Tag Archives: anorexia nervosa

The golden toolbox of recovery

What’s in your toolbox?! I was recently at a meeting and friend turned to me and said “I have a strange picture that I’ve seen, it’s you with a golden toolbox. It’s like you have everything you need in that toolbox to deal with life”.

This spoke volumes to me as a person and as a health care professional. Having worked in a team which was predominantly psychological I was immersed in the language of the therapists and the word toolbox often came up. I sat in on plenty of group therapy sessions and got to experience a whole range of different therapies.  Also, in our team meetings we used these skills on ourselves as part of the debrief process. It showed me how important it is to look after not just your patients, but yourself. If you have a life with some stress in it (let’s face it that is probably everyone) then you need to have some skills to hand that help you deal with that stress. Stress and anxiety can be a huge factor in an eating disorder, in mental health conditions and also to physical digestive issues such as IBS. When you have a stressful event how do you respond? What does it trigger in you? When you know how you respond you can start to work on a more effective and helpful mechanism. 

 I will never forget my interview for my eating disorder post. I was asked such an eclectic mix of questions that I had no idea how I had done on leaving the room. When I received the call to say I had the job, I asked why I was chosen. The response “we could see you are robust and able to cope with the strains of this work”.  In the eating disorder field this robustness is certainly needed. I continually need to keep on top of my own anxiety and practise what I preach. 

I want to  highlight some skills or tools that we all, health professionals, patients, people, could include in our golden toolbox. Tools you can use regularly for moments of anxiety, tools you can pull out for those emergency moments.

I remember being on a train that got stuck in a tunnel and suddenly feeling trapped and my anxiety levels rising. It was not an experience I was prepared for and suddenly I knew I needed to use one of my tools. At that point visualisation of a calm beach with lapping waves and some square breathing helped immensley. I know if I had not practised these skills  previously, I wouldn’t have been able to use them there and then. So practise really is the key. 

Here are some of my favourite toolbox tools that I use myself and recommend. 

Journaling –

I’m a seasoned journalling fan. This is something I have always done since my teenage years, I now have a lot of full notebooks with a collection of my teen angst, my working life, my spiritual life and my family life in them. Looking back it shows me how I have evolved and where my stress triggers are. I can see the patterns that I fall into and work on improving my reactions. I dig out my journal when I have a moment I need to work through, when my mind feels cluttered or when something erupts! I also love to journal the good and positive, so any life events or just when I get the urge.

If you are on a recovery journey then I recommend that you journal daily  or at least 4 times a week. It needs to become a discipline and a part of your coping mechanism. A good way to start is to write down 3 things that went no so well in your day and how you could have dealt with these better. Then always finish on a positive, so 3 things that have gone well or that you coped with well. You can also take a single scenario and write out alternative endings. Using an eating disorder example: You had an argument with a friend, this increased your stress and you responded by missing your snack. Thinking through why this was not a useful response – restriction of food does not help your emotional well being, it is a quite fix but not a long term cure. Now you have missed out on some nutrition for the day and your body is hungry. Your body needs regular food right now as you work towards recovery. So take a think through how you could have responded instead…. maybe you could have gone for a walk, taken a bath or done some mindfulness to help you reduce your anxiety after the argument instead of turning to food.

Mindfulness and Breathing –

Such a buzz word at the moment, but this is not a fad. I’ve been using mindfulness with eating disorder clients for over 10 years and I’m sure it has been used for far, far longer than this. Just 10 minutes before a meal or after a meal can make a huge difference. It is all about calming your thoughts and body. I personally love just deep breathing, there are so many variations on this so try a few out. For me, the breathing  is something that spills over from Pilates practise and so I get a double benefit from Pilates of exercise and mindfulness. There are some great free resources to help here. 

Exercise –

This is something to decide upon according to your recovery stage. Exercise can be amazing as a mood booster and a de-stresser. However if you are working on weight gain then it will also have an affect on this. If your BMI is less than 17.5 then you will want to modify your exercise so that it is physically safe. 

