Teens and Eating Disorders: 5 Mistakes To Avoid if You Are a Parent

cropped-img_1418.jpgI will call her Jessica. She was one tough cookie, starting from the day her mom brought her in for her first visit with the dietitian. She was 16 years old and referred by her pediatrician for weight loss and a possible eating disorder. I could tell from Jessica’s demeanor and angry face that she would rather be having her toenails pulled out than be here. I met with mom first (I have learned that having both parent and teenager in together almost always turned my otherwise very pleasant counseling room into a war zone). Anyway, Jessica’s mom filled me in on the fact that her daughter did not want to come today. Mom wanted to prepare me for a very bad visit. I let her tell the story of why she was there, and just as with many parents I have seen, the feelings  transitioned from anger to sadness and eventually tears. A newly diagnosed eating disordered teenager is ….well…..so difficult for me to even put into words, because I just can’t imagine how painful it is to watch your son or daughter fading before your eyes. I also know it is scary  for a teenager when they are being taken over by this deadly disease. So when a parent finds out their teenage child has an issue with their eating, what they do can be critical.

With today being the very last day of February, Eating Disorder’s Awareness Month, I thought it might be helpful to share my experiences with the intent to help parents understand just a little bit about what is happening when their teenager seems to be falling into the grip of disordered eating. Let me make it clear that from my experience, every single parent I have ever met who has brought their teen to come see me for help are always caring parents who love their children and only want the best for them. But most of them don’t understand what is going on, and their reactions to their teenagers behavior are often not helpful.

So here are just 5 things I wanted to bring to the attention of any parent who may have to struggle through this with their teenager:

  1. Do not ignore weight loss.

You know how it is when you see someone everyday….sometimes small changes go unnoticed. Sometimes, when teenagers are wearing baggie clothing (which is very common in people with body image concerns) we just don’t realize a significant weight loss has occurred. And sometimes, if a teen is a bit on the larger size, she may get attention for losing weight. Parents sometimes feel happy and proud when weight is lost. They don’t want their daughter to be overweight, the importance of avoiding obesity is all over the media, why wouldn’t they be happy? The problem is (and I see this all the time, when people don’t stop to think) sometimes weight is lost in a way that is not healthy at all, and even dangerous. Sometimes kids skip meals, teenagers stop menstruating (a huge red flag) or even may suffer from dizzy spells and fainting. Parents need to investigate when a teen loses weight, