Living With Food: The Science Supporting Eating Disorder Treatment

With rare exception, eating disorders cannot be treated by medications alone. Nonetheless, part of your treatment at CCED may involve the use of medication. There are several reasons for this. First, some medications have been shown to be helpful in reducing some eating disorder behaviors. In particular, purging behavior can be significantly reduced for many people with the use of selective serotonin reuptake inhibitors. The most studied medication for this is Prozac. Prozac has also been shown in some studies to reduce the risk of relapse in patients with anorexia. Additionally, other symptoms besides an eating disorder may also be present when the eating disorder is severe enough to require treatment. Anxiety and depression are seen in over half of patients with eating disorders. For some of these individuals, the use of medications to treat anxiety and depression is critical and may lead to a significant reduction in misery and may also lead to an improvement in eating disorder symptoms. 

Not everyone welcomes the use of psychiatric medications. There may be well founded reasons to want to avoid these medications based on personal beliefs, previous use, or physical symptoms. At the same time, many people are very pleased to discover that medications exist that can provide them with more rapid relief of depression, anxiety, and behaviors. For this group of people, options may be available. 

In order to make good decisions about medications, it is quite common for all patients receiving an assessment at CCED to be asked whether they would also like a psychiatric assessment. Psychiatry is available at CCED for any patient having any treatment here. For patients in higher levels of care, a psychiatric assessment is necessary and is provided as part of that higher level of care. 

A psychiatric assessment does not mean that you will take medication. It does mean that medication options, risks and benefits, pros and cons, and personal choice can be discussed so that the best and most effective treatment plan can be created for each individual.

If you have questions or comments about this post, please email blog@eatingdisorderscleveland.org.

Contributions by Sarah Emerman

By, Sarah Emerman and Julie Norman, RD

Understandably, nutrition is an important service that we offer. Depending on your needs, you may see a dietitian on an outpatient basis, or as a part of one of our programs. The dietitian’s job is to assess your current eating style and behaviors to determine if your body is getting what it needs, and to work with you towards correcting imbalances. She will also provide nutritional education about the reality of how food works in your body, as well as dispel common food myths. Thoughts and feelings around food and behaviors will be touched upon but will mainly be worked on in group or with your individual therapist. When setting food goals the dietitians will do their best to meet you where you’re at while challenging and pushing you.

You will be prescribed a meal plan and following this meal plan is an essential part of your treatment and recovery. The meal plan will be based on your own body’s needs as well as your feedback, medical data, medical history, and evidence based nutritional guidelines. Your meal plan will be continually re-assessed as you progress through recovery. Because feeding your body correctly is a journey, not a destination, the dietitian remains a crucial part of your long term recovery.

Should you have questions or comments regarding this blog post please email blog@eatingdisorderscleveland.org.

Understandably, insurance and payment for care is of great concern to anyone contemplating treatment for their eating disorder. Historically, eating disorders have not been well understood or treated with parity by payers, and people with eating disorders or their families have been asked to bear the vast amount of cost for the treatment for these disorders. While insurance coverage for eating disorders is in the process of improving, in many cases it is no where near as good as we would like it to be. 

Prior to admission into a program at CCED, a detailed conversation with our director of billing will take place to determine coverage for our services.  In general there are two separate pathways that will happen at this point: 

1. If your insurance company is contracted with CCED, we will work with you so you can access benefits that have been guaranteed through those contracts. In general this means that clinical information from the person who did your assessment is shared with your insurance company.  For some insurance companies with whom we have contracts, no prior approval is needed for coverage, however, this is not true for all companies that we are contracted with. We will not know until after your assessment and subsequent conversation with our billing department into which category your situation may place you.  If we are contracted with your insurance company, in general you may be responsible for a deductible and coinsurance for your services and the insurance company will reimburse us directly for a percentage of the cost of your care.  
2. If we are not contacted with your insurance company, we will attempt to negotiate what is known as a single case agreement. Many companies, particularly those who do not have other resources in Northeast Ohio (and there are no other resources similar to CCED in Northeast Ohio) are willing to treat us as if we are in network even though we are not and they will negotiate a rate with us for payment.  With several of these companies we are in the process of joining their network and have a good relationship with them. With a single case agreement in place, you are likely to be responsible for a deductible and coinsurance, but the insurance company will reimburse CCED directly for services. 

As must be clear by now, the insurance piece of obtaining treatment is very complicated. We will do our best to give you as much information in the earliest possible moment, but we often need to take several steps through the process before we can be certain how your insurance company will interact with your treatment needs.

