26(2), 136-149. https://doi org/10.1002/casp.2240 Gaudiani, J. L. (2018). Sick enough: A guide to the medical complications of eating disorders. Routledge.
[3] Machado, P. P., Grilo, C. M., & Crosby, R. D. (2017). Evaluation of the DSM‐5 severity indicator for anorexia nervosa. European Eating Disorders Review, 25(3), 221-223. https://doi.org/10.1002/erv.2508
[4] Smith, K. E., Ellison, J. M., Crosby, R. D., Engel, S. G., Mitchell, J. E., Crow, S. J., ... & Wonderlich, S. A. (2017). The validity of DSM‐5 severity specifiers for anorexia nervosa, bulimia nervosa, and binge‐eating disorder. International Journal of Eating Disorders, 50(9), 1109-1113. https://doi.org/10.1002/eat.22739
[5 National Eating Disorders Association. (2022). Eating Disorder Myths. Retrieved from https://www.nationaleatingdisorders.org/toolkit/parent-toolkit/eating-disorder-myths.]
[6] Gentile, M. G., Manna, G. M., Pastorelli, P., & Oltolini, A. (2011). Laboratory evaluation in pa tients with anorexia nervosa: Usefulness and limits. La Clinica Terapeutica, 162(5), 401-407.
[7] Gaudiani, J. L. (2018). Sick enough: A guide to the medical complications of eating disorders. Routledge.
[8] Photo “You are enough” Retrieved from [CoCoart_ua]/Adobe Stock.
[9] Photos of people Retrieved from SlidesGo. 

Written by Gabby Davis, B.A., Lab Manager and Christina Ralph-Nearman, PhD, Postdoctoral Research Associate

​Body Mass Index, or BMI, has long been utilized by medical professionals and the general public alike to categorize the health of individuals. First seeing widespread use starting in the 1970s, BMI was created by a team of healthcare professionals to ‘accurately’ assess the health of their clients based on their height and weight.
 
Or is that really the case? Spoiler alert: it’s not the case at all. BMI is invalid.
 
In actuality, the weight-to-height formula used in calculating BMI was first introduced in 1832 by Adolphe Quetelet, a Belgian astronomer and mathematician (notably, with no medical background). Quetelet’s formula sought to categorize bodies based on body fat percentage with no initial connection to assessing the health of the individuals being categorized.
 
However, in 1972, Dr. Ancel Keys first coined the term “body mass index” in a manuscript published in an academic journal. Following the publication of that article, BMI was widely used to categorize sedentary populations’ weight health [1], and then morphed into a primary health screening tool for medical professionals and the National Institutes of Health. BMI was (and still is) primarily used in assessing personalized health risks almost exclusively related to being fat.
 
We also want to note that BMI was developed, tested, and ‘validated’ only on a white male sample. BMI was not developed, tested, or ‘validated’ for individual health, and another problem with BMI is that it does not account for the many diverse types of bodies in women and diverse ethnicities. It’s worth taking a read more about how BMI is actually rooted strongly in racism. A great read to check out is: Fearing the Black Body: The Racial Origins of Fat Phobia Dr. Sabrina Strings.

You may ask yourself, “Okay, but why is that a bad thing? Isn’t it good to know the health risks you face at higher BMIs?” I asked myself the same question, too. The truth is that BMI’s categories were arbitrarily determined without any scientific evidence backing the claims being made by proponents of the measure. Since the use of BMI as a health screening tool first began, several studies have come out demonstrated correlations – not causal effects – between high BMI and chronic diseases such as heart disease, stroke, and some cancers. Surely this demonstrates that BMI has some scientific validity, right?
 
Unfortunately, there is a significant blind spot that researchers have not investigated nearly as much. Several studies have demonstrated that the rates of chronic disease in those with “high” BMIs (>25) were similar to, or even lower than, those with “healthy” (18.5-25) or “low” (<18.5) BMIs, and that public perception of the “dangers” of being obese are dramatically skewed or at times entirely inaccurate [2,3]. In fact, data shows that a BMI between 25-35 is actually correlated with the lowest risk of early death [4,5]. Take a look at the chart down below, which visually demonstrates the risk associated with different BMIs – it might not be what you expect [5]. This research seems to go mostly ignored or discounted. Why is that? The reality is that there are far more factors than the ratio of one’s weight-to-height, such as stress, genetics, and mental health, that influence the onset and development of chronic diseases and other health-related consequences.

Despite this, portions of Western society remain hyper-fixated on weight loss as a “cure-all” for chronic diseases. This leads to fat individuals experiencing potential medical trauma after being told countless times that their weight is the primary reason that they are not well. With only a 5% success rate, weight-loss diets are not sustainable or effective, and many individuals end up feeling defeated and developing a troubled relationship with food and their bodies as a result of repeated attempts at weight loss [6,7,8]. 

Western society is deeply rooted in what is known as diet culture, or a system which prioritizes a person’s weight, shape, and size over their health and well-being. The continued use of BMI, both professionally and colloquially, as a measure of the health of an individual is both a result of diet culture beliefs being spread and it also reinforces these beliefs, such as an individual feeling they need to be a certain BMI in order to be considered “healthy.”
 
However, for many individuals, it is impossible to attain their “ideal” BMI through no fault of their own. As mentioned before, there are several other factors that play a role in an individual’s health and well-being, including genetics. If an individual is fixated on attaining a particular BMI but are unable to do so by traditional means (dietary and exercise changes), this may pave the way for disordered eating behaviors to emerge, which then have the potential to develop into an eating disorder.

​​So how do you end the cycle of diet culture in your own life?

THE FIRST STEP is to identify and challenge the ways you may think about weight and size that may be rooted in diet culture. Changing the way that you think about these topics is the first step to take in helping us dismantle diet culture.
 
THE NEXT STEP is to practice engaging in RESPECT – an acronym with actions to take to help combat the negative influence of diet culture.

