Does Your Teenager Have an Eating Disorder? Signs and Symptoms You Should Not Ignore

scaleThey came to their visit together. Jessica (not her real name) did not want t be there. I let her stay in the waiting area fixated on her cell phone (she made up her mind she hated me, at least that is what her facial expression conveyed). Instead, I took her mother into my individual counseling room to get the story before I met with Jessica. It was one I have heard before. In fact, the entire scenario became predictable. Mom was all over the place, at first angry that her teenager was being so rebellious, she was driving them all crazy. She refused to go anywhere with the family, she hid out in her room, refusing to sit at the family dinner table. Vacations were a night mare. “She used to be such a sweet girl, so happy and care free, she LOVED helping me in the kitchen and really enjoyed going out for pizza with the family, but now she is like someone else. We don’t know what to do”. Next, after the anger, comes the crying. “She looks horrible. She passed out the other day and it was so scary. Yet, she won’t stop this. It does not make sense!”Jessica took to wearing very loose and baggy clothes, and it wasn’t until her mother walked in on her changing that she noticed her protruding ribs and the obvious weight loss. After lots of threatening, Jessica agreed to go to her pediatrician’s and was then referred to us. How did it get to this point, and how did this family miss it?

Eating disorders can happen at anytime, but transitions are especially tough. Back to school, back to college, back to normal life. Simple, predictable, or is it? Not for everyone. Times of transition and change, such as starting a new school, going away to college, new teachers, different friends, all of it can be a challenge for some kids. Times like these can be risky when it comes to falling into the grip of an eating disorder. Couple that with society’s obsession with losing weight and it is pretty easy to understand why lots of eating disorders often go unnoticed until it is almost too late. As a parent, what signs or symptoms should you look for? Some things that you should not ignore:

  • Weight loss. Sounds obvious, but actually, especially in teenagers who are larger or fatter, parents mistakenly tend too think the weight loss is a “good” thing. Even doctors make the mistake of automatically praising weight loss, especially if it brings a child closer to a “healthy” BMI (gag).  That meaningless number does it again…….clouds the judgement of otherwise smart and well-meaning people (parents and professionals alike). The great news is the American Academy of Pediatrics came out with a new report in August highlighting the risk of treating obesity in adolescents with disordered eating as well as the importance of focusing on health verses weight. See this article in American Academy of Pediatrics for the specifics. The bottom line is that we need to get off the losing weight bandwagon, fight the cultural message that everyone needs to be thin, or a certain BMI, and NEVER EVER praise weight loss in a teenager. Yes, there are times when a kid may lose weight. A teenager who is very sedentary who goes away to college and finds themselves having to walk 9 miles a day just to get to all their classes may indeed lose some weight. This is not what I am talking about. But even then, making a big deal about weight loss is never good. Even this kid, if they get lots of attention for losing weight may decide they like the attention, and start doing things to purposefully lose weight (I have seen this happen many times). Don’t do it. Don’t compliment weight loss in a kid. Instead, compliment growing up and being successful.
  • Food refusal. When your teenager has always loved your home-made macaroni and cheese, and even begged you to make it, but now refuses to eat it, NOT GOOD. Unless there is a really good reason for refusing a favorite (recent stomach bug, stomach ache, cramps, etc) don’t ignore this red flag. Should you try to force your kid to eat it, or pressure them to answer you as to why they don’t want it? Like I said, one refusal because they don’t feel good is normal, but a few times in a row is just not normal, however responding with anger is not helpful. Instead, I have found those parents who are able to open up a caring dialogue with their teen have a better chance at getting to the bottom of it. It is important to pay attention to all signs and symptoms so you can then make a plan to address it. Forcing food or anger does not help.
  • Decreased socialization. For a teenager with an eating disorder, any situation that involves food and eating is threatening. You will start to notice they don’t want to go to their friends houses, or to birthday parties, and they especially will try to get out of family functions (those typically aren’t a teen favorite anyway, but they are doubly horrifying because of the food involved). They may lose interest in going to what once was a favorite restaurant and a big treat. They will refuse to eat the family’s favorite pizza on “pizza night”. Red Flag.
  • Loss of menstrual period. Not that you need to keep track of your teenage daughter’s cycle, but if you notice she does not ask you to buy feminine hygiene products the way she usually does, ask. Don’t ignore it as this can be a sign of weight loss and inadequate calorie intake.
  • Obsession with exercise. If you notice your teen going out for long runs, or running both morning and night, or if you notice the bedroom door is always closed and when you walk in she just so happens to be exercising, this could be a sign that something is not right. Yes, being active is good for all of us, but if doing calisthenics is something new and different, and especially if your teenager seems to be hiding it, then this is also a red flag.
  • Going to use the bathroom after every meal. If this has always been normal for your child that is one thing, but if it is a new behavior, it could mean they are purging or throwing up their food. You can check the bathroom for evidenced or you may hear it, but don’t ignore this. Vomiting on a regular basis is an eating disorder behavior and could leads to electrolyte imbalances that can be deadly.
  • Body checking. Do you notice your teenager looking at her body, especially her stomach obsessively? Does she tend to squeeze her arms as if to check for fat? This is a common behavior for people with body image issues and should not be ignored, especially if other signs are present.
  • Obsession with food labels, writing food in a journal, or counting calories. I can’t tell you how many food journals complete with calorie counts I have seen in my life. It is NOT normal. It is NOT a good thing. Yes, there are apps and websites and even the My Plate site has trackers for this. I hate them.This is as far away as normal, intuitive eating as you can get.

So what should you do if you notice any of these symptoms? Remember, your teenager is not doing this on purpose. They can’t stop. It is a very complicated disease and the triggers and causes are different for each person. It is important to be empathetic, kind and loving and to avoid blaming as this will not help. The first step might be to call your pediatrician and share your concerns. They will probably want to see and evaluate your child and may recommend therapy and a visit to a dietitian. Be sure that both specialize in treating eating disorders. Your teenager probably won’t be happy, but you can also get support from the therapist as far as how to handle resistance. The sooner you address the issue, the better chances for recovery. Remember, it does not matter what size your kid is, if they are fat or thin. It is very easy to ignore some of these red flags, like I said, some are so socially acceptable and desirable that it is sometimes hard to see what is going on. Don’t ignore these signs. They won’t go away on their own, and the longer you put off getting help the harder it will be.

There is hope. You can get your old teenager back.But you gotta move fast.

For more information and for great resources, check out the website: Eating Disorders Awareness and Prevention.

Should You Put Your Teenager on a Diet?

stock-photo-74105099-unhappy-teenage-girl-sitting-on-floor-looking-at-bathroom-scalesI still remember that day I was sitting around a long conference table in the Endocrinology department at the children’s hospital where I was just hired to help develop a weight management program for teens and children. There were several nurses, a few endocrinologists, myself, another dietitian and my manager. They had decided the children would keep food logs as well as track their calories. I was so glad I was there to enlighten them about that! I explained that counting calories was a very bad idea as this would not only lead to more focus on food, they would likely gain weight, not lose, and even worse could develop an eating disorder. I explained that even the thousands of adults I had worked with over the past 2 decades were never successful with counting calories, and the only ones who were good at it had eating disorders. Phew, now we can move on (I thought).

No luck. They basically ignored all I said, and my manager was fuming. I was flabbergasted.  So the other dietitian and I decided we would gather the research articles refuting this approach, and share it at the next meeting. We did just that but again, no luck. Although I was floored, I had faith they would learn their lesson when it all unfolded.

