Building Our Food Community

I heard a very disturbing story the other day. A woman --not a patient--spoke about a group of young mothers all of whom see a doctor for weight loss. These are all thin women who want help to look even thinner. The doctor employs two main tactics: he prescribes diet pills and he screams at them to eat less and lose weight. Apparently, some people go to doctors to induce anorexia! Is that really how we share food in our community?

This story finally brought me back to reality: food no longer brings us together. For some, it is an enemy to avoid at all costs, even by seeking out dangerous pills and abusive doctors. Food may still help drive a sense of community but not in traditional ways. We share diets or weight loss stories. We swap stimulants or juice fasts. Or we all trek down to the local McDonald's for processed food that has replaced real meals. We have all had to put down our political stake in the world of food. Many people opt out of the entire food debate. They just eat. For those who do enter the fray, there are many decisions to make: Organic? Vegetarian? Meat-lover? Fast food? Farmer's markets? Pro-industry? Striving for thinness? Food network? This is our current community: find a political (or apolitical) stance and connect with like-minded people. Is there room for another way to share food? Can anyone shift the way our society thinks about food?

I don't believe this society can go back to seeing food as culture. Each home can refocus the conversation around food as I wrote in the last post; however, global food commerce, powerful multinational food corporations, compliant federal regulatory agencies and omnipresent nutritionism are all too influential for the world to turn back now. Obesity, dieting and eating disorders are persistent public health problems. The new community of food resides in this current reality. 

What does it mean for a society to define food through abstinence or gluttony? How does community persist when The Biggest Loser and pro-Ana websites represent such strong cultural voices? Food has become the vehicle for capitalism, for entertainment and for the post-feminist woman. I see food as one of the loudest and most powerful forms of communication. Our approach to food quickly reveals, to anyone paying attention, our approach to life. As disturbing as it is, the group of women seeing the weight loss doctor knows what is most important to them. In their community, these women find a sense of belonging. We all can find people who speak the same language of food, who share the same meaning of food. Whether food represents health, culture, control or safety determines which community of food fits one's lifestyle. By no means are we then bound to that one point of view: as we change what food means to us, so can we change where we belong. 

These dramatic changes in food and culture place a large burden on individuals and parents to find a new balance. Taking responsibility doesn't have to mean taking the blame: the core food industry message. Although government--and to some extent industry--has a duty to protect society from undo harm and public health hazards, everyone must decide what they will eat. We all need to make that decision every day. Change on an individual level--by making informed decisions about food--is necessary for our world of food to change. Our own active role and decisions matter for us, for our families and for our community. 

The next post will bring the blog back to eating disorders, more specifically binging and overeating later in life.

Talking Food with your Kids

Over the past century the basic social structure we live in has changed from isolated communities to a hyperintegrated world. This has had a profound effect on raising children. Parents dismiss the guidance and wisdom of the older generation: how can they understand the brave, new world? In a community of so much homogeneity, the experience of peers is meaningless: why should they know more than anyone else? Even commiserating with like-minded parents has become a thing of the past. Although mothers share many of their own frustrations and worries with each other, it is almost taboo to reveal too much. The most basic struggles of parenting remain a dirty secret borne by isolated mothers.

This void leaves ample room for experts--via self-help books, talk shows and practitioner specialists--to swoop in and provide relief with often unsubstantiated advice. Nowhere is this more evident than in feeding children. Local cuisine is overrun by omnipresent fast food. Parents and children are bombarded simultaneously with junk food
marketing and contradictory nutrition advice. Meanwhile, the societal pressure about food and weight is spreading like wildfire all over the globe. Numerous studies have shown that when fast food enters a new country, obesity, striving for thinness and eating disorders are sure to follow. It's clear who is most influenced by these cultural shifts: kids. It's equally clear who feels powerless as a result: parents.