Health At Every Size (HAES) is a great resource to check out. The HAES model seeks to decrease weight stigma and dismantle diet culture by promoting and supporting the idea with empirical research that all individuals can be healthy, regardless of their BMI. Instead of focusing on controlling an individual’s weight, HAES instead supports people wanting to make changes to health-related behaviors for the sake of their overall well-being, and not making weight loss the primary goal. See the HAES website here to learn more: https://asdah.org/health-at-every-size-haes-approach/
 
Interested in learning more? Women 18 or older may elect to check out either the Diet Culture Intervention or Wellness Resource, two free self-guided therapeutic interventions targeted at learning more about health, wellness, and combatting diet culture. You may only participate in one of these studies. You also will have a chance to win one of two gift baskets valued at $150 each, including an Amazon gift card and anti-diet culture books and resources! Submit an interest form here: https://www.louisvilleeatlab.com/online-single-session-resources.html or reach out to louisvilleeatlab@gmail.com with inquiries.
 
References

1. World Health Organization (1995). Physical status: The use of and interpretation of anthro-pometry. Report of a WHO Expert Committee. Retrieved on April 21, 2022: https://apps.who.int/iris/bitstream/handle/10665/37003/WHO_TRS_854.pdf
2. Liu, J., Lee, B., McLeod, D. M., & Choung, H. (2019). Framing obesity: Effects of obesity labeling and prevalence statistics on public perceptions. Health Education & Behavior, 46(2), 322–328. https://doi.org/10.1177/1090198118788907
3. Michaëlsson, K., Baron, J. A., Byberg, L., Höijer, J., Larsson, S. C., Svennblad, B., Melhus, H., Wolk, A., & Warensjö Lemming, E. (2020). Combined associations of body mass index and adherence to a Mediterranean-like diet with all-cause and cardiovascular mortality: A cohort study. PLoS Medicine, 17(9), e1003331. https://doi.org/10.1371/journal.pmed.1003331
4. Flegal, K. M., Kit, B. K., Orpana, H., & Graubard, B. I. (2013). Association of all-cause mortality with overweight and obesity using standard body mass index categories: A systematic review and meta-analysis. JAMA: Journal of the American Medical Association, 309(1), 71–82. https://doi-org.echo.louisville.edu/10.1001/jama.2012.113905
5. Hotchkiss, J. W., & Leyland, A. H. (2011). The relationship between body size and mortality in the linked Scottish Health Surveys: cross-sectional surveys with follow-up. International Journal of Obesity, 35(6), 838–851. https://doi-org.echo.louisville.edu/10.1038/ijo.2010.207
6. Lowe, M. R., Doshi, S. D., Katterman, S. N., & Feig, E. H. (2013). Dieting and restrained eating as prospective predictors of weight gain. Frontiers in Psychology, 4, 577. https://doi.org/10.3389/fpsyg.2013.00577
7. Mann, T., Tomiyama, A. J., Westling, E., Lew, A.-M., Samuels, B., & Chatman, J. (2007). Medicare’s search for effective obesity treatments: Diets are not the answer. American Psychologist, 62(3), 220–233. https://doi.org/10.1037/0003-066X.62.3.220

Written by Claire Cusack, M.A., First Year Graduate Student


​
​You may be wondering how eating disorder treatments have been developed, how that is currently shifting, and what this might mean for you in your recovery. This post centers these questions. I briefly describe what has been done in the past research, some ways our lab is changing the game, and what that means for you.
 
How we develop treatments
The process for developing evidence-based treatments for psychiatric disorders is undeniably complex. At its most basic (and perhaps ideal) form, the process involves developing a theory (e.g., a testable hypothesis of what causes or maintains disorders given a certain set of assumptions) of what causes internal suffering and/or challenges in work, school, or social life, coupled with strategies to address this cause.
 
Generally, a group of people with said suffering complete surveys inquiring on a range of symptoms. 

Then, a random half of participants receive the treatment, and the other half does not (i.e., a randomized clinical trial; RCT). The group of participants who do not receive the treatment are referred to as the control group, and they may be on a “waitlist,” or receive an existing treatment. 

After completing treatment, participants in both groups report their current level of symptoms again. 

If the group that received the treatment demonstrated improved therapeutic outcomes (e.g., less symptoms, less impairment, greater quality of life) relative to the control group, the treatment has initial empirical support. 

If research accumulates with similar findings, this treatment may enter guidelines for treating a given problem. You may be familiar with this design in terms of new pharmaceutical drugs: there’s a pill with the actual medication and there’s a placebo or “sugar pill.” A similar process had been adopted to therapeutic treatments.

To illustrate, Cognitive Behavioral Therapy-Enhanced1 is considered the gold standard treatment for eating disorders2–4. The idea behind this treatment is that over-valuation of weight and shape (e.g., thoughts like “I must be thinner,” “I will be rejected if I gain weight”) cause eating disorder behaviors (e.g., restrictive eating, binge-eating, purging, driven exercise). These behaviors fuel the eating disorder thoughts, and thus create a cycle. 

Therefore, when an individual starts Cognitive Behavioral Therapy-Enhanced and engages in processes such as regular eating, evaluating thoughts, and weekly weighing, they learn to invest in other values (such as friendships) and manage uncomfortable emotions in healthier ways. 

Cognitive-Behavioral Therapy-Enhanced is the leading evidence-based treatment for eating disorders. As several studies have replicated these findings, guidelines suggest that this approach is the frontline treatment for eating disorders2–4. 

Researching Groups and Treating Individuals
Unlike many medical diseases, in psychology, we often don’t know what causes a disorder, and perhaps there are different causes that drive a disorder across individuals. The response rate across evidence-based treatments for a range of concerns is up to 50%5–7. This finding means that our best treatments work for half of people. There are many reasons why treatments are generally effective for half of people . One reason that may explain these rates are RCTs have historically compared groups, not individuals. For example, researchers average symptom scores for the group who received treatment and test whether it differs from the average symptom scores for the group who did not receive treatment. For example, do eating disorder symptoms decrease more in a group who received cognitive behavioral therapy versus the group who received dialectical behavioral therapy.
 
