By: Maria Nemec, LCSW, CEDS, Pathways to Peace, Inc.

A new study (2018) finds that giving estrogen replacement to female athletes with exercise-induced irregularities improves a drive for thinness, body dissatisfaction, and uncontrolled eating.
This study was conducted by lead researcher, Madhusmita Misra, MD., MPH, professor of pediatrics at Harvard Medical School and pediatric endocrinologist at Massachusetts General Hospital in Boston, Mass.
Dr. Misra found a relationship between estrogen and disordered eating behavior, and the potential of estrogen replacement as a treatment target, not just in athletes, but also potentially  in other conditions characterized by abnormal eating behavior and frequent menstrual dysfunction, such as anorexia nervosa.
Dr. Misra compared 109 female athletes with exercise-induced menstrual irregularities, 50 female athletes with normal menstrual cycles, and 39 female non-athletes. All of the females were 14-25 years old and were in a normal weight range.
The athletes with irregular periods reported a higher drive for thinness and more mental control over their food intake compared to athletes with regular periods and non-athletes. They also had higher body dissatisfaction scores than athletes with regular periods.
Athletes who had irregular menstrual periods were randomly assigned to: 1.) an estrogen replacement patch, at a dose that resulted in estrogen levels seen with normal menstrual cycles, or 2.)  a commonly used oral contraceptive pill containing estrogen, or 3.) no estrogen for 12 months. The athletes receiving the estrogen patch also received progesterone.
Over the course of a year, the groups that received estrogen showed reductions in drive for thinness, body dissatisfaction, and uncontrolled eating, compared with those who didn’t receive estrogen.  The patch was the most effective, leading to significant decreases in body dissatisfaction and uncontrolled eating.
“These results highlight the importance of normalizing estrogen levels in female athletes with irregular menstrual periods,” Misra said.  “This not only improves their bone health but may also improve their eating behavior”.
More studies are necessary to confirm these findings.

Read full article here: https://www.sciencedaily.com/releases/2018/03/180318144853.htm ​

A new study found that a persistent low body mass index (BMI) in children, starting as young as age 2 for boys, and 4 for girls, may be a risk factor for the development of anorexia in adolescence.  
The study also found that a persistent high BMI in childhood may be a risk factor for later development of bulimia, binge eating disorder, and purging.
By looking at growth records of thousands of children over time, researchers can see early warning profiles that could signal children at risk.
Cynthia Bulik, Ph.D., Professor of Eating Disorders at UNC states, “Clinically, this means that pediatricians should be alert for children who fall off and stay off the growth curve throughout childhood.”  The same holds true for children who exceed and remain above the growth curve – increasing their risk for bulimia and binge eating disorder.

Read full article HERE.

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By: Maria Nemec, LCSW, CEDS, Pathways to Peace, Inc.
Anorexia Nervosa is a severe mental illness with a high rate of mortality. Ten years post hospitalization, the mortality rate is 10 times greater than that of an age and gender matched population. Half of all deaths occur within the first 3 years after discharge. Medical complications and suicide are the most common causes of death and the average age at death is 34.
Predictors of mortality include chronicity of illness, critically low body weight, and binging and purging behavior. Impaired judgment and delusional beliefs caused by starvation often result in these patients adamantly resisting treatment efforts.
Despite the severity and risk of the illness, providers are often reluctant to initiate involuntary treatment for patients with anorexia. However, this respect for a patient’s autonomy may lead to a fatal outcome in patients with eating disorders.
Recent legal cases are cited in this article suggesting that the court’s role generally is to decide if the patient meets criteria for commitment including having a serious mental illness, being perceived as gravely disabled, and the potential to bring harm to oneself by not taking in the nutrients necessary to sustain life.  In one case, the court went so far as to order involuntary medications and tube feedings.  However, in most cases, the courts refrained from rulings involving the treatment of anorexia as long as the treatments were believed to be the standard of care.  It is important to note that patients who may resist treatment initially, may later realize they needed treatment all along.
 
