Living With Food: The Science Supporting Eating Disorder Treatment

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.