There is value in studying groups. A group-level approach is important because it can be helpful for psychologists to know what “generally works.” The shortcoming is that RCTs risk assuming people with a disorder are the same (e.g., experience the same symptoms; respond to treatment in the same way), which often results in a one-size-fits all treatment8. Yet, therapy is often delivered to an individual. The decision to treat the individual is intuitive. However, despite decades-old calls to study individuals, research has largely remained at investigating groups[1]. On one hand this reality is discouraging because we still don’t know how to best treat individuals. On the other hand, work investigating individuals is growing. Though this topic is relevant to most mental disorders, the rest of this post will describe why and how our lab is centering the individual in studying eating disorders and developing personalized treatments for eating disorders.

[1] Note: There has been some work investigating treatment at the individual level over the years, but this work lags in comparison. Further, the methods have not been that rigorous until recently due to smart phones and watches.

Why study eating disorders within an individual?
Anorexia nervosa and bulimia nervosa are eating disorders that enter the mainstream, but there are more than two eating disorders, such as, binge eating disorder, avoidant/restrictive food intake disorder (ARFID), other specified feeding and eating disorders (OSFED). Most of these disorders share common features, such as weight and shape disturbance, restricting food intake, binge eating, and compensatory behaviors. Despite these similarities, eating disorders look very different across diagnoses (e.g., bulimia nervosa vs ARFID) and within one disorder (e.g., one person with anorexia nervosa may binge and purge and another person with anorexia nervosa may not)9–11. OSFED is the most common eating disorder diagnosis12 and it captures eating disorder presentations that do not “neatly” fall into other eating disorders. This diagnosis includes people who may meet criteria for anorexia nervosa aside from being underweight, people who would meet criteria for bulimia nervosa but purge one day less a week, people who would meet criteria for ARFID but do not have a nutritional deficiency, etc. Further, co-occurring concerns, such as anxiety, depression, substance use, etc., may also influence how a person struggles with eating, weight, and shape concerns. What this suggests to us is eating disorders can look very different from person to person!
 
This reality causes challenges for scientists and clinicians who are left asking questions like, “Where do we start treatment?” “What treatment will be most effective at relieving symptoms and most efficient in terms of time and money?” The answers to these questions may depend on the person, which is why our lab is studying personalized approaches to eating disorders.
 
How do we study eating disorders within one person?
To find an effect of treatment, we need observations, usually lots of observations. Many observations help researchers not only gather enough observation for analyses, but it also provides us with rich detail about how eating disorders look so that we can develop and implement the best treatments. When studying groups, we gather observations by recruiting a large number of participants. When studying individuals, we gather observations by asking individual participants to report on symptoms many times a day for several days. These symptoms are obtained from surveys delivered to individuals’ mobile devices. We then have lots of information on one person, so then for each person, we have something that looks like this:

From the example above, what we have is a sheet for one person (ID001) reporting on their urges to binge eat, urges to purge, and current anxiety. What we see is that for this person, their urges to engage in eating disorder symptoms, as well as the anxiety they are experiencing within a given moment, change over the course of the day (e.g., anxiety ranges from 33 at 8AM to 93 at 9 PM on March 1). What we can then do is apply statistics to model how these different symptoms relate to each other across time.

In this figure, the green arrows represent positive relationships, and the red arrow represents a negative relationship. For instance, increased urge to binge eat is related to increased urge to purge. However, an increased urge to purge is related to less anxiety. By modeling a person’s specific symptom relationships, we can use data to help clarify our existing case conceptualizations and determine which intervention maps onto symptoms that may be driving an individual’s distress11. For this person, we may wonder if purging serves the purpose to reduce anxiety, which may be caused from binge eating and/or weight and shape-related concerns.
 
Regardless, you can imagine how these relationships vary across people. By studying the individual, we are moving toward personalized treatment, or “precision medicine,” so that your treatment makes sense for you, rather than what *might* work for the group. As it stands, our gold-standard treatments work for 50% of individuals with eating disorders.
 
I think researchers and clinicians can do better by you, participants and/or patients. Our lab find promise in using individual approaches to data analysis to inform personalized treatment to do just that. Our preliminary data using a data-driven approach to personalized treatment shows reductions of eating disorder symptoms after treatment, as well as one-year post-treatment for the individual13. What this means is that the improvements in eating disorder symptoms may be maintained over long stretches time. When the current state of the field shows that half of individuals achieve full recovery, with many experiencing diagnostic cross-over (e.g., meeting criteria for anorexia nervosa and later meeting criteria for bulimia nervosa), we hope that these insights offer a glimmer of hope that the eating disorder field is progressing while keeping you at the center of our work.
 
How you can play a role in advancing eating disorder treatments
We are launching a new treatment study for eating disorders that tests a Personalized Treatment approach versus Cognitive Behavioral Therapy-Enhanced. Participants enrolled in this study will receive 20 sessions of free individual therapy for their eating disorder. To learn more about this study and see if you are eligible, please click this link which will direct you to our website.