I was right. When it came time to teach the classes (parents would come as well as the child and siblings if they wanted), the first step was to share their notebooks. These were also brought to individual sessions with the nurses and dietitians. Lo and behold, almost none of the participants did it! Or if they did they were so obviously inaccurate, it was almost funny. Guess what? It took at least 2 years if my memory is correct but eventually they eliminated the calorie counting (Thank God!). The great news is they eventually hired a full time psychologist who had lots of experience with eating disorders and weight issues, and who went on to change the entire program to be more evidenced-based, and focus on health (and not dieting).

Anyway, I picked this topic to write about this week after getting my monthly newsletter from the weight management “practice group” I belong to in the Academy of Nutrition and Dietetics (AND). It included an article entitled “Alternatives to Calorie Counting: Consideration for Pediatric Weight Management”. The article mentioned the AND Position Paper’s recommendations that “treatment plans for managing pediatric overweight should emphasize multi-component, family based programs, which combine nutrition education, physical activity, and behavioral strategies….alternative approaches to calorie counting should be implemented for this population as a means of self-monitoring nutrition decisions”. The article summarized exactly what these “alternative approaches” were.

The author (Giselle Willeford, MS, RDN) does a great job of summarizing the research describing the detrimental affects of having kids or teens count calories (increased focus on food and eating, increased risk of eating disorders or further weight gain). Here is a brief summary of the “alternative to calorie counting” that were described:

  1. Traffic Light Approach: this method (originally developed by Leonard H. Epstein) calls for dividing foods into 3 categories, Red, Yellow and Green. Green foods are things like vegetables and fruits that you can help yourself to (low calorie and low fat). Yellow foods are those foods that have more calories and that you need to be careful with portion sizes (chicken, rice, etc) but are still healthy. Red foods include sweets, fried foods etc. that you should try to limit and/or decrease in your diet. I am NOT A FAN of the “Stoplight Diet”. Although it sounds simple enough, I have seen first hand the damage it can do. I have had several very young children (age 8, 9) that took this diet to heart. They were those really “good” students who got all A’s and did not want to disappoint their teachers, so when they got the message that red foods should be decreased, they stopped eating them altogether. The patients I saw lost weight when they should have gained, stopped gaining in height, with great repercussions to their family relationships (“she won’t come out for pizza with us anymore”, or “he only will eat the “green” foods so we can’t go out to eat anymore, it is driving us crazy!”  These children were on the verge of developing serious eating disorders and actually were at risk for stunting their growth if they kept it up. The good news if I have been successful with helping these kids because they just needed to hear another authority figure (“The Dietitian”) tell them all the reasons it was ok to drink milk and eat cheese and even pizza again. My recommendations: skip the traffic light approach. Traffic lights are for cars.
  2. Plate Visuals: this is an easy tool to use for those who can’t read or write, so it makes sense to use it with children and teens. You might be familiar with the colorful diagram, and if not see the website: My Plate The visual shows half of the plate with “colors” and this means half your plate should be fruits and vegetables. A quarter of the plate is for “meats” or protein food and a quarter of the plate is for “grains”. The dairy is on the side and that is your serving of milk. There are some things I really like about “My Plate” for education. It is simple and the message is about adding in and not as much focused on taking away. I have used to demonstrate how much fruits and vegetables we need if we want to be healthy. The downside is that some kids, especially picky eating teenagers, really struggle with vegetables because they don’t like the texture or the taste, and so through most of their life refused them. Parents in turn, sometimes just stop making them with the unfortunate outcome being nobody in the family has been exposed over time to vegetables and so nobody eats them. When you show a teen that plate, they tend to feel bad, and like a failure because there is no way they are going to get to that amount of colors on their plate (unless you count brown or yellow, you know, french fries, macaroni and cheese, Doritos). I don’t like making teenagers or even adults feel guilty, so instead we work on increasing exposure and sometimes start with more fruits. Check out the website for more information.
  3.  Portion Sizes: this method uses your own hand to estimate portion sizes. So a “fist” might be a serving of rice. I am not especially irritated by this method, however what if you want 2 fists of rice? I guess the awareness that you are having 2 servings is ok, but then again, will it trigger guilt and overeating? This method traditionally has been used with diabetics, who really do need to follow a special diet with balanced amounts of carbohydrates, so for these folks, it could be very helpful.
  4. Hunger and Satiety Cues: this of course, being the “non-diet” approach for kids and teens, is my favorite! It teaches strategies to help individuals pay attention to their body signals. For younger children, it is called the “Trust Model” promoted by Ellyn Satter (see Ellyn Satter Institute for specifics). This model describes the “Division of Responsibility” with a focus on the parent’s role of buying healthy foods, determining structured meal times, not catering to kids but allowing them to eat as much or as little as they want at a meal. This teaches children to trust their hunger and fullness mechanisms and promotes a healthier relationship with food and eating. With teens, it becomes tricky because sometimes, after over 10 years of being restricted by parents, an abnormal focus on food (such as sneaking food) has developed (survival!). It may require some counseling for some teens who have a significant “disconnect” between their hunger and fullness related to parental restriction. If your teenager sneaks food or binge eats, or restricts and alternates with binge eating, don’t ignore it. Get help by a therapist who specializes in eating issues.