Distraction – 

I often suggest that people put together a list of distraction techniques that they can use. For example, after a meal,  or when a the urge to binge strikes, at times when anxiety levels are rising it can be useful to have an activity planned. Things like craft, having a friend to call, painting your nails, reading a book, cleaning out a cupboard – something that immerses your mind and changes your thoughts. Puzzles, crosswords, knitting, collage are all great things to have on your list.

Positive thoughts –

Those anxious, negative thoughts are something that we all get. It is how we deal with them that is key. I love the thought of noticing the thought, and finding the opposite reaction. So turn that negative into a positive. If you practise this regularly it can turn into a habit that you hardly notice you are doing. I’m now working on this one with my children too, teaching then that there is always a positive side to things. It is a great skill to learn at a young age but one that you can learn at any age.

I’d love to know what tools you find useful. 

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Restriction and Eating Disorders.

Having an eating disorder can make you feel invincible, it can sometimes be hard to see how being underweight and restricting your food intake can cause physical health issues, but there are so many knock on effects of being a low weight. When your body is not getting the nutrition that it needs it can lead to knock on consequences for your bone health as the minerals are take from yoour bones for use elsewhere in the body. Another big one is  muscle wasting throughout the body including your heart. Your brain will start to conserve energy and shut down some less vital functions, brain power, memory, reactions and concentrations can be impaired. The blood may not be pumped as well around the body leading to cold extremities. Mood swings and poor sleep are common. Skin, hair and nails will start to suffer. I’ve had some people who have lost their hair in large clumps.  Less of a physical symptom, as your body craves nutrition your mind becomes increasingly pre-occupied with food, recipes, the next meal, it can become all consuming. 

Dietitian UK: Restriction and eating disorders infographicIf you or someone you know is struggling with restricting their eating, it can be helpful to think through the physical affects on the body and use these as a motivation to focus on slowly eating more. If you need help with this, seek out an eating disorders therapist, dietitian or see your GP for signposting. 

I work with people with Skype, so get in touch if you need support.

Where should I set my weight goal?

Where should my weight goal be?

Why does my body keep on gaining when I want it to stop?

Why have I reached a plateau?

If you were perfectly in tune with our bodies you would be able to eat when hungry, stop when full, even decide what to eat whilst thinking about the signals your body was sending out. This would likely result in your weight remaining relatively stable. Why? 

The theory is that the body has a genetically determined weight set point. This is the point where the body functions best. It will work to gain/lose weight back to this point. So with small losses and gains of weight your body will adapt it’s metabolism to bring your weight back. 

If you constantly ignore the bodies hunger/fullness signals you can override this system and push the body into a new “settling point”. Your body will work to get back towards it’s set point but external factors may mean this is not possible so it compromises. This can explain why you find it easy to gain/lose a little weight below your normal weight but then have to make bigger changes to alter your weight further. It also shows why a WEIGHT BAND is needed and not a single figure. 

Dietitian UK: set-point-theorywhere-should-i-set-my-weight-goal

Looking at the research on weight restoration after people have been at a low weight you find it takes time for them to get back to their healthy weight bands. For example simulation using the data from the Minnesota starvation study show it took over a year for the men’s bodies to resettle back to within 5% of their original body fat. 

In my practice of eating disorders I see similar results. Getting the body to regain weight back to it’s former set point is not as easy as you would imagine. There can be phases of regular weight gain and then plateau periods. It can take a few months for weight maintenance to be established. Almost as if the body is testing to make sure it is safe for it to settle into it’s groove again. Following a pattern of either bingeing and restricting or eating more and then compensating another day will make it harder for the body to normalise itself. Mindful eating, a regular pattern of meals and listening to your body’s signals is the key.

When you lose weight, below the set-point, your metabolism decreases. Your body uses less energy for jobs such as digesting food. Your overall energy expenditure decreases and your resting energy expenditure decreases. So you use less calories than you were using. As you start to weight restore your metabolism will at some point start to increase alongside this. This can result in a weight plateau, but it can also help you justify eating more.