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References
1.  Fairburn, C. G. Cognitive Behavior Therapy and Eating Disorders. (Guilford Press, 2008).
2. Fairburn, C. G., Cooper, Z. & Shafran, R. Cognitive behaviour therapy for eating disorders: a ‘transdiagnostic’ theory and treatment. Behav. Res. Ther. 41, 509–528 (2003).
3. Fairburn, C. G. et al. A transdiagnostic comparison of enhanced cognitive behaviour therapy (CBT-E) and interpersonal psychotherapy in the treatment of eating disorders. Behav. Res. Ther. 70, 64–71 (2015).
4. Murphy, R., Straebler, S., Cooper, Z. & Fairburn, C. G. Cognitive Behavioral Therapy for Eating Disorders. Psychiatr. Clin. North Am. 33, 611–627 (2010).
5. Carter, J. C., Blackmore, E., Sutandar-Pinnock, K. & Woodside, D. B. Relapse in anorexia nervosa: a survival analysis. Psychol. Med. 34, 671–679 (2004).
6. Trivedi, R. 1975-, United States. Department of Veterans Affairs. Health Services Research and Development Service, Durham VA Medical Center, & Duke University Evidence-based Practice Center. Evidence synthesis for determining the efficacy of psychotherapy for treatment resistant depression. (Department of Veterans Affairs, Health Services Research & Development Service, 2009).
7. Batelaan, N. M. et al. Risk of relapse after antidepressant discontinuation in anxiety disorders, obsessive-compulsive disorder, and post-traumatic stress disorder: systematic review and meta-analysis of relapse prevention trials. The BMJ 358, j3927 (2017).
8. Spring, B. Evidence-based practice in clinical psychology: What it is, why it matters; what you need to know. J. Clin. Psychol. 63, 611–631 (2007).
9. Forbush, K. T. et al. Understanding eating disorders within internalizing psychopathology: A novel transdiagnostic, hierarchical-dimensional model. Compr. Psychiatry 79, 40–52 (2017).
10. Levinson, C. A. et al. Personalized networks of eating disorder symptoms predicting eating disorder outcomes and remission. Int. J. Eat. Disord. 53, 2086–2094 (2020).
11. Levinson, C. A. et al. Using individual networks to identify treatment targets for eating disorder treatment: a proof-of-concept study and initial data. J. Eat. Disord. 9, 147 (2021).
12. Galmiche, M., Déchelotte, P., Lambert, G. & Tavolacci, M. P. Prevalence of eating disorders over the 2000–2018 period: a systematic literature review. Am. J. Clin. Nutr. 109, 1402–1413 (2019).
13. Levinson, C. A. et al. Longitudinal group and individual networks of eating disorder symptoms in individuals diagnosed with an eating disorder. J. Psychopathol. Clin. Sci.

Written by Jamie-Lee Pennesi, PhD, Postdoctoral Research Associate

This blog was first posted on the F.E.A.S.T. website on 15th Dec 2021: https://www.feast-ed.org/eating-disorder-relapse-how-to-prevent-it/.
 
The following blog is directed toward for someone who has or has previously had an eating disorder in mind, but it can also be helpful for a friend or a loved one, a therapist, or others who wish to support someone with an eating disorder or someone who is recovering from an eating disorder.

In this blog I will talk about eating disorder relapse and provide helpful strategies and tips on how to prevent relapse.

Recovering from an eating disorder is not easy. It takes a lot of courage, strength, perseverance, hard work, and support. Most people do not recover from an eating disorder without a few slips or occasional setbacks; that is normal, expected, and okay.

‘Relapse’ is when someone who is in recovery goes back to disordered eating or weight control behaviors. This is different from a ‘lapse’ which is a temporary slip or return to a previous problematic behavior (usually a onetime occurrence). It’s not uncommon for people who have recovered from an eating disorder to relapse. In fact, up to 60% of people who recover from an eating disorder will relapse in the first 1-2 months after treatment.
 
The best way to prevent a relapse is through ‘relapse prevention’. Relapse prevention is a cognitive-behavioral approach used in treatment to identify and prevent high-risk situations, such as re-emergence of problematic eating and weight control behaviors, or negative thoughts about eating, body, weight, or shape.
 
Relapse prevention often involves a personalized ‘relapse prevention plan’. A relapse prevention plan is developed during treatment with the therapist and is tailored to you. Here, one size does not fit all. For the best chance of success, a relapse prevention plan should include early warning signs, triggers, and high-risk situations specific to you, so that you can be prepared and ready to deal with any setbacks. 
 
A relapse prevention plan should consider the following issues:

• Times of high risk. Try to identify specific times when you found it harder to stick to your treatment or maintenance plan; times when it felt especially hard for you to manage your disordered eating habits and resist the urge to engage in these behaviors. You’re likely towards the end of treatment at this point, so you may already have an idea of which situations these might be. These situations are known as “at risk” times, and it is likely that these will happen. Times of high risk can involve situations such as: weight gain or weight loss; high stress; exams; feeling sad, anxious, or lonely; periods of dieting; loss of a loved one; or the holidays. These situations make it harder to engage in or stick to helpful behaviors that keep you well. For example, it might be harder to challenge negative or unhelpful thinking, or harder to follow the maintenance plan when you are stressed or upset. It’s important to identify times of high risk so that you are prepared to deal with setbacks when they occur.

 

• Early warning signs. It’s also important to identify early warning signs; signs that warn you of possible setbacks or slipping. These signs warn you that your problematic eating and weight control behaviors are creeping back in and you need to try to prevent them. Recognizing these problems early is essential to keeping you on track. The better you become at detecting these signs, the better your chances of staying well. Some common warning signs may include skipping meals, over exercising, avoiding situations that involve food, weighing yourself more often, thinking of yourself as “fat”, an increasing need for control, or trying to be perfect. Try to identify your own early warning signs. It will be helpful to think about your past experiences: What situations or thoughts did you have right before your last setback? And what about the one before that? What may have triggered your problems? These may be early warning signs.

 

• Addressing warning signs. It’s important that you create a plan for dealing with early warning signs ahead of time so that you are prepared and ready to face them when they happen. First, you need to identify when to act. Having a clear understanding of your early warning signs will help you to determine when you will need to act. Try to describe each one and be specific and as detailed as you can so you know what to look out for. For example, if a warning sign for you is weighing yourself more often, it may be a problem if you find yourself checking your weight two days in a row. If a warning sign for you is skipping meals, it may be a problem if you skipped two meals in a day. Second, once you recognize the need to act, act immediately. Don’t wait for the problem to get worse. It’s much easier to deal with an early warning sign than it is to deal with a full-blown disordered eating behavior. Third, have a plan. You need to create a personal plan for dealing with your early warning signs. Let’s go back to the previous example of “weighing yourself more often”. Critically examine this behavior. Why are you doing it? Do you need to do it? Does it make you feel better or worse? Is it in line with your maintenance plan? What about if your early warning sign is a thought such as “I’m fat”? Critically examine this thought. Where did this thought come from? Is it rational? Is there evidence to support it? Is it helpful? Use these answers to help you address the warning sign.