Should you have any questions or comments regarding this post, please contact blog@eatingdisorderscleveland.org

Contributions by Sarah Emerman

We will be taking a break from our series on "What to expect at CCED" to share a unique piece written by one of our clients. We will resume with "What to expect at CCED" next week.

Ed has been with me for 14 years now. I met him in the second grade before a school fashion show. He criticized my outfit, and told me I looked rather rotund in it, to put it nicely. But instead of thinking That Jerk! I believed him. I continued to take his unsolicited advice. He’s right, I thought. I continued to feel in such a way for years to follow, until we became so intertwined that his thoughts became my own.

As an eighth grader at a small Catholic school, we became an “official” couple during lunchtime in the cafeteria. You know how those grade school romances are – short-lived and oh so dramatic. But there was something different about Ed, something comforting and intriguing. Ed was much more attractive than Chris or Nick or Zach. He seemed to promise me everything I could ever want (seemingly better than Britney Spears tickets), and always made me feel safe and secure.

Weekly dinner dates gave way to daily luncheons, and soon we were connected at the hip. He soon had me convinced that I needed him, and him only, in my life. Before I knew what was happening, I became his next victim, joining the ranks of so many other that he had seduced before. I was naïve to his hefty abusive record, and so there I went blindly falling deeper and deeper into danger. But Ed made me vow never to make a peep about what had been really happening; for if I did, he would become that much more vicious.

Perhaps I should start from the beginning, Ed.

You told me I looked chubby in my pink flowered overalls and made me go on a diet. You put me on the scale only to make me feel ashamed of the number and tell me I was fat. When I finally lost a few pounds, you made me feel a temporary sense of relief. I was seven.

You made me swing for hours in hopes of fitting into a smaller clothing size. You showed me an “8 minute abs” video only to disappoint me when I looked at my reflection 8 minutes later. It didn't change, and neither did you. I was eight.

You made me suck in to feign a hollow stomach at dance class and gymnastics practice, since you had convinced me I was not thin enough to excel at either. I was nine.

You told me I looked pregnant with a face much too round and made me cry at my own reflection. I was ten.

You made me feel embarrassed to eat in front of others. I was eleven.

You told me my hips looked way too wide in my cheer uniform. I was twelve.

You began to steal my lunch and make me starve, finding more flaws in my reflection. I was thirteen.

You convinced me that it was best to exercise and not eat anything at all, leaving me sick, pale, withdrawn, and absolutely consumed by your demands.  I was fourteen.

When I tried to fight back, you left me feeling hopeless, inferior, and never good enough. I was fifteen.

You tried to convince me I could not live without you, and would tease me by leading me into a vicious cycle of letting me eat one week, and starving me the next. I was sixteen.

You told me it was okay to eat, as long as I stared at your face in the white porcelain bowl after. But, you said, my feeble efforts were still not good enough. I was seventeen.

You assured me that I was far too large for my prom dress and my dance performance costumes, and slowly but surely lured me back into your endless demands. I was eighteen.

When I lived in abroad, you forbade me from ever indulging in the famous cuisine. Even the scent of food in the winding streets caused you make me feel guilty, only to send me running into the rainy night. I was nineteen.

You starved me for months upon months, sucking the life out of me one meal at a time. You sent me running in the snow and ice, regardless of injury or sickness. You locked me up in my room and never let me go out with my friends, leaving me with four walls and a scale. I was twenty.

You made my best friends worry and my family cry. You ripped my hair out, wiped the color out of my face, and cut my heart rate in half, dragging me out to the middle of nowhere and leaving me for death. You made me fear food and crave exercise. You controlled my every waking moment, turning me into a miserable shell of my former self. I am twenty-one, and I want myself back.

You tainted my childhood innocence, corrupted my teenage years, and kept me from leading a “normal” college life. You robbed me of my natural enthusiasm and joie de vivre. When I look into the mirror, it’s not myself I see anymore. It’s you, Ed. You’ve permeated my whole being and left me with no concept of self. It is because of you that I base my entire self-worth on my reflection and the number on the scale. It was because of you that I feared to sleep alone, afraid that my heart would stop in my sleep. It was because of you that I had to forfeit a dream internship for a summer spent in treatment. But, I am not giving up without a fight. I want to feel the true love in my life that surrounds me, not just the omnipotent allure of your filthy, deceitful presence and empty promises. I have dreams to reach and hopes of children to raise. I have people to meet, family to love, lessons to learn, and memories to form. I have lazy mornings to be spent content beneath crispy white sheets, cookies to bake, and champagne to drink in celebration of my emancipation from you, calories included. I want to have my wedding cake and eat it, too. I want to learn to love and accept myself for the unique and productive vessel that I am, instead of destroying the only body I have which was created to be much more than an ornament. I want something more substantial in life to hold onto than the once sharp handles that were my hip bones. I want to live. I have too much to live for, whereas the only thing I can attain while embracing you is another statistic, another victim, another stone slab atop hollow ground that reads, And here lies a girl who wanted to be thin.