So the answer is: NO do not ask your teenager to count calories. If they are using some app on their phone to track their food intake, pay attention. Instead, work together to find healthy recipes and meals, go grocery shopping to pick fruits and vegetables your children will eat, have taste tests with new ones. Shut off that TV during meals, sit at the table, don’t allow kids to nibble all day, and instead plan for snacks where kids sit down and enjoy it (not in their rooms, nibbling for hours in front of a computer…..who is going to want to try squash when dinner time rolls around?). Consult with a dietitian regarding strategies to make your environment healthier as well as ideas for healthy but yummy meals. But don’t focus on calories or dieting in your home. Instead, focus on EVERYONE being as healthy as they can be. Enjoy eating out, ordering pizza once in awhile, going out for an ice cream cone. Set an example by living the kind of life you want your child or teenager to live. Remember, kids do as you do, not what you say. If you count calories and diet, your teenager will too. If it hasn’t worked for you, it won’t work for them.

Should you count calories?

calorie labelI was a little concerned when restaurants started to post the calorie content of menu items. I have to admit, I am a bit torn between the importance of educating people about nutrition and my mission to prevent disordered eating and promote a healthy relationship to food. My friends and family often argue with me when I say “listen to your body”. My husband says “my body told me to eat the whole thing!”.

What my husband is referring to is most likely the “trigger” that yummy food is to most of us (and not true hunger, something not very easy to tune in to for many). We are all different in the way we respond to food and eating, and not everyone is able to “listen to your body” because they have a unique eating, weight, dieting, genetic history that no one can understand except themselves. So what does counting calories have to do with anything? Why would I have any concerns with labeling calories on menu items? Should you count calories to have a healthy weight?

My answer: The Top 5 Reasons you should not count calories:

1. It is hard enough to work on the task of paying attention to your hunger and fullness, so when you attach a number to a meal or snack, you are almost guaranteed to become “disconnected” to your true body signals. Imagine you have determined you need a certain amount of calories for the day, and by evening you feel full after your last meal and do not want that pm snack you are supposed to have. Should you force yourself to eat it? or what if the opposite happens and after your dinner with the specified calories, you are still hungry? Do you forbid yourself a snack and think about food all night long? What if you made a mistake, which leads me to reason number 2.

2. You will not be accurate! The calories posted on many packages and menus may not be accurate! Check out this interesting video about a small experiment in NYC regarding this topic. WARNING: this video only looked at a few foods and most had more calories than stated on the package or menu. The reverse is also likely, where menu items have less than stated. The message is, nobody is held responsible for accuracy! If you are obsessive already about eating and calories, this video may be triggering and you should skip it.

3. It encourages obsessive thinking about food which can backfire. When you use “cognitive restraint” such as counting calories, you become MORE focused on food, not less. Research shows that people who are overly restrictive tend to be more likely to binge eat. Even worse, this behavior is more likely to lead to disordered eating patterns.