How do your work out your set-point?

This is the tricky bit. There is no direct way to measure it and it can change over time. For some women pregnancy will change the set point. Ageing can have an affect. Medications and illness too. 

What we do know is it isn’t likely to be dead on a BMI of 20. BMI is a guide and a range it isn’t definitive. So you may have to continue gaining past BMI of 20 and listen to your physical health signals. Your energy levels, your menstrual cycle, your bone health, the condition of your hair and nails, your blood results. Ignore the numbers on the scales and think about your body as a whole.

General tips: look back over your weight history. If you have had a stable period when you ate normally and were moderately active then your weight at this time will be a huge clue. 

Look at the weight of siblings and parents. If you are female think about the weight when your menstrual cycle was occurring regularly, this is a huge clue. 

Remember, the body wants stability and to feel safe. So give it a routine and listen to what it is asking you for. 

If you need any advice then do get in touch for a Skype or face to face consultation.

 

References:

CCI: set point theory http://www.cci.health.wa.gov.au/docs/set%20point%20theory.pdf

Mirror-Mirror : Set Point Theory: http://www.mirror-mirror.org/set.htm 

Muller, JM et al (2010). Is there evidence for a set point that regulates human body weight? F1000 Med Rep. 2010; 2: 59. Accessed via PubMed.

Eating Disorders: Prevention is better than cure

Eating disorders are a mean, cruel illness. Once seen to be a disease of affluence, there are now so many reasons an eating disorder can begin. The roots can be due to trauma, family issues, relationship problems, low self esteem, bullying, loneliness and wanting to fit in, a desire to be healthy, a need to achieve. Often there seems to be this air of mystery surrounding them and they can even be seen as a status. However, once you are in the cycle of truly trying to recover you will wish you had never become drawn into the disorder in the first place. 

Healthy eating taken to the extreme can seem like a good idea, but for some it can rapidly become an obsession. Counting calories, measuring portions, having the right balance of food groups can be positive. But when it lead to these measures being down to the nth degree, becoming obsessed with what your next meal will be and anxious if you have to eat something out of your plan, then there is a problem. 

When I meet someone who is low weight and wants to weight restore I always emphasis that it will not be easy. Not because I want to put them off, but I always find it is important to be honest and forewarn them. Recovery from an eating disorder is a cruel business. Why do I say that? Well if you have an eating disorder you have issues around food, often you are restricting your intake and eating high calorie foods causes anxiety. You don’t like feeling full, bloated or heavy and putting on weight around your tummy is not something you want to happen. Guess what? When you weight restore all these things happen. It is like everything you are scared of you have to go through, a bit like one of those awful challenges where they put you in a box full of spiders to get you past your fear of them (yes I’m scared of spiders). Someone weight restoring will have to:

  1. Eat more.
  2. Eat more calorie dense foods. 
  3. Increase the variety of foods they eat.
  4. Eat more carbohydrates, fats and sugars.
  5. Will feel bloated after a meal.
  6. Will have to continue eating when full, pushing past that feeling of wanting to stop.
  7. Will have anxiety around mealtimes.
  8. Will gain weight and this may initially go to their tummy but will then redistribute.

So you can see some reasons why it is so hard. All the things you fear are the things you have to go through. I wish I had a magic wand or an easy solution. However recovery is definitely possible and so so worth it. 

What I do know is:

Dietitian UK: Prevention is better than cure

 

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stories

 

Here is a quote from a  client talking about weight restoration to inspire you:

It seems like forever ago now and I can’t lie – I hated it at the time. I really struggled. I did the ISP after an admission and it was tough. I hated it at the time. I remember going through a folder of portion sizes with you and lying through my teeth. I couldn’t accept the help.  But I’ve been out of hospital for 3 years now. I’m small but not underweight. I had a lot of help and eventually knew how to use it. From there to now – I don’t think I could have got from there to where I am now without the support I received.