 

• Dealing with setbacks. it is likely that you will experience slips or minor setbacks. It’s important to think about setbacks as a ‘lapse’ and not a ‘relapse’. Just because you have a slip doesn’t mean you have fallen back into your old pattern of disordered eating or weight control behaviors. It also doesn’t mean that you “failed” or “going backwards”. Instead, think about a lapse as temporary slip. Try to take a step back and critically examine the situation. Try to examine your lapse as if you were looking in as an observer watching someone else. What led to the lapse? Were there any early warning signs? What could have been done to prevent the lapse? What could be done better next time? What can be done to get back on track? Use the lapse as a learning opportunity. Try to learn from your mistakes.

​

Other strategies for preventing a relapse:

• Develop a support system. It’s important to surround yourself with people who care, love, encourage, and support you, and have your best interests in mind. These people may be friends, family, loved ones, or even your care providers. It may be helpful if one or more of these people are aware of your eating disorder journey (or better still, are aware of your maintenance or relapse prevention plan), however this is not essential; even just having a supportive people around you will be incredibly valuable. They will be able to help you when you are struggling or going through a difficult time. It may not always be easy to reach out, but it’s important that you reach out and ask for help when you need it.

 

• Have realistic expectations. Once you have overcome your eating disorder, it’s likely that you want to put it behind you and never think about it again. Unfortunately, your vulnerability to disordered eating and weight control behaviors will likely last forever. It’s almost as if the eating disorder is a webpage that you visited and even though you’ve closed the webpage, it’s still in your browser history and you can’t delete it. While you may have stopped engaging in the problematic behaviors, you will always have to be on the lookout for warning signs that these behaviors are creeping back. When these behaviors re-emerge, you will need to be prepared and ready to face them.

​I hope this blog has provided you with important information about eating disorder relapse and given you useful strategies and techniques to consider using to prevent relapse.
 
If you are looking for additional support or know someone who might need it, you may be interested to learn about our Online Eating Disorder Relapse Prevention Study. Participants are paid up to $200 in compensation and receive five sessions of free treatment which may help to decrease anxiety and eating disorder symptoms and may help to prevent eating disorder relapse. The information collected from this study may also be helpful to inform future treatments for eating disorders, prevent relapse, and promote full eating disorder recovery.
 
We are looking for participants who 1) are aged 18-65, 2) have current or past anorexia nervosa, atypical anorexia nervosa, or bulimia nervosa, and 3) have been discharged from inpatient, residential, partial hospital, or intensive outpatient program for an eating disorder in the past month. Following a phone screening and online questionnaires, you will be asked to complete one of two five-session online treatment sessions and complete five follow up assessments.
 
This study is conducted by the Eating Treatment Anxiety Lab at the University of Louisville and supported by the National Institute of Mental Health.
 
For more information or to schedule a phone screening, please contact us at onlinerelapsepreventionstudy@gmail.com or (502) 822-6778. Further information can also be found on our website at www.louisvilleeatlab.com/online-relapse-prevention-study.
 



References:
BC Children’s Hospital, Kelty Mental Health Resource Centre (n.d.). Relapse prevention. Retrieved from December 8, 2021, from https://keltyeatingdisorders.ca/recovery/relapse-prevention/
 
Fursland, A., Byrne, S., & Nathan, P. (2007). Overcoming disordered eating. Perth, Western Australia: Centre for Clinical Interventions.
 
Iulia. [@iuliastration]. (2021, October 13). Progress is not linear Or the artwork which allowed me to expand my creative universe. I was so nervous about posting this half a year ago because it was so different from my previous work. One day I just went for it and it became one of my most loved creations. Yet another reminder to let that inner voice lead the way. Prints via link in Bio (this design is also available on a mug) #iuliastration #illustrationart #digitalart #procreate #illustratorsoninstagram #womenofillustration #mentalhealth #strongwomen #empowerment #motivation #dailymotivation #progress #growth #growthmindset #affirmations #quoteoftheday #quotestagram #strength #positivevibes #innerchild #positivethinking #healing [Instagram photo]. Retrieved from https://www.instagram.com/iuliastration
 
Iulia. [@iuliastration]. (2021, September 9). Some days strength is just keeping it together – art and words by @iuliastration Prints via link in Bio #iuliastration #illustrationart #digitalart #digitalillustration #procreate #illustratorsoninstagram #procreateart #selflove #selfcare #yogapractice #spiritualart #yoga #meditation #growth #growthmindset #affirmations #feministart #motivation #dailymotivation #trusttheprocess #quotestagram #trustyourself #positivevibes #positivethinking #feminineenergy #goddess #strength #womenofillustration #illustrationoftheday [Instagram photo]. Retrieved from https://www.instagram.com/iuliastration
 
Iulia. [@iuliastration]. (2021, July 10). Cheers to you! Prints available via link in Bio Free worldwide tracked shipping on all orders of 3 prints or more with code ARTLOVE #iuliastration #illustrationart #digitalart #digitalillustration #procreate #illustratorsoninstagram #procreateart #selflove #selfcare #selfcareideas #spiritualart #lookwithin #meditation #growth #growthmindset #affirmations #motivation #dailymotivation #trusttheprocess #quotestagram #trustyourself #positivevibes #positivethinking #feminineenergy #goddess #strength #womenofillustration #illustrationoftheday [Instagram photo]. Retrieved from https://www.instagram.com/iuliastration
 