Many food writers have started to ask a simple question. What did we all do before the food industry, agribusiness and nutritionism decided what we should eat? I think the same can be said for families. How did we all feed our children before carbonated beverages, marketing to children, childhood feeding specialists and childhood obesity and diabetes? When it comes to the culture of food, the global community has stripped people of a sense of identity and, by proxy, a sense of belonging. The spreading influence of capitalism and marketing into our food supply and our food choices has replaced tradition with brand loyalty, family recipes with the local fast-food joint. For generation upon generation, food has represented culture and country on a large scale and home for the individual. Embedded in the identity of food is the knowledge of nutrition and healthful eating. Recipes and meals
represent the good feeling of spending time together and the generational knowledge of how to eat well. Feeding children was a shared family and community responsibility to teach them about culture, heritage and health. Food was a source of pride, not a repository of endless shame. There was no need to seek expert advice because everything we needed to know was right in front of us on the dining room table.

Cut off from family and culture, kids look more and more to peers and school for an identity through what they eat. The marketing machine relentlessly exploits the absence of parental oversight by connecting kids to brands. The food industry has self-righteously edged its way into schools and labelled their marketing strategies as educational. Schools then provide junk foods--the only thing kids apparently will eat--while the company justifies the profit-taking by providing schools with sorely needed funds. In this food environment, peer pressure only encourages pursuit of the tastiest morsels of processed foods now available to kids throughout the day. Meanwhile, family dinners, home-cooked meals and a culture of food has largely evaporated. Kids have become the most coveted capitalist asset: an investment paid back with years of brand loyalty.

These external pressures can feel suffocating. The covert message from the food industry is that parents are powerless to affect children's food choices and are simultaneously responsible for childhood obesity. Government interventions also undermine parents' authority by suggesting a meal plan that kowtows to nutritional standards directly influenced by the food industry lobbyists. The overall effect is that parents feel as if they cannot trust anyone, least of all themselves, to know anything about food. The fallacy of this argument is that parents still decide what takes place inside the home.

How does a parent change the conversation in the big, bad world of food capitalism? The answer lies within the home, perhaps no longer on the dining room table but in recent--and easily accessible--family memory. Children remain fascinated by understanding their place in the world. Marketing experts have learned how to manipulate that desire in children into connecting through consumerism. Kids can get a sense of identity from the latest caffeinated, sweetened beverage, or parents can steer the conversation about food to tradition and heritage and
reopen the door for children to belong in a different way. This may mean cooking and eating recipes passed down from older generations. It may mean talking about the role food and cooking played in the family. Or perhaps it is just making grandma's favorite dish for dinner. Parents have the ability to shift the childrens' focus on food to
tradition and culture. Although children will still feel the societal pressures, they will have a different way of thinking about food. Parents can create a home influenced but not dominated by our current culture of food. In a way, each time a parent's voice is heard eliminates a marketing opportunity for the food industry.

One thing I still have not addressed is how parents can feel less isolated when it comes to feeding children. Bringing new ideas about food into the home opens new opportunities for conversation, but the families are still alone. The bigger question--to be addressed in the next post--is how to recreate a community around food.

How Not to Pass Your Food Issues onto to Your Kids

Every parent wants her child to eat normally and healthfully. Every parent wants her child to be free of the societal pressures to eat less and lose weight. However, most parents struggle with their own demons when it comes to eating. No one is immune from the pressures to be thin, the newest fad diet, the endless stream of food advertising or the onslaught of confusing nutritional advice. The unspoken truth is that children carefully observe their parents' behavior around everything, including food. Kids will be aware of the discrepancy between how their parents eat and how they eat. They will notice how daddy skips breakfast or how mommy sneaks dessert or how daddy is always on a diet or how mommy is ashamed of how she looks.

The obvious answer is for parents to fix their own food issues. But parents, at age 30 or 35 or 40, have been trying to solve their eating problems for years. Although parents often report a shift in their eating habits after having children, there is no magic fix. Sooner or later, parents will find the same old thoughts and behaviors creeping up on them combined with the added pressure of trying to hide these embarrassing habits from their children.

So is this just another unavoidable source of parental guilt? Are children doomed to the same endless cycle of food and weight preoccupation? Are parents not equipped to teach their children a new way of eating? Based on the last post, I laid out the concept that children have an innate sense of when to eat and when to stop. A parent's job is to teach kids how to identify and recognize their bodies' needs and then act accordingly. It isn't necessary for the parent to solve her own food issues in order to teach her children about their own internal cues. The parent doesn't have to be perfect because it is not about modelling behavior but learning about your body. The conversation shifts from junk food and thinness to healthful eating and hunger. Every family will have to handle the same outside pressures, but creating a new avenue for discussion will allow children an alternate way to talk about food inside the home.