If you have questions or comments about this post, please email blog@eatingdisorderscleveland.org.

By Sarah Emerman, Joanna Hardis, and Dr. Mark Warren

Making the decision to bring your child in for an assessment can be a difficult and trying process. Your child may be resistant to coming and/or may try to convince you that they can decrease behaviors without help. The truth of the matter is that it is very rare for a child to make the decision to get treatment on their own. Because adolescence is the period of time where brain and bone development take place, avoiding or putting off getting treatment can be detrimental to your child’s health. When you come for an assessment at CCED, our goal is to make your family feel supported, and insure that you have a plan on how to best get treatment for your child.

Adolescent assessments last approximately two hours. Similar to adult assessments, we ask that you bring the paperwork mailed to you and come twenty minutes early to fill out additional measures. We recommend you make a list of questions and read as much as possible about Maudsley Family Therapy prior to your assessment so that the clinician can address your questions and concerns.

Within the first forty-five minutes of your child’s assessment, our clinician will speak with your child privately to gain insight into their perception of the illness. Since the assessment is a diagnostic procedure and not individual therapy, we will tell you what your child says. Our assessment clinician makes your child aware that what they say is not confidential. The clinician will then meet with you privately to get a sense of the parents’ concerns, perceptions, and observations. In addition, the clinician will provide psychoeducation about eating disorders and Maudsley Family Based Therapy. At the end of the assessment the clinician will make treatment recommendations regarding level of care and the next steps to be taken.

The treatment recommendation will be based on the support needed by the family, family history, the sense of urgency, current behaviors, issues from nutritional insufficiency, and medical risks and recommendations. The ultimate goal of an adolescent assessment is that the family leaves feeling comfortable that there are options for a plan that will serve the needs of the family and, most importantly, guides your child on a path to recovery and health.

For more information on Maudsley Family Therapy, we recommend FEAST, Maudsley Parents , and Dr. Sarah Ravin’s blog.

If you are interested in setting up an assessment for your child, please contact (216) 765-0500.

By Sarah Emerman, Joanna Hardis, and Dr. Mark Warren

When you first come in for your ninety minute assessment you will be asked to bring the paper work that was emailed to you after your intake. In addition, we ask that clients come thirty minutes early to fill out standardized measures regarding your eating disorder behaviors and mood. To give a context and history to the measures, your clinician will ask questions to understand how your illness started, how it's evolved, what's worked and hasn't in terms of treatment and what you'd like to work on. It is often recommended that you bring someone you trust to your assessment, so that they may support you during the process and help you gather and retain information. You and the clinician will discuss your reason for seeking treatment, your family and social history, and how the eating disorder has impacted your life. She will ask specific information about your behaviors, and the frequency of your symptoms in order to get a sense of the eating disorder. The clinician will also provide psychoeducation about eating disorders and the evidence based treatment available at CCED. 

The assessment will usually conclude with the clinician taking your height and weight, followed by a conversation about what the best and most appropriate care would be for you. Our responsibility is to make two things clear: what we think is best and what is possible given your goals and real life situation. If we agree on a plan, we will move forward with that plan. If we do not come to an agreement, we will enter a period we refer to as motivation and commitment, where we try to ascertain as clearly as possible what you want, what that means for your health and well being, and how to get it.  In some situations we will recommend in house treatment and in other cases we may decide together that the best option for you is elsewhere. If we feel this is best, we will assist you in finding that care.  

The assessment is not only an opportunity for us to get to know you, but also for you to get to know CCED. Goodness of fit is a vital part of treatment and we strive to make sure that clients leave the assessment knowing what we’re about and why we do what we do. Our hope is that we have an appropriate program for you. We want to give you the opportunity to see what is available at CCED and decide what your best plan for achieving your goals will be.  

Should you have any questions or would like to set up an assessment please contact (216) 765-0500.

By, Sarah Emerman, Joanna Hardis, and Dr. Mark Warren

Over the next few weeks we will be blogging a series about what to expect at CCED. This series will answer many of the common questions about how one decides to get eating disorder treatment, accesses that treatment and what the treatment will involve. We will also attempt to walk though the typical experience at CCED to explain why we do what we do. 