Iulia. [@iuliastration]. (2021, April 16). The journey of a lifetime Prints available via link in Bio #iuliastration #illustrationart #digitalart #digitalillustration #procreate #illustratorsoninstagram #procreateart #selflove #selfcare #selfcareideas #spiritualart #lookwithin #meditation #growth #growthmindset #affirmations #motivation #dailymotivation #trusttheprocess #quotestagram #trustyourself #positivevibes #positivethinking #feminineenergy #goddess #strength #womenofillustration #illustrationoftheday [Instagram photo]. Retrieved from https://www.instagram.com/iuliastration
 
Iulia. [@iuliastration]. (2021, February 3). With time and care we bloom with time and care we bloom Prints available via link in Bio #iuliastration #illustrationart #digitalart #digitalillustration #procreate #illustratorsoninstagram #procreateart #selflove #selfcare #selfcareideas #spiritualart #lookwithin #meditation #growth #growthmindset #affirmations #feministart #motivation #dailymotivation #trusttheprocess #bodypositivity #trustyourself #positivevibes #positivethinking #feminineenergy #goddess #strength #womenofillustration #ladieswhodesign #illustrationoftheday [Instagram photo]. Retrieved from https://www.instagram.com/iuliastration
 
Walsh, B. T., Xu, T., Wang, Y., Attia, E., and Kaplan, A. S. (2021). Time course of relapse following acute treatment for anorexia nervosa. American Journal of Psychiatry, 178(9), 848-853. https://doi.org/10.1176/appi.ajp.2021.21010026

Written by Julia Nicholas, B.S., First Year EAT Lab Graduate Student


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For many people, the holiday season brings gatherings with loved ones, cherished traditions, and a break from our everyday routines. If you are in recovery from an eating disorder, you may find that you have an uninvited plus-one tagging along to holiday gatherings: your eating disorder. Let’s talk about some strategies for talking back to eating disorder thoughts that may come up during the holidays.
 
Navigating Holiday Meals
​

It’s no surprise that many holiday traditions revolve around food. Food provides nourishment, connects us with our cultural heritage, and gives us a practical reason to gather: to cook and eat together. All this focus on food can be stressful for someone with an eating disorder. Holiday meals may disrupt your eating routine and you may worry that special holiday foods are “unhealthy” or that eating them will cause you to gain weight. It may be tempting to eat less in anticipation of holiday meals. It’s important to remember that regular eating is a crucial part of eating disorder recovery. For example, it helps prevent the cycle of restriction and binge eating (Fairburn et al., 2003). Following your regular eating schedule, including all your meals and snacks, can actually help you enjoy special holiday foods in moderation, because you will be less likely to feel extremely hungry and out of control while eating them. Continuing to eat regularly can help you live in line with your values, for example, by giving you the energy to spend quality time with your family and create treasured memories.
 
Reconnecting with Loved Ones
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Reconnecting with family and friends you haven’t seen in a long time may bring up concerns about your physical appearance. It doesn’t help that the first thing many people say when seeing someone after a long time apart is something along the lines of, “You look great!” In these situations, it may feel like there is a magnifying glass on your weight.
 
Pause for a moment and think of someone you care about. Now, imagine you’re going to spend time with them for the first time in months. What do you look forward to? Their sense of humor, their knack for storytelling, their warm hugs? Now, put yourself in the other person’s shoes. What are they looking forward to about spending time with you? I’m willing to bet that the reasons your people love you have nothing to do with your appearance or your weight.
 
So why is physical appearance often the first thing people comment on when there are so many more important aspects of who we are? Because diet culture teaches us that weight is an indicator of health or moral goodness (news flash: it’s not), people sometimes attribute deeper meanings to weight that are simply not true. These beliefs about weight are deeply ingrained in society. While there are ways you can fight diet culture, sometimes it can be helpful to accept that others are in different places in their personal journeys to freedom from diet culture. If someone judges you based on your weight – or any aspect of your appearance – that says more about them than it does about you.

People may also bring up weight or dieting as a topic of conversation. If someone tries to talk about weight over the holidays, you can set a boundary and change the subject: “I’d rather not talk about weight. Have you watched any good TV shows lately?” Alternatively, if the thought of setting a boundary with the other person is daunting, you can start by setting an imaginary boundary. Imagine the other person trying to hand you all their body image angst. Say, “Thanks, but no thanks,” and hand it right back to them. Their overvaluation of weight is their work to do – not yours.
 
Another way to practice acceptance is by using “maybe, maybe not,” a strategy from Acceptance and Commitment Therapy (ACT). This response to eating disorder thoughts can help you accept uncertainty in a situation – for example, when you worry that someone might be judging you based on your weight. Maybe they are, maybe they aren’t. You can go on enjoying the holiday either way.

Setting New Year’s Resolutions

The new year provides an opportunity to reflect on our goals for personal growth. Unfortunately, diet culture has many people convinced that they should make weight loss their New Year’s resolution. Despite the fact that diets don’t work, the dieting and fitness industry profits enormously from weight-loss New Year’s resolutions when people sign up for new gym memberships and dieting programs every January. It can certainly be tempting to set a weight-loss resolution, especially when it seems like everyone else is doing it. Ask yourself: What are you hoping to gain by losing weight? Are you striving for happiness, confidence, health? Remember that your eating disorder will not bring you these things. But there are infinitely many New Year’s resolutions that have nothing to do with weight loss that might help you achieve these bigger-picture goals. For example, building mastery in a hobby can help boost your self-confidence (Kelly et al., 2020). Starting a daily mindfulness practice can lower your blood pressure and improve your cardiovascular health (Shi et al., 2017). Think about the values you want to live by and use them to inform your New Year’s resolutions.
 
Practicing Self Compassion

As the holidays approach, check in with yourself. What are you looking forward to in the holiday season? What parts of the holidays will be challenging? Make a game plan for the difficult moments. In the whirlwind of the holiday season, it may seem easier or safer to give in to your eating disorder thoughts. And if you do, have compassion for yourself. After all, a lapse is not a relapse. Be gentle with yourself, and treat this holiday season as a learning experience on your path to eating disorder recovery.