As the parent refocuses the discussion from conforming to societal norms to child-based learning, she needs to know how to handle her own food issues. Any parent will be tempted to do one of two things. The first is to hide her concerns about food because they are too shameful. The second is to impose her own rules on the child. This would simultaneously lift the pressure on the parent and confuse the child by obfuscating her ability to learn how to eat.

The most effective strategy is to expect that food and weight are complicated topics any family will tackle slowly over time. Parents will struggle how to explain this issue to the best of their ability, just as with the age-old discussion about where babies come from. Success rests on two points: sharing just enough information appropriate to the child's age and showing just enough humility. Children will be curious but usually need a simple answer to satisfy them. Too much information confuses them and too little only piques their curiousity. Many parents will either avoid the topic completely or feel obligated to have a long discussion which goes way over the child's head. In this instance, the parents' clue to stop the conversation comes from the child. Children will ask questions until they understand enough and then move on. Parents should move on too. The conversation is likely to continue on and off for years. Once children know their parents are open to discussing food and weight, they will understand it's all right to ask more questions. 

There is no need to hide that the parent is still learning about food or thinks about weight. It can be comforting to the child when a parent is honest. Since the child will observe a parent's behaviors or hear her discuss her worries, a sincere response will match the child's thoughts. Hiding or lying forces a child to reconcile her confusion often in deleterious ways. This approach to discussing food won't shelter children but instead will allow them to understand and hopefully, in time, find a different way to think about food.  

Younger kids need to learn about food and their bodies. Older kids are more curious how people think about eating or why others talk about being thin. As kids get even older, outside pressures will become more powerful. How can a parent even begin to compete? What do these conversations with kids look like? This information rests in the home, family and community. And that is the topic of the next post.

How to Think about Kids and Food

About once per week I receive an email from a parent about a problem feeding his or her child. The concerns vary from picky eating to arguments at mealtime to overeating to diet advice. Sometimes the child is at risk for an eating disorder, but more often this is a normal family struggle about food.

My instinct was to ignore the emails and pass the worried parent on to the child's pediatrician, a child feeding specialist or perhaps her own therapist. I came to realize there was a reason I was receiving these calls for help. The parent was looking for both reassurance that the child was relatively normal and guidance to handle the current issue. These emails highlighted a gap in resources available to parents. There is plenty of advice about what to feed your kids, but parents always want to know if they are doing the right thing. I know I cannot answer that question but I could discuss what seemed to be the missing link. How to think about your kids and food?

There are a few common themes. First, parents don't know where to turn for a coherent strategy for feeding their children. Second, parents are terrifed of passing their own imperfect or even disordered eating onto their children. Third, families are very isolated from community--both relatives and friends--and choose to ignore old world advice in a new world of dietary challenges.

The marketing of foods to children and the transformation of our food supply have changed the landscape of parenting about food drastically. Useful, accurate information is hard to find. The best educational materials are often just skillful marketing tools, misguided public health statements or nutritionism (turning eating into a chess game of nutrients and minerals). By creating an array of foods made to appeal to our deepest desires, the food industry undermines our faith in our ability to regulate food. We all struggle to find a healthful, balanced diet and are plagued by the constant temptation to stray. How then can a parent become an expert in feeding his or her own child? Where does a well-intentioned parent even start?

Parenting is marked by moments of self-doubt and even despair followed by an important, usually self-evident revelation. In this instance, that moment begins when a parent realizes she already knows how to feed her child. If a parent can accept this premise, the outside influences are not as confusing. Any advice from society appears to be tainted by ulterior motives. Any professional suggestion needs to be balanced with a parent's understanding of her child. People have survived with eating advice passed down through families and tradition for centuries. Why, all of a sudden, would we all be clueless about how to feed our kids? In fact, the real worry is who will protect them? Although the movement to regulate the food industry is gaining steam, it is unlikely to have broad impact for many years. So parents are left to fend for their children on their own.