Read full article here: http://jaapl.org/content/jaapl/45/4/419.full.pdf
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In a study published in the Journal of Behavior Therapy and Experimental Psychiatry researchers found that controlled exposure to an individual’s own body in a mirror was effective in reducing body dissatisfaction and symptoms in women with bulimia nervosa.
Researchers compared two different controlled exposure techniques to reduce negative thoughts and feelings related to body image. Guided exposure asks participants to observe their bodies in the mirror while describing what they see in an objective manner.  The second method, pure exposure, has participants observe their bodies in the mirror while expressing the thoughts and feelings that come up. All participants received 6 exposure sessions.
The results of this study showed that both techniques were shown to reduce negative thoughts in bulimic women AND increase positive thoughts and cortisol levels over the course of the 6 sessions. However, pure exposure was found to be significantly more effective in improving body satisfaction and reducing overall subjective discomfort with one’s own body.
Sandra Diaz Ferrer, lead author of the paper and University of Granada researcher says the findings suggest that pure exposure “could be an effective therapeutic strategy for reducing body dissatisfaction in people with eating disorders.”
The most surprising finding in this study is that techniques which allow for negative expression of one’s body were more effective than those which guide patients through more neutral descriptions.
To read the full article:
https://brookhavenhospital.com/mirror-exposure-therapy-reduces-body-dissatisfaction-in-women-with-bulimia/  

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By: Maria Nemec, LCSW, Pathways to Peace, Inc.
In this article, Dr. Julie O’Toole notes the differences between Anorexia and ARFID as well as a shift in thinking among physicians.  Twenty years ago, most patients with eating disorders were diagnosed with anorexia nervosa.  However, there are currently many more patients with the ARFID diagnosis (Avoidant Restrictive Intake Disorder) which points us to a shift of physicians, dieticians, and therapists toward a more advanced understanding of weight loss and poor growth in childhood.
DSM -5 defines ARFID as: an eating or feeding disturbance (e.g., an apparent lack of interest in eating or food, avoidance based on the sensory characters of food, concern about aversive consequences of food) as manifested by persistent failure to meet appropriate nutrition and/or energy needs…
DSM – 5 further lists associated issues including significant weight loss or nutritional deficiency, dependence on nutritional supplements or enteral feeding, interference with functioning in society, and the lack of other medical reasons for the eating disturbance.
Dr. O’Toole points out that ARFID is based on additional factors, not only selective eating. Such factors could include depression, ADHD medication reaction, or even cancer.
Dr. O’Toole states that ARFID and Failure to Thrive are essentially the same thing, only one is a medical term and one is a psychological term. The treatment for both is essentially the same as well.  That is, ordered eating in an age appropriate setting with health care providers who will take the steps to make sure malnutrition is reversed so that growth and development occurs as well as healthy psychosocial functioning.
To read the article in it’s entirety:
 https://www.kartiniclinic.com/blog/post/arfid-revisited/

by:The International Journal of Eating Disorders
Summary submitted by Grace Sturgiss, MS, RD, LD

​This study explored the definition of #cheatmeal on social media and content associated with this phrase.
The researchers reviewed #cheatmeal over two non-consecutive days on Instagram. These pictures were categorized into food, person, and written content, which were further broken down into subgroups.
Results showed that #cheatmeal was associated with larger quantities of food, higher calorically dense food, and highly muscular body types. 
Further research is recommended to continue to explore how this commonly used phrase can impact an individual’s relationship with food.

by: The International Journal of Eating Disorders
Summary submitted by Grace Sturgiss, MS, RD, LD

​This research article focused on parental strategies around meal times and the impact this may have on weight and eating psychopathology at end of treatment outcomes in adolescents with Anorexia Nervosa using family-based treatment. 
 
Methods included participants completing an eating disorder examination along with weight and height. Family meals were observed with the 5 most common parental strategies being used around mealtimes. 
 
The results showed that the direct and non-direct eating prompts during family meals was linked to further weight gain at end of treatment. There was no significant findings on the impact around the participants eating psychopathology at end of treatment.
 
Further research is recommended to further explore strategies around family meals and long-term outcome of weight gain.

By: Jason Klemka, LD/N, Nutritional Guidance

Resource: Guido, Frank K.W, Megahn Shott, Carrie Keffler, and Marc-Andre Cornier. “Extremes of Eating Are Associated with Reduced Neural Taste Discrimination.” International Journal of Eating Disorders 49:6 (2016): 603-612.
 