4. Counting Calories does not translate into healthy eating.  As I said earlier, although I believe in “listening to your body” I also believe it is good to want to be healthy. That may mean learning about nutrition, healthy cooking, what your body needs to feel good, etc. If you only look at calories, you are missing the boat.

And Finally,

5. Counting Calories is not fun and really interferes with your social life! Not only is it harder to go out to eat once in awhile with friends, even family celebrations become a chore instead of something that should be enjoyed as one of the most wonderful parts of life. Not only that, people who are restrained eaters (such as calorie counters) tend to be more depressed.

So the bottom line is: it is ok to educate yourself about nutrition, but calorie counting is not a great thing. You can’t avoid seeing the calorie count on the menus, and if you get indigestion every time you get that certain giant burger, well, seeing the calories may help you understand why….but your tummy will tell you that, you really didn’t need to know the number after all : )

Warm Weather Dieting Woes


IMG_4090Happy Spring!!

Have  you ever noticed how the start of warmer weather gets people focused on dieting? I have been biting my tongue at work these past few weeks as it seems so many people are talking about the crazy eating plans they are starting. The new buzz seems to be a one or two food diet that is supposed to magically “cleanse” your system in a few weeks (a “kick start” as some people refer to it). I usually keep my mouth shut unless someone notices the dietitian sitting at the computer and dares to ask “what do YOU think?”

I love it.

Today I got asked the question, and I gave my answer. The research has connected dieting (any kind of cognitive restraint where you tune out your body signals) with binge eating. And weight GAIN in the long run. Yes, any trick to make you eat a lot less will of course result in weight loss (that good old “kick start” that is supposed to motivate you). Unfortunately, that short term weight loss ends up frustrating people rather than motivating them. They of course can’t keep up that rate of weight loss (and if they did, the loss would be valuable muscle). They end up feeling bad and usually just go back to their old ways.

Instead, what I shared with my coworkers was that it is smarter to take a non-judgmental look at your lifestyle and eating habits. Do you often eat when not hungry just because food is there? Do you have the habit of watching too much TV or sitting in front of a screen for hours on end? Instead, work on listening to your body. If you are hungry for a snack, and you want a cookie, eat a cookie. It is the non-hunger eating that goes against your body’s needs. Sometimes it is our sedentary lifestyles that prevent us from feeling better about our bodies.

I’ve said it before, and I will say it again! Work on being healthier in every way and forget about dieting!!!! In the long run you just might end up being happier AND healthier.

Does 3500 calories equal a pound?

why 3500 calories is not a poundFor all the years that people have been dieting, especially those who count calories, they have followed the golden rule: cut 500 calories a day out of your diet and you will lose a pound a week. That is because 3500 calories is equivalent to one pound of adipose tissue (body fat).

While this is true, it does not follow that if you decrease your intake by that amount of calories over time that you will lose a pound. New research now proves this to be true!  The way your body responds to a calorie deficit is dependent on baseline body composition, age, height, gender, and degree of caloric restriction. The result is a curvilinear pattern of weight loss over time rather than the linear pattern predicted by the 3500 kcal rule.

In other words, no two people are alike. Some have more muscle mass than others, and even at rest, muscle uses more energy (so muscular people, even at the same weight will need more calories). Also, quick weight loss typically results in loss of muscle mass, which then results in your body needing less calories. Finally, your body adjusts to a lower body weight once you do lose weight, so your energy needs change.

If your weight has creeped up higher than your normal weight, instead reflect on any lifestyle changes or eating habit changes that may have occurred over the years. Did you change jobs from a very active one to a sedentary one? Did you start a job at a restaurant where you now get food for free (and so you take it, even when you are not hungry)? Are you going back to school and no longer have time to cook, so eating fast food every day instead? If you focus on ways to shift into a healthier lifestyle, your body will know what weight it wants to be! So stop counting, and start living!