Let me be clear about one thing: parents know how to feed their children. The real issue is how can a parent harness that instinct. In recent years, the national mantra is that parents are to blame for their childrens' eating habits. But it is clear that the individual parent is powerless in the face of massive societal forces. Shielding children from advertising, television and junk foods is impossible. Teaching children about their own bodies remains very effective. The key is simple. When the child is hungry, she will eat. When she is not hungry, she won't. However, applying this concept is much harder. First, a parent has to trust the child's instincts implicitly. Second, the parent has to learn how the child experiences and acts when she is hungry or not hungry. Third, the parent needs to translate the child's experiences into words and to teach her to know when she is hungry or not hungry. Last, the parent has to learn to avoid his or her own vulnerabilities about food and not pass them on to her children.

Even though this application seems straightforward, nothing is ever easy in parenting. Industry and government still dictate how we all think about food. No movement has yet had much impact on our culture of food. However, a parent can focus on other components of eating--ones that have been drowned out by the myriad confusing messages--to help the child navigate this confusion.

This has turned into a topic too big for one post so look for the next several to address these topics more fully.

Families and Recovery

One necessary but often neglected component of recovery is the role of family and significant others in the treatment of an adult patient. Even with a cohesive, supportive and knowledgeable team, the patient has to navigate many hours and many meals alone. The people in her life who love and care for her can provide daily support. However, more often than not, this is not the case. Some families do not have the emotional stability to aide in recovery and others, much more rarely, are the source of the illness itself. Even for families capable of contributing to the treatment process, most patients exclude their family from recovery. This lost resource is the result of two problems in communication. First, families struggle to find education and guidance about their role in treatment. Second, patients feel misunderstood by their families and do not know how to ask for what they need. This rift only leads to an impasse and an unnecessary, added obstacle to progress. 

The essential piece of advice for families is don't talk about food ever. Don't ask about a meal. Don't ask if she ate. Don't ask if the food was good or bad. Just don't bring it up. If the patient talks about food, any response needs to be encouraging and brief. The patient's internal thoughts about food are critical and relentless. This means she will misinterpret any comment about food to mean that she ate too much or ate the wrong food or is fat. The entire process of eating causes intense emotional pain that she needs professional help to navigate. Any caring family will want to address what appears to be the problem, food. If only she would eat, the problem will go away. The hardest step is to recognize how discussing food is counterproductive. In fact, this is how the family becomes the enemy, not the source of support and comfort.   

So what does help the patient? Because she is bombarded with critical thoughts, she needs kind words of support and encouragement. By the time a patient is in treatment, families are already very worried and frustrated about how powerless they feel. This is primarily a reflection of how powerless the patient feels. The presence of the eating disorder makes normal, loving family interactions seem impossible. The daily conversation needs to shift away from food and back to the topics from before the eating disorder. Showing interest in the person outside of her illness will remind her of the other parts of her life. She needs to remember that she has relationships that matter to her. She needs to know her family cares about her, not just if she eats.   

Another important aspect of recovery is that progress is often not visible, especially early in treatment. Setting up a treatment team, establishing treatment goals and putting initial plans into action takes time. The changes begin in small ways. Many key transformations can be internal and involve quieting the eating disordered thoughts. But this progress is often not seen by families who want immediate, concrete changes. They want their loved one to eat meals and be herself again, almost instantly. This desire comes from love and caring but translates quickly into disappointment and frustration. As a therapist, I focus on progress and patience in therapy. This approach helps the patient learn how to treat herself with compassion through the process of recovery. When the family realizes how powerful patience and compassion can be, recovery can move forward even more quickly.      

If the patient will allow it, one session with the primary therapist can be very helpful. The goal is to understand the most effective ways to support the patient in recovery. This meeting allows the patient herself the opportunity to express what she needs. It also sends a clear message to the therapist that the family wants to be a source of support in recovery.  

Last, the family needs to recognize that eating disorder recovery is a long and trying process. Every family will be frustrated and will make mistakes. It is best for the patient if the family works hard to educate themselves about eating disorders and to find their own support. There are associations for families to provide these services. Individual and family therapy is also effective. Seeing her family seek out their own support will help the patient understand that everyone is working hard to be well and that she does not need to take care of the family too.  