It hasn’t gone. It’s still there but I’ve got a lot to lose now (life, friends, family and definitely not weight) and I won’t give that up for anything. I never said thank you at the time because I couldn’t see that you were helping me. So I wanted to say thank you now. 

It is so good to be living again 😊

5 tips for recovery from an eating disorder.

1. Make recovery a priority:
This may mean taking a break from normal life. A year out. Recovery takes a lot more energy and effort than you may originally think. It needs to be right up your priority list. Time off work, school, certain friendships, travelling, exercise. Whatever it takes, this is important for this season.

Dietitian UK: Make recovery a priority

2. Find yourself again:
What do you like to do? It’s often hard to know what things make you, you. The busyness of life gets in the way of our identity. 
Book out some time to find you again. Try some activities you used to enjoy. Often creative projects can be a useful part of recovery. Maybe photography, baking, sewing, painting, collage, scrap booking, gardening,  I love the phrase “Find what makes you come alive, then go and do it”.

3. Mindfulness:
Sitting in silence and paying your full attention to your breath and body can help you bring an awareness of your thoughts and feelings. This practise helps you let go of the unhelpful thoughts and be more compassionate to yourself. Practising letting thoughts go in your mindfulness practice will enable you to take this into everyday life so when an unhelpful thought comes along you are in a better place to acknowledge it, but not to act on it.  

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4. Value yourself :
Take time to look after your body: nutritionally and physically. Some self care time in your week can make a real difference and can remind you that you are important and worth looking after. For some people an eating disorder can be a form of self neglect and may have some punishment aspects to it. Creating the emphasis on it being good to care for yourself and give yourself pamper occasions helps build self esteem and love for your body. 

Some ideas: A long bath, a manicure, pedicure, haircut, moisturising your body, shaving. Taking time to tidy your home, buy yourself flowers or something nice to look at each day, light candles in the evenings. 

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5. Fuel your body:
The right fuel at the right times of the day is vital. This may mean going against your feelings and thoughts, but with repetition a routine will evolve and habits will form. 
It is likely your have no idea what normal eating should be for you now. Plan out 3 meals and 3 snacks a day with general timings to stick to if you can. There will always be days things don’t fit into your plan, that is also part of normal eating! For more advice take a look at my healthy eating in Anorexia post.
Go for as much variety as you can. There is no perfect meal plan, it’s all about making small steps and challenging yourself as often as you can. 

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Feelings of Fullness

“I feel full after eating a small amount”

“When I eat more than usual my stomach feels uncomfortable and bloated”

“I feel like I have a food baby”

These are phrases I often hear from clients with eating disorders as we work on increasing their meal plan. Unfortunately there is no magic cure here and it is a stage that has to be worked through. What can help is understanding what is happening.

Dietitian UK: Feelings of Fullness

The Science:

In someone who has been under-eating for some time, the digestive track slows down. As a result food moves slower through the system. That feeling of the food remaining in the stomach for a long time can be true and is known as “delayed gastric emptying”. This can also lead to a heightened sensitivity to feelings of fullness and bloatedness. It is not necessarily that you are fuller than anyone else, but you may feel that way.

If you have an eating disorder you are likely to have been blocking out those feelings of hunger and of fullness too, there is a disconnection and a loss of sensitivity to them. Fullness is regulated by the hypothalmus in the brain. 20 minutes after you eat a signal is sent to the brain. This is an easy system to overide so it needs your sensitivity. This connection has to be rebuilt and relearnt which takes time. It may feel like you cannot trust the signals the body is sending. Actually it is your reading of these signals that is the issue, sticking to a balanced, regular intake of meals and snacks will help to realign your thinking with your feelings and food.

Thoughts are powerful. If you think you should be full or are full then this can trigger anxiety leading to feelings of fullness. Try to keep mealtimes relaxed and have a period of time afterwards where you distract yourself with something like art, craft activities, phoning a friend, reading a book. It takes 20-40 minutes for the feelings of fullness to subside. 