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References
Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for eating disorders: A “transdiagnostic” theory and treatment. Behaviour Research and Therapy, 41(5), 509–528. https://doi.org/10.1016/S0005-7967(02)00088-8

Kelly, C. M., Strauss, K., Arnold, J., & Stride, C. (2020). The relationship between leisure activities and psychological resources that support a sustainable career: The role of leisure seriousness and work-leisure similarity. Journal of Vocational Behavior, 117, 103340. https://doi.org/10.1016/j.jvb.2019.103340

Shi, L., Zhang, D., Wang, L., Zhuang, J., Cook, R., & Chen, L. (2017). Meditation and blood pressure: A meta-analysis of randomized clinical trials. Journal of Hypertension, 35(4), 696–706. https://doi.org/10.1097/HJH.0000000000001217

Written by Caroline Christian, M.S., Fourth Year EAT Lab Graduate Student


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​Before reading this blog post, please first take a minute and think about what factors you believe influence how much a person weighs.

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            What was on your list? Was anything on your list related to food or exercise? Were these factors near the top of your list? In American society, as well as in many other parts of the world, there is a common belief that weight is determined almost exclusively by the amount and type of food consumed and amount and type of physical activity. While this is partially true (energy input and output from food and physical activity can impact how much you weigh) there are several, far more important factors that are often left out of the equation, which I will discuss later in this article.
 
If you feel resistant to the idea that weight is more than diet and exercise, you are not alone.
 
            Many systems in our society are based on this belief, including virtually every diet and exercise plan that you see advertised today. And it is not an accident that this belief is so pervasive, as many corporations make a ton of money (over 70 billion dollars a year) from this commonly held belief (Marketdata, 2021). Industries that are benefitting include insurance companies, gyms, clothing stores, diet food companies, diet pill corporations, plastic surgeons, weight loss nutritionists, social media influencers, and many more. Do you know who doesn’t benefit from this belief? You.
 
            In fact, this belief contributes to many problems in our society. One of which is that this belief fuels stereotypes and discrimination towards people in larger bodies (Nadler & Voyles, 2020). For example, over one third of people in a larger body report being discriminated against due to their size, including being denied jobs and proper healthcare (Sikorski et al., 2016). Second, mental health concerns, including depression, negative body image, and disordered eating, are also linked to misinformation and myths about weight control (Carels et al., 2013; Hayward et al., 2018). Third, this belief leads people in all body types to spend excessive amounts of time and money on products and programs that don’t actually improve health or even influence weight in a lasting way.
 
            Beyond the fact that the weight = diet x exercise belief is harmful, this belief is not supported by science. Yes – food and physical activity can have an influence on weight, but these are two of many factors that determine weight (Bacon, 2011). Below, I talk about some of the other factors that are more important to influencing weight than food intake and exercise output.
 

1. Genetics. The single most important factor determining adults’ weight is genetics. Over 300 different genes have been found to have some connection to weight, and these genes play a variety of roles, including appetite regulation, fat distribution, and rate of metabolism (Goodarzi, 2018). In fact, for some individuals, genes explain over 70% of weight (Meyer & Stunkard, 2020). Genetics may play an even bigger role in your weight if you have always been in a larger body, if your parents are in larger bodies, or if you have trouble losing weight when dieting. The same way your height and eye color are heritable, and predisposed from birth, so is your natural, healthy weight range. This idea is referred to as set point theory. Set point theory states that the human body has a built-in weight control mechanism that helps the body maintain a genetically predetermined, healthy weight (Rose et al., 2021). In line with this theory, the body will slow metabolism, signal food cravings, and increase fat consumption if one is under their set point to get back to this healthy weight range. This theory is supported by science and is a major factor as to why it is very difficult to “control” your weight if it is different than your genetic predisposition, even with very rigid diet and exercise plans.
   
2. Stress/mood. Another important factor in influencing weight is stress. When we feel stressed, our body releases a hormone called cortisol, which is designed to help our body survive stressful situations. Cortisol does this by shifting your natural rate of metabolism, increasing cravings for high calorie foods, and changing other hormone levels, in order to maximize the energy you have to fight off stress (Katsu & Baker, 2021). With chronic stress, this response can lead to weight gain, especially around the essential organs (Hewagalamulage et al., 2016). Dieting-related stress, including stress about making “perfect” food-related decisions and dread about going to the gym, are still stress and can ramp up this stress response. Beyond stress, overall mood and general mental health have similar impacts on the body’s physiology, and can influence weight by disrupting hormonal cycles, energy levels, and motivation to engage in health-promoting behaviors (Staiano et al., 2016; Wurtman & Wurtman, 2018). Addressing chronic stress and mental health concerns, like depression, anxiety, and eating disorders, through therapy, self-help, social support, and psychiatric medications leads to overall better physical health, making it easier for the body to find and settle in its healthy weight range.
   
3. Environment. Another big and underrated factor that influences weight is the environment in which one lives. Environmental factors that influence weight are numerous, and include access to food, income, employment, socioeconomic status (SES), education, and family life. First, there is considerable research showing lack of food accessibility as a major determinant in weight. In many places, both urban and rural, there is an absence of diverse and affordable food options (Franklin et al., 2012). This lack of food variety and nutrient dense foods, along with stress of seeking food options, can influence one’s weight. Second, individuals from low SES or working-class families may have less time to cook balanced meals, establish social patterns around meals, and face additional stressors, fueling an intergenerational cycle of food and health inequity (Pickett, 2005). Third, children develop persistent patterns of eating and food preferences from young ages, which influence unhelpful styles of eating in adulthood. For example, many children are exposed early on to low-nutrient diet foods and pressures to diet, which leads to dieting in adulthood. Dieting, contrary to popular belief, is one of the leading causes of weight gain (Lowe et al., 2013). Restrictive diets make the body believe it is in “starvation mode,” and the body will respond by trying to gain weight. Thus, physiologically, diets are destined to fail in the long-term, and research shows diets are not helpful or sustainable 95% of the time. This cyclical pattern of restrictive dieting, especially from a young age, raises the body’s predetermined healthy weight and raises risk for serious health issues, including heart disease and type II diabetes (Rose et al., 2021; Roybal, 2005).