This post has led me to consider the family's role in a different light. In my first post I wrote that I received a call from a father about how to feed his daughter. That conversation brought up the obvious question: how to feed your children? From my vantage point, if the goal is to help your children understand how to think about food, I think there is a more important question. How do you talk about food with your children? Look for the next post.

How to Prevent an Eating Disorder from Becoming Chronic

The last two posts made a few things clear. Almost everyone is exposed to the risk factors for developing an eating disorder: dieting and adolescence. In addition, most people have an evolutionary predilection towards starving or binging. The combination of these variables leads some people into the prodrome, the precarious mental state that precedes the eating disorder, and then into the illness itself. There are two critical questions to answer in order to fully understand the prodrome: who recovers from early illness? and how to prevent the progression to a chronic disorder?

I don't want to minimize any stage of an eating disorder. The symptoms hijack the patient's life and overturn any semblance of a stable family. However, the early stage of an eating disorder is critical because there is still a significant chance of full recovery.  Eating disorder treatment for patients in the acute, early illness involves weight restoration, normalizing eating and a return to regular life. For most patients, this transition is very hard but often a relief from the physically and emotionally punishing cycle of the illness. For most, this treatment is enough. The difference between recovery and chronic illness is comorbidity--the presence of another psychiatric disorder in addition to the eating disorder. When the eating disorder masks the comorbid disorder, normal eating leaves the patient fully exposed to the comorbid symptoms. In fact, the eating disorder becomes a very powerful and successful coping mechanism for the underlying problem. Following the rules of the eating disorder gives a sense of control and satisfaction. The world is ordered and makes sense. The other disorder makes little sense and has no rules. Under these circumstances, the patient with comorbidity will choose the eating disorder, essentially the lesser of two evils. After "failing" at treatment, this patient will quickly be labeled chronic.

The most common comorbidities are trauma, depression and anxiety. A history of abuse, particularly as a child, contributes to a strong need to hold onto the eating disorder. Like an abusive parent, the eating disorder provides both comfort through eating and punishment through the  internal monologue that is harsh and unrelenting. The  eating disorder hides her fear that she will be subjected to more trauma. This calms the feelings and memories of the abuse and structures the patient's adult life. Depression and anxiety often accompany the descent into the illness, but a minority of these patients have severe depression or anxiety as the primary symptom. In these circumstances, fully treating the comorbid symptoms will also largely cure the eating disorder. Conversely, untreated or undertreated depression or anxiety will lead to chronic illness: the eating disorder helps the patient manage her other symptoms.

There is one more category of patients who become chronic. I will label them as the "delusional" type. Here the comorbidity could be seen as part of the disorder, but I prefer to label this aspect of the illness as separate from the eating disorder itself. The delusion reflects the patient's inability to differentiate between the most punishing and extreme thoughts and behaviors of the eating disorder and reality. There are many examples: some patients literally see themselves as 100 pounds heavier in the mirror, some are convinced they have eaten calories when they drink water or even by watching others eat, others truly think the eating disordered thoughts will punish them, some don't believe they are sick at all. These patients lack the perspective to see the disordered thoughts as part of the illness. Recovery makes the patient feel as if she will lose herself. Her identity is woven into the disorder so that she does not know herself without it. Needless to say, the treatment course is significantly prolonged.

What can be done to prevent the patient from developing a chronic eating disorder? A thorough initial evaluation followed by a  comprehensive treatment plan will identify those people at higher risk to determine who needs treatment for the comorbid illness as well. This involves trauma therapy concurrent with eating disorder treatment
or comprehensive treatment for depression and anxiety. For the patient with a delusional comorbidity, the treatment is more complex. This patient may end up in several rounds of treatment, often both inpatient and outpatient, before she is accurately diagnosed and finds the right help. The key to success is a strong therapeutic bond which can generate the internal motivation and courage needed for the patient to question the delusions. In addition, the treatment must nurture the growth of the patient's identity separate from the eating disorder. This is no easy task but is critical for real recovery. The delusional comorbidity also can break down even the most supportive families. Their role is to work hard to find the best help for their daughter. Participating in the eating itself is almost always  counterproductive unless supervised and instructed by the treatment team. However, families can and must provide emotional support and compassion through the treatment. The process is long and arduous, and families themselves may need support to handle their own frustration.