Boosting your nutritional intake – the healthy way to weight gain.

I work in the topsy turvy world that is eating disorders. Most of the media focus, food manufacturers, shops and nutrition business is on how to lose weight. whilst I work with people on how to gain or maintain their weight. Gaining weight may sound like it is easy to do but it often isn’t. You need to increase your dietary intake by 350-500kcals per day to start gaining weight. Now if you don’t have an eating disorder that may seem like no hard thing. A latte and slice of cake will easily hit the mark. However often the clients I work with are keen to increase the energy density of their diet in healthy ways. Now I’m all for eating plenty of veggies but you will have to eat a whopping amount if you are going to gain weight on extra veggies alone As I had to explain to one client recently – 350kcals extra in salad alone would mean you would be eating salad all day long. However there are options, if you can keep an open mind. 

Foods like nuts, seeds, avocado, dried fruit, nut butters, hummus, yoghurt, cheese, eggs, olive or rapeseed oils and fruit juices, will provide a nutrient dense way to increase the calories of your diet.

Dietitian UK: Why almonds are so good for you

 

Some of these foods may be on the scary side but they all provide nutrients that the body needs.

Dietitian UK: Gaining weight the healthy way for eating disorders

Here are some of my top suggestions of ways to boost up your intake by around 350kcals:
 
Add 1 tbsp seeds and 1 tbsp dried fruit to your normal cereal then top with your usual milk plus 2 tbsp yoghurt and add a glass of fruit juice.
Make your own snack boxes with nuts, dried fruit and small crackers (e.g: 15 almonds, 5 dried apricots, 7 rice crackers).
Homemade smoothies with yoghurt, chia seeds and fruit (e.g. 1 banana, 100g yoghurt, 100ml milk, 1 tbsp chia seeds and 1 handful blueberries).
1 serving Granola with 1 serving of Greek yoghurt.
1/2 avocado on 1 slice toast with a glass of fruit juice.
2 tbsp almond butter on 3 oatcakes with 1 banana sliced on top.
3 peanut butter cookies with a portion of fruit.
 
To read my healthy eating tips for Eating Disorders go here.

 

Mealtime Guidelines for Eating Disorder Sufferers.

 When you have an eating disorder or disordered eating it can lead to mealtimes becoming a stressful, hated time. For parents, carers, loved ones and friends it can become an anxious minefield. With everyone treading on eggshells, what should be a relaxing eating experience turns into an emotional melting pot.

I’ve spent a number of years eating more meals than I can count with people suffering from all types of eating disorders. In that time I’ve worked with hundreds of clients and listened to their stories of meal times, spent time finding ways to make eating more bearable and sat with them practising it. I’ve had food thrown at me, been shouted at and watched all kinds of odd food behaviours. I’m no stranger to tears at the table, tantrums and food mysteriously disappearing. I’d pretty much say I’ve seen it all and this means I know how hard it is for the sufferer and for the carer too. So here are my top tips for sufferers on making mealtimes easier.

Planning and Preparation.

Plan out in advance what is going to be eaten, don’t get caught out by the element of surprise. If you are preparing the food yourself then keep it simple as the act of preparing the food can put you off eating it.

Distraction is your Friend.

Find some good ways of distracting your mind from your food.

  1. Have someone sit with you and talk to you, but set boundaries such as not talking about food, diets and body image. Having a list of topics to discuss can help the person sitting with you. Good topics include holiday destinations, movies, music, topical TV shows. If you get stuck have the paper to hand to get topics or even read a quotations book aloud.
  2. Have “feel good” music on in the background or the radio, but not the TV.
  3. Read a magazine/book.

Keep Calm and Carry On Eating.

Eat in a calm, quiet and comfortable atmosphere and place. Keep it as stress free as possible. As soon as you feel anxious your “fight or flight” pathway kicks in. Think about it. Your heart beats faster, you may feel hot and sweaty, you may feel shaky and clammy, your throat constricts, your appetite gets less – so it will definitely be harder to eat!