 
            These are just a few of many examples of how genetic and environmental inequities can influence weight and health; however, these few examples begin to highlight the sheer complexity of how weight can be determined by factors largely out of our control. Briefly, other important factors include

1. Hormones
2. Gender
3. Aging
4. Sleep
5. Depression
6. Grief
7. Cultural factors
8. Chronic illness
9. Acute illness
10. Trauma
11. Disability
12. Medications
13. Gut microbiome
14. Addiction
15. Eating disorder history
16. Yo-yo dieting

 
            The media, gyms, and diet companies will continue to push the narrative that your weight is a direct consequence of your behaviors related to food and exercise. However, science supports that although a balanced diet and physical activity can improve health, they will not drastically change your weight from its intended set point. There are also numerous systemic and medical factors out of our control that prevent people from engaging in different health behaviors. Thus, it is important to practice compassion for yourself and others around weight. Even now, equipped with this information, you will likely continue to notice automatic judgment towards yourself and others, which is understandable given how engrained these messages are. AND we can do better. I encourage you to try to actively challenge these biases and false beliefs and to show acceptance and kindness to others, regardless of weight, to help dismantle the harm that weight misinformation and stigma can have.
 
If you are interested in reading more about weight and health, I encourage you to explore the following resources.

• Bacon, L., Aphramor, L. (2014). Body Respect: What Conventional Health Books Get Wrong, Leave Out, and Just Plain Fail to Understand about Weight. United States: BenBella Books.
• Bacon, L. (2010). Health at Every Size: The Surprising Truth about Your Weight. United States: BenBella Books.
• https://haescommunity.com/find/

References:
Bacon, L. (2011). Health at Every Size Revised and Updated. ReadHowYouWant.com.

Carels, R. A., Burmeister, J., Oehlhof, M. W., Hinman, N., LeRoy, M., Bannon, E., Koball, A., & Ashrafloun, L. (2013). Internalized weight bias: Ratings of the self, normal weight, and obese individuals and psychological maladjustment. Journal of Behavioral Medicine, 36(1), 86–94. https://doi.org/10.1007/s10865-012-9402-8

Franklin, B., Jones, A., Love, D., Puckett, S., Macklin, J., & White-Means, S. (2012). Exploring Mediators of Food Insecurity and Obesity: A Review of Recent Literature. Journal of Community Health, 37(1), 253–264. https://doi.org/10.1007/s10900-011-9420-4

Goodarzi, M. O. (2018). Genetics of obesity: What genetic association studies have taught us about the biology of obesity and its complications. The Lancet Diabetes & Endocrinology, 6(3), 223–236. https://doi.org/10.1016/S2213-8587(17)30200-0

Hayward, L. E., Vartanian, L. R., & Pinkus, R. T. (2018). Weight Stigma Predicts Poorer Psychological Well-Being Through Internalized Weight Bias and Maladaptive Coping Responses. Obesity, 26(4), 755–761. https://doi.org/10.1002/oby.22126

Hewagalamulage, S. D., Lee, T. K., Clarke, I. J., & Henry, B. A. (2016). Stress, cortisol, and obesity: A role for cortisol responsiveness in identifying individuals prone to obesity. Domestic Animal Endocrinology, 56, S112–S120. https://doi.org/10.1016/j.domaniend.2016.03.004

Katsu, Y., & Baker, M. E. (2021). Cortisol. In Handbook of Hormones (pp. 947–949). Elsevier. https://doi.org/10.1016/B978-0-12-820649-2.00261-8

Lowe, M. R., Doshi, S. D., Katterman, S. N., & Feig, E. H. (2013). Dieting and restrained eating as prospective predictors of weight gain. Frontiers in Psychology, 4. https://doi.org/10.3389/fpsyg.2013.00577

Meyer, J. M., & Stunkard, A. J. (2020). Twin Studies of Human Obesity. In The Genetics of Obesity. CRC Press.

Nadler, J. T., & Voyles, E. C. (2020). Stereotypes: The Incidence and Impacts of Bias. ABC-CLIO.

Pickett, K. E. (2005). Wider income gaps, wider waistbands? An ecological study of obesity and income inequality. Journal of Epidemiology & Community Health, 59(8), 670–674. https://doi.org/10.1136/jech.2004.028795

Rose, K. L., Evans, E. W., Sonneville, K. R., & Richmond, T. (2021). The set point: Weight destiny established before adulthood? Current Opinion in Pediatrics, 33(4), 368–372. https://doi.org/10.1097/MOP.0000000000001024

Roybal, D. (2005). Is “Yo-Yo” Dieting or Weight Cycling Harmful to One’s Health? Nutrition Noteworthy, 7(1). https://escholarship.org/uc/item/1zz4r4qk

Sikorski, C., Spahlholz, J., Hartlev, M., & Riedel-Heller, S. G. (2016). Weight-based discrimination: An ubiquitary phenomenon? International Journal of Obesity, 40(2), 333–337. https://doi.org/10.1038/ijo.2015.165

Staiano, A. E., Marker, A. M., Martin, C. K., & Katzmarzyk, P. T. (2016). Physical activity, mental health, and weight gain in a longitudinal observational cohort of nonobese young adults. Obesity, 24(9), 1969–1975. https://doi.org/10.1002/oby.21567
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Wurtman, J., & Wurtman, R. (2018). The Trajectory from Mood to Obesity. Current Obesity Reports, 7(1), 1–5. https://doi.org/10.1007/s13679-017-0291-6