Writing about this critical part of the evolution of an eating disorder has led me to address the role of the family. Most patients in the prodromal stage are in their teens or early twenties and are still dependent on the family for support. The next post will address the best ways for families to support the child with an eating disorder.

Hunger and Fullness

Hunger and fullness are the internal cues we use to regulate eating. They are also what our current culture of abundance of food and obsession with thinness looks to exploit. Last, they are what goes awry in an eating disorder. Relearning these cues is a cornerstone of eating disorder treatment.

At the most basic level, hunger is critical to our survival. It is clear that identifying hunger and acting on it is necessary to avoid starvation and death, both as an individual and as a species. Most of us feel mild hunger on most days, but hunger need not be a regular part of daily life for a majority of the population anymore. Experiencing hunger seems more like a social statement--or even a medical condition--than an evolutionary necessity. But forced hunger and starvation are very different. Prolonged hunger leads to a primal, visceral response which includes obsessive thoughts about food, a voracious ability to eat endlessly, cravings for odd food combinations, mindlessly performing strange food behaviors and a complete loss of rational thought around the social norms and propriety of eating. In other words, anyone who is chronically starved exhibits the symptoms of anorexia nervosa. This point highlights another curious aspect of eating disorders. Anorexia looks more like an adaptive mental state in starvation than a psychiatric illness.

It is less clear what role fullness, or satiety, plays in our lives. Historically, eating until one was full, very full, was looked upon as socially correct behavior. If there was an erratic food supply, eating a lot was a way to store energy for the future. Eating large amounts and gaining weight was a sign of prosperity and wealth. The expression of love and caring in many cultures is through providing food and eating together, usually to excess. Similar to anorexia, overeating or binging looks like an adaptive response to an environment with excess resources: eat and eat and eat. It is a physiological response to help avoid hunger in the future.  Calling it a binge is a new classification of an old, adaptive behavior. Any compensatory action to repair the "damage" done by the binge, i.e. purging, are panicked responses to the social judgment and perceived consequences of the binge. Fullness has no clear relevance to survival. There has been little reason to hone our instincts to identify fullness, at least until now. Bombarded with a neverending supply of food crafted to appeal to all of our senses, fullness is now necessary to avoid overeating and obesity. In that vein, fullness is not adaptive at all. It is a social construct created because of our ideal of thinness and a culture serving up endless quantities of food. Our society acts as if fullness is a natural instinct, and by extension a failure for those who cannot recognize it, not an ingenious way to place responsibilty for the obesity epidemic upon the individual.

Like all adaptive, evolutionary traits, hunger and overeating are exhibited along a spectrum. Some people will experience the starvation response more quickly and profoundly while others can tolerate hunger and function. Some will gorge around excess while others will not be capable of overeating. From an evolutionary standpoint, this variability within a population ensures the survival of a species. Certain people will survive in famine and others will prosper in times of excess. In modern times, these traits transform from evolutionary traits into eating disorder risk factors. Suddenly, people who can withstand hunger try a diet and find that their tolerance for hunger is rewarded by society and by the internal, visceral high of starvation. Others who have the adapted trait to overeat when food is abundant find that the food industry products trigger a primal craving, such as sugar cravings or carbohydrate cravings. In our current culture, it is a short leap from evolutionary leanings to a full-fledged eating disorder.

If risk factors for an eating disorder are adaptive traits, where does that leave those most susceptible? If we live in a world with food aplenty and processed food designed to appeal to our most basic desires, how can those susceptible not get an eating disorder? How effective can intuitive eating--a treatment designed to help us get back in touch with our internal sense of hunger and fullness--successfully compete with evolutionary adaptations? These are sobering thoughts. They leave eating disorder treatment in a bind between our most basic instincts and the missteps our society has made about how we handle food.

Although I am tempted to address the larger picture first, I want to stick with the original point of writing this blog: the treatment plan. So the next post will look at the transition from adaptive response to eating disorder. As I described in the last post, it is called the prodrome.