Portion Perfect.

Only put on your plate what you need to eat. Don’t overload it as it will seem overwhelming.

Meal Motivation.

Keep in mind the reasons why you need to eat these foods. Either think it through in your head or have a list of reasons written out to refer to at the table or just before your meal. Use your long term goals, physical health reasons or any others that are positive. 

Reflect.

After a meal reflect on what went well/not so well. If you struggled, think through how you could improve this for next time, what would help/did not help. There will always be highs and lows in recovery. That is normal, the trick is to not give up.

After Activity.

Have something planned to do afterwards to distract yourself and to help you relax. Listen to relaxing music, watch TV or phone a friend are all good options. 

If you need one to one support, an individual meal plan and more guidance on this, please get in touch. An eating disorder is a very difficult illness to live with, live through and for some to let go and live without BUT it CAN be beaten,

Healthy Eating for Anorexia Nervosa

I’ve worked in the field of eating disorders for about 10 years. It’s an area that both frustrates me and brings me to life. I find it challenging work, emotional at times and I have to constantly remember to celebrate every small thing. Yet I absolutely LOVE this work.

In a world where obesity is on the increase, healthy eating and low fat eating predominates. The Eat Well plate has been developed as a way to demonstrate healthy balanced eating. I use this visual guide as a talking point but with the emphasis that this is aimed at a healthy population trying to maintain weight or at overweight people trying to lose a little weight. Therefore the proportions may not be correct if you are trying to gain weight.

 

Here is my walk through the Eat Well Plate for Anorexia Nervosa:

 Fruit and Vegetables:

Most people with anorexia nervosa I come across have no problems in meeting the 5 a day target, in fact they can have the reverse issue and be eating too many portions!

  • These foods should make up about 1/3 of your plate at each meal and no more.
  • It’s important to eat a range of colours and types so you get the full range of nutrients.

Dietitian UK: Healthy Eating in Anorexia Nervosa, Fruit and Veg

 

Starchy Foods/Carbohydrates:

These foods are often thought to be the villains. Yes over-eating these will lead to weight gain, but not eating them will mean your body does not have enough energy. Carbohydrate foods (bread, rice, pasta, cereals, potatoes etc..) are the bodies preferred energy source so that means it will choose to burn them off as fuel over anything else.

  • Include them at every meal.
  • Go for wholemeal, whole grain versions where possible.
  • The more active you are the more you will need.

 

Dietitian UK: Healthy Eating for Anorexia Nervosa

Dairy Products:

Dairy foods are important as they provide the body with calcium, protein and in some cases Vitamin D. Super important for your bones. When you are a low weight and not eating enough the kidneys remove calcium from your bones to supply the body with needed calcium, leaving your bones weakened. This needs replacing!

 

  • Eat 3-4 portions per day (e.g. 1 glass milk, 1 small yoghurt, 30g cheese).
  • If you are weight gaining steer away from the low fat options, often these just have more sugar and additives in them anyway.
  • Think about the long term impact of having weak bones, it’s a great motivator.

 

Dietitian UK: Healthy Eating for Anorexia Nervosa

Meat, Fish and Other Proteins:

This includes eggs, tofu, soya, beans, pulses, lentils, nuts and seeds. Include these foods twice a day in your meal plan either as a main meal or a snack.

Dietitian UK: Healthy Eating for Anorexia Nervosa

 

Fats and Sugars:

These are included as part of healthy eating. Your body needs fat and sugar in order to function. There is a layer of fat around your internal organs acting as insulation and protection, there are essential fatty acids that your brain needs to function well and monounsaturated fats are good for your heart – so fat is not all bad.

 

  • Work up to including healthy fats in your diet – avocado, olives, oily fish, rapeseed oil, nuts and seeds.
  • Build in a challenge each week to eat a “scary” food.

Dietitian UK: Healthy Fats