What Families Should Know about Eating Disorders

Treatment for an eating disorder is a long hard road. Part of the reason relapse rates are so high and full recovery so difficult is the enduring emotional struggle even after normalizing food and weight. It takes personal fortitude and outside support to help people in recovery not succumb to the iron will of an eating disorder. The crucial but often missing piece for families to understand is that the battle isn't over when someone looks normal again.

It's standard to educate families of people with eating disorders for the best chance for full recovery. Most treatment programs provide family groups in which the group members bring families for an education session. Primary therapists usually include the family in sessions from time to time for the same reason. Recommending books to families can help the patient feel better understood and expand what kind of support is available in the treatment. There are a few practical points all families need to best participate the process.

Everyone is aware of the eating disorder behaviors, restricting, binging and purging. Most families assume that ending these behaviors means full recovery. That false statement is especially worrisome when the patient goes to an inpatient treatment program. Upon admission, the relief for the family is significant, and the expectation is that the patient leaves the program fully cured. Unfortunately, that's never how it works. From the moment of admission, families need to understand that a program can jump start treatment, but that support will be even more necessary once the loved one comes home.

Learning how to eat back in the world has new challenges both in choosing and preparing food and in handling the stresses of life without returning to the eating disorder symptoms. In addition, it's very difficult to struggle to eat while trying to accept the changes to one's body. The underlying, internal critical thought process, the main psychological symptom of an eating disorder even after resuming normal eating, is much stronger after treatment. Consistent, loving support is the best antidote.

One inevitable mistake families make is to focus on the food. Patients avoid families most frequently because of feeling constantly watched at meals. The monitoring always comes from a caring place. After feeling so powerless, families wish that just ensuring enough food passes the patient's lips will be enough to lead to a cure. Instead, patients feel exposed and avoid families rather than submit to being constantly watched and criticized. The most effective way to handle meals is to provide food the person feels comfortable with, allow her to choose and eat as she wishes and simply ask if everything is fine. Giving her the freedom to act like an adult will be most encouraging while watching her at every meal only reinforces the eating disorder.

Families understandably want a clear treatment course with a definite prognosis and endpoint. The process of getting better from an eating disorder is a much more complex road. The exigencies of stabilizing the body and mind to relearn how to eat normally and how to function as an adult without the security of the eating disorder rules are cumbersome. The path to recovery involves many ups and downs and demands a resiliency to weather the tough spots and remember the light at the end of the tunnel. It's extremely difficult for the patient, battling daily in the trenches, to see any light at all. One of the most helpful things families can do is to reinforce the need for patience and to remember treatment is a long, arduous process. Believing in the family member even at the toughest of times reflects a level of confidence and love that endures and strengthens her resolve each day.

By focusing on the positive steps and remaining steadfast on the hard days, families express a sentiment that an eating disorder has surely eroded over the years: trust. The shame of being sick pushes patients to sneak and lie and leads families to question this person who had always been seen as trustworthy and reliable. The internal, critical thoughts of an eating disorder only get stronger when families decide they can no longer trust. I routinely suggest families learn to distinguish the hiding that comes with the shame of being sick from one's true character. Re-establishing trust can make the difference between a full recovery and a partial one. When families work hard not to criticize and blame but instead to forgive and love, the effect on the course of recovery is immeasurable.


Practical Steps to Fight Obesity, Part III

Even if parents understand the message about food and weight that can help their kids, it's not clear how to reinforce it. One way parents date themselves is how they discuss the role of television in their family. It's especially quaint when the smug ones boast about not having a TV in the house at all, as if they've risen above the riffraff to aspire to new cultural heights.

But the statement "I'll never let my kids watch television," once considered a critical element in defining ones family, is meaningless today. Sure, television still matters but only as one of many forms of entertainment. At least for now, the internet age has turned us all into consumers of content, however it gets into our home. And that's a fact for no one more than today's kids.

Children no longer need to wait for their favorite show each week, now it's instant gratification. Content in all its forms is available on every electronic gadget in the house and in every possible form to rope in a child. Perhaps even more troubling to adults who aspire to TV-free households would be the definition of content today. Scripted shows, reality videos, YouTube and movies all clearly fall into the content category. What about novels and news outlets? What about research, which, to kids today, constitutes creative googling or emailing questions to an expert they find online? When the only successful internet business model is based on clicks, a website will do whatever it takes to lure readers or viewers. As the line between knowledge and content blurs, there's no easy way to eliminate entertainment from the house. Every bit of information comes with an ulterior motive. It's all content now.

Advertising clued into this new opportunity long ago and capitalized on the easy access to children's minds with, not surprisingly, problematic results. The business goal was to rally children to ask parents to buy products, but the actual effect was to inculcate the suggestible with misguided information. The repercussions of the advertising onslaught were profound, note the toy fads and growing tween culture considers critical to the economy, and not challenged by alternative messages until decades later.

Public health spots and non-profit campaigns, the first alternatives were no competition for advertising. The ideals of consumerism and a free market even for children persisted. However, more recently, the creative freedom allowed by exponentially growing content outlets led some forward-thinking creative types to make shows intended to teach children ethical and moral lessons. These shows are so powerful that kids use and apply the information in school and at home.

That I know of, these lessons, easily tolerated by parents, are from the bottom of the creators' hearts. Among the messages are kindness towards others, tolerance of difference and self-respect. Sometimes the messages are more concrete like do your homework and clean your room. On that list a common theme is eat healthy food, but the message to eat more carrots, as I have written many times, has no real impact on how children learn to live in the world of plenty. 