Taste amongst other senses are important components of food intake. The brains primary taste cortex “the insula” may be altered resulting in how patterns of information regarding food intake is interpreted. The insula connects to higher order brain structures that control how much we eat. Thus the insula could have a role in the pathophysiology of disordered eating regarding taste information transmission. The insula is important for responding to body cues such as hunger or fullness which tend to be altered in eating disorders. In eating disorders, the size and function of the insula is altered. Functional brain imaging typically studies strength of brain activation in response to specific stimuli.
Study 106 women, 27 healthy comparison women, 21 restricting type AN, 19 recovered from AN 20 women BN, and 19 with obesity. Participants completed breakfast based on their meal plan and resonance brain imagining (fMRI) was performed upon completion of meal. The fMRI measured brain activity in regions of the brain. During the fMRI participants were also given 3 test stimuli to evaluate taste- sucrose solution, no solution, and artificial saliva.

This study indicated that Anorexia Nervosa and obesity are associated with reduced taste quality in the insula. In recovered Anorexia Nervosa and Bulimia Nervosa, there was no difference when compared to the healthy comparison group. When contrasting two of the test taste stimuli to remove effects of texture and other sensory stimulation in the mouth there was evidence of encoding differences of the brain specific to taste quality. Thus presenting the possibility of deficits in neuronal encoding of distinct taste qualities in Anorexia Nervosa and obesity. Leptin and other hormones are altered with eating disorders and obesity by affecting taste perception and reducing insula pattern classification due to primary structural changes within the insula or within signaling pathways from other regions of the brain to the insula. The insula is also connected to other pathways that are responsible for internal emotional states. The insula has also been associated with self-recognition (abstract representation with one’s self) as well as gastric distention and self-reported fullness. As a result, many intertwined functions are used for processing and altered on different levels within the insula when presenting with eating disorders or obesity. If normal taste is disturbed, this could possibly lead to altering the normal insula inputs which in turn, may lead to altering other processing centers affect taste and influencing the drive to eat or not to eat. Anorexia Nervosa and obesity also have altered dopamine function, elevated or reduced cognitive control as well as high anxiety resulting in a change in eating pathology when the insula is altered. Therefore, in eating disorders, if there is a diminished insula signal in response to taste, than dopamine levels could have a stronger impact on food choices.

Acceptance and Commitment Therapy Bootcamp Overview
By: ​Blanche Stokley LMHC, CEDS
Address: 225 S Swoope Ave #205, Maitland, FL 32751
Phone:(407) 691-0477 

Hi folks. Just returned from a ACT bootcamp in Raleigh, NC. ACT stands for Acceptance and Commitment Therapy, a behavioral based therapy within a relational frame. This training was intense starting at 9am to 6:45pm for four days. Basically it is a a blend of behaviorism and rogerian therapies.

The primary object in ACT is to help others achieve “psychological flexibility” as opposed to ‘psychological rigidity”. Flexibility is often a sign of health in our bodies, minds, emotions and spirit. Asking a eating disorder client to consider psychological flexibility in their selected food choices challenges them. We know this includes eating with others and eating in restaurants. Asking for such flexibility in decreasing exercise, reconsidering a sport and reducing time in the gym is difficult for a client to accept and commit to recovery.

Emotionally we are asking a client to accept feeling emotions when the eating disorder has been successfully rendering the client numb. The client is often surprised by the extent of their repressed feelings. Flexibility often means accepting that feelings have their own time table. I use the metaphor of being pregnant. Your body has its own process which you can’t control. It might be nausea, fatigue or food cravings. And when the baby is ready, then it’s delivery time. Waiting and patience takes on new meaning!

We are also asking the family to be flexible. The family’s expectations whether realistic or not play a role in recovery. The supportive family will struggle and succeed in accepting the client’s eating disorder and the perhaps the client’s new or reemerging identity. But sometimes the most challenging idea for a client is the acceptance of a parent who may never elect to change. No amount of family therapy can convince this parent to become accepting and flexible.
Rigidity is risk avoidant and it makes an eating disorder client’s life small. The longer the disorder is un-arrested the smaller the life. Slowly encouraging the client to move out into the world helps them face maturity and rejections fears.

We as clinicians are challenged to be flexible as well. It is hard when insurance companies cut off necessary treatment payment. We see clients who cling to their disorder out of fear. Progress often is slow. However the rewards can be amazing! So consider bringing in the theme of psychological flexibility as a goal in treatment. Thanks for taking the time with me.