If you have any questions that you would like answered in this series or questions about what we’ve written please email blog@eatingdisorderscleveland.org. 

The first step in getting treatment at CCED is the intake call. When you call CCED you will likely speak to an administrative support person who will transfer you to one of our intake clinicians. Our clinician will ask you for basic information, such as your name, age, insurance carrier, and how you heard about us. You will then be asked to give an overview of your reason for calling, what the current symptoms and behaviors are, frequency of behaviors, and current height and weight. We may also ask questions related to your medical stability in order to determine if an assessment would be appropriate. 

If you are an adult calling in regards to yourself the intake clinician will provide you with an overview of the types of services we offer and give you information about the assessment, including the fee and what the assessment entails, as well as insurance information, and the levels of care offered. The clinician will then schedule you an assessment and email you a pre-assessment packet to fill out prior to your appointment. 

If you are an adult calling about your child, the clinician will give you some background information on Maudsley Family Therapy, which is the type of therapy provided to families at our center, as well as the programs we offer, levels of care, family and individual therapy, insurance, and what happens at the assessment. The clinician will then send you a pre-assessment mailer to fill out prior to your child’s assessment. The clinician will also ask that you obtain your child’s growth charts prior to the appointment. If you are a parent calling about a child who is 18 years or older the intake clinician will be happy to take clinical information, however the client must call back to give permission to schedule the assessment. 

While it is important for us to gather background information during the intake call, much of the call will serve to provide you with information about evidence-based care and answer any questions or concerns you may have about treatment and treatment options. Since the intake call will most often be the first point of contact with CCED, we want to do our best to help you get from the place of thinking about what to do to actually making that very hard step of moving towards the life you want. This moment is often a complex one, as eating disorders have a way of holding us in place, even when we want to move forward. During the intake call we want to answer whatever questions you may have about what we do, why we do it, how CCED works, and why it will make sense to take the steps you need to fully realize who you want to be by moving towards recovery. While this may be an anxiety provoking, or even frightening moment, it is also a time of great excitement and hope. Our intake coordinator will do her best to answer any questions you may have and to provide reassurance and understanding that there is effective and accessible treatment available. 

If you are interested in our services, or would like to know more about our programs, please call (216) 765-0500 to speak with our intake clinician.   

One of the best known and most feared complications of eating disorders is osteoporosis. Osteoporosis is a disease in which there is loss of bone mass, often throughout the body, and a significant increased risk of fracture and pain. Osteoporosis is a diagnosis made through bone scans, particularly a DEXA scan. A score of -2.5 or greater on a DEXA scan is considered to be osteoporosis. A score of -1 to -2.5 is defined as osteopenia. Anyone with osteopenia is at great risk of developing osteoporosis. Statistically, 40% of patients with anorexia will have osteoporosis and as high as 90% will have osteopenia. 

Osteoporosis results most often from nutritional insufficiency, caused by a depletion of necessary nutritional elements. Changes to the body’s composition, as well as endocrine changes, also contribute to osteoporosis. In addition, the low energy state of the body and the energy imbalance created by restriction increases bone loss. There are many other hormonal changes implicated in osteoporosis. The most specific risk of osteoporosis is the chance of fracture, particularly bone fracture of the vertebra, hips, and long bones. When exercise is present, the stress of the exercise with osteoporosis also increases fracture risk. This is one of the many reasons that patients with anorexia should not engage in stressful exercise. 

While hormone replacement therapy may be an effective treatment for osteoporosis that is not caused by an eating disorder, medications designed to treat osteoporosis for post menopausal women are likely less effective in patients with anorexia. In addition, medications designed for post-menopausal women should not be used in women of a childbearing age, as we do not know much about their long-term safety. Unfortunately, because osteoporosis that results from anorexia often occurs at a young age, often during bone formation, it my be more serious then bone loss at a later age. 

The upshot of all of this it two-fold: 1. The best way to manage osteoporosis is not to get it in the first place. Osteopenia is often reversible while osteoporosis may not be. 2. The best treatment for existing osteoporosis is refeeding and weight restoration. In practical terms, early recognition, early diagnosis, and aggressive treatment of the underlying eating disorder at the earliest possible moment is by far the most effective way to manage osteoporosis. As we have stated many times before, therapy that focuses on anything but refeeding has a significant chance of leading to harm rather than improvement. If you have any concerns that you might have osteoporosis, have your physician refer you immediately for a bone scan.

Contributions by Sarah Emerman

Some of the most common medical complications of eating disorders are those related to the heart. Cardiac complications from anorexia nervosa, along with suicide, are the leading causes of death from this diagnosis. Cardiac complications are often present with bulimia nervosa as well, and can also be fatal. Cardiac complications from anorexia are sometimes predictable, but often not. The predictability can arise because symptoms such as slow heart rate, (bradycardyia), and significant changes in blood pressure and pulse between laying and standing (orthostasis) may be present. Both of these symptoms may predict future cardiac risks and dangers. However, the main danger to the heart is electrolyte imbalance in the face of a weakened heart. This, combined with the loss of heart mass, can occur before all the weight loss has occurred. Therefore, it is not just the extremely underweight who are at risk.

In people with anorexia, cardiac changes that appear on an electrocardiogram may also occur. This particular change, called a prolonged QT interval, is also a predictor of fatality for a patient with anorexia. In general, individuals with prolonged QT intervals will require hospitalization. The only way to know if a QT interval is prolonged is by obtaining an electrocardiogram, which should be a routine recommendation in the assessment of an eating disorder.

For patients with bulimia, death from cardiac issues is usually due to changes in their electrolytes, particularly changes in potassium, magnesium, and phosphorus. Because these changes are impacted by purging behaviors, death from bulimia is often sudden and unpredictable. Patients who use ipecac to induce vomiting increase their risk for death from cardiac issues by a different mechanism. Ipecac is toxic to the heart and essentially poisons the cardiac muscle, which can result in death.

Common symptoms someone might experience if they are at risk for cardiac abnormalities include: tiredness, lightheadedness, fainting, heart palpitations, chest pain, shortness of breath, and reduced tolerance to exercise. Anyone with these changes should have an assessment immediately. Although dangerous, cardiac changes can be treated, and the treatment for them is straightforward. They all involve bed rest, stopping all behaviors, and in some cases, hospitalization. If cardiac complications are present, treatment for the eating disorder is an absolute immediate necessity and will usually include refeeding and the establishment of a safe and healthy meal plan. The body is wise enough to repair the heart as soon as it has a chance and the resolution of cardiac complications is an early sign of improvement in the healing of an eating disorder.

A special thank you to our consultant for this post, Dr. Ellen Rome from The Cleveland Clinic Foundation.

Contributions by Sarah Emerman

This letter was written by a client in one of our programs. It is published with her permission in hopes that it will inspire others to seek help and get treatment.

Dear ED,

You’ve hurt me time after time, breaking my heart while convincing me that you were all I needed. You lied to me and convinced me to lie to my parents, friends, doctors and therapists. You’ve told me that I was succeeding, when really all I accomplished was sabotaging myself and my own life.

You crept into my life. Two years ago, you told me to start eating salads for lunch to be healthy and lose a few pounds to be in better shape. I did, eagerly. I lost weight and continued to “eat healthily” but it wasn’t enough for you, it never was.

ED, you ruined my relationship with food. When I was younger, my mom used to brag that I’d eat anything and it was true. You changed that, causing me to feel anxious about certain foods and dictating rules about which foods were “good” and “bad” and how often I could eat them. You convinced me to punish myself when I broke your rules, and you even forbade me from eating my favorite fruit. You made me forget how to eat normally.

You stole my passion and dedication for the sports I played and replaced it with your definition of exercise: mandatory but not fun. You persuaded me that it was ok to not eat before or after practices and that I didn’t need to eat an adequate amount of food in order to achieve my goals. You were wrong. Because of you, I never met those goals and never will be able to. Instead of enjoying time with my friends on a team, you made me exercise alone. And even though I felt dizzy and my chest hurt you wouldn’t let stop.

But of course, you couldn’t stop with food and exercise. You are so greedy that you hurt my body, too. You made my hair fall out and caused my skin to appear pale. You made my brain fuzzy so that I couldn’t concentrate but worst of all, you damaged my heart. You are the reason I spent two miserable weeks in the hospital and you caused my body’s demise.

You not only abused my body, but also changed my personality. You depleted me of my natural enthusiasm and optimism and caused me to isolate myself from my family and friends. You made me forfeit birthday parties, girls nights out, and even chance to travel because you didn’t want to me to eat certain foods and you told me I needed to exercise. You took away my sense of humor and instead made me sad and hopeless.

The truth, ED, is that I do NOT believe your lies anymore. I am done with accepting your limits and I refuse to deny myself the right to enjoy foods that I like. I will engage in physical activity without it damaging my body. I want both my body and mind to heal, neither of which you will ever allow me to do. I claim the choice to living a healthy live and I chose to eradicate you from it.

Should you have questions or comments regarding this post please email blog@eatingdisorderscleveland.org.