The last post explained the new paradigm adults can use to teach children about food, weight and identity. The content children consume must reflect the same values to compete with the extant pressures from advertising and the drive to be thin. Older shows like Sesame Street and Mr. Roger's Neighborhood were primarily educational and aimed at younger children. A new genre for older kids provides ready-to-absorb values to take into their world. Coming from coveted content, children accept this information much more readily than anything parents might say. Ironically, content provides an opportunity to challenge what kids learn in the world of plenty.

The momentum needed to start a shift in children's content about food and weight already exists. I began this blog almost three years ago in response to desperate emails from confused parents unsure where to turn for help with their kids' eating. Those emails keep rolling in. As many have told me, it's a full-time job just to get some worthwhile advice. The faulty paradigm of eat less and move more reinforces the problem. As the internet economy attracts the bright, creative minds today, content could quickly spread a new thought process about food and weight to kids, which if accompanied by adults and peers who feel the same way, might start to undo the toxic climate in the world of plenty.

The new approach to food and weight has three simple points. What you eat and how you look do not determine the person you are. In other words, it takes years of growing up to figure yourself out and there's no magic fix, including food and weight. Eating is about pleasure and sustenance. The body needs a variety of foods to survive, and human culture has long connected food with enjoyment and connectedness. Last, kids need to dissociate eating from good and bad behavior. Eating is only about eating, and praise and punishment must be separate from food.

The message is clear and simple. More importantly, rather than attempting to refute the years of successful advertising, this paradigm creates a new way to incorporate food and weight into kids' lives and minds and perhaps a new way to spread the word.


Practical Steps to Fight Obesity, Part II

The conclusions of the last few posts about the obesity epidemic are sobering and perhaps even bleak. The causes of the problem are systemic and deeply embedded in our culture. A drastic change in lifestyle by returning to the era before processed food, agribusiness, the drive for thinness and chronic dieting is highly unlikely. The expectation of an immediate solution to weight loss via surgery, crash diet or miracle pill is pure fantasy. The solution is a hard road through moderation in food intake with reduced expectations for the future. That doesn't mean quick weight loss followed by stabilization but instead slow, steady, sustainable change.

Most epidemics spread horizontally, through a generation, both old and young, and must be contained from sweeping through an entire population. This one grows vertically. A child needs to be taught by adults, peers and advertising how to engage with the world of plenty, how to become obese. The challenge to care for the currently obese isn't enough to stop this epidemic.

The real hope lies with helping future generations avoid the same fate. The current world of plenty may shift slowly over time but not fast enough to save today's youth. Without tools to avoid this fate, children are mere fodder for the societal forces that lead to obesity. Adults and public policy must know what to say and what to do in order to make a difference. The perils of processed food and mass marketing are dire but invisible to kids. They need to be convinced that there's a different way to live around all this food.
Practically, direct education and public health initiatives aimed at children don't do the trick. Certainly, some obedient children will respond to information as law to live by or to fear-based propaganda as horror stories to avoid. However, the innate propensity for children to test adults and rebel against authority will make food rules just another set of parental edicts to disobey. Getting into the minds of children takes somewhat more creativity. Two points are essential to make a difference with kids: educating parents and adults how to talk to kids about food and weight and getting into children's heads through content they'll listen to.

Both parents and public health administrators need to be aware that the teaching points available to educate children are ineffective. Eat less, move more and learn "healthy eating" facts--the trifecta of food education--neither change food behavior nor lessen the risk of obesity. Cooperative, motivated adults are fonts of nutrition knowledge yet find that knowing what to do has no effect on their own behavior and weight. Children, moved more by the innate urge to pick the poison apple, will take on food rules as a challenge to either squeeze extra sweets from exhausted parents or sneak them at any opportunity. The simple education model is a boon to the food industry. Sophisticated marketing and advertising trounces any earnest public health campaign.

Children are all instinct and emotion. The tack of using logic and reason to change clearly preprogrammed urges is hard enough for adults and unrealistic for kids. But there's one thing business already knows: the malleable minds of children are open to suggestion. And much of what draws children in to focusing on food and weight is the promise of a secure identity.

The basis of a child's personality is largely genetic, but the birth of identity forms around relationships. In other words, we are born with many character traits that define how we react to the world, but only by engaging with the world do we learn how to perceive ourselves. Personality doesn't come with a guidebook. Other people provide the feedback to form identity. Self-awareness is a gradual dawning over years that reveals our mental perception of who we are.

In childhood, the powerful desire for an identity comes with the urgency to feel instantly fully formed. Food and weight, the overarching obsession of this generation, is an easy barometer of identity. That can be the kid who eats anything, the kid who doesn't eat, the kid who is thin or who is fat. But food and weight can provide instant identity.

Accordingly, the practical first step is to teach kids to let food be food. Children can't learn food choice is related to good and bad behavior or be praised for eating in any particular way. They can't believe they are special because of how they eat or how they look. They can't learn to associate guilt with dessert or that eating is always a shameful act. They must learn food is necessary for life and a regular part of every day, that meals can be enjoyed and not scary and that weight is not a barometer of success and failure. They have to hear a new philosophy of food and weight every day and allow their internal search for identity bypass food and weight to look for different ways to see themselves. And they need to hear over and over again that it takes time to figure out who you are. Focusing on a quick fix like food and weight won't speed anything up. In fact, it doesn't work for anyone.

If this is the message adults need to teach kids, the second key point is how to get them to listen. That will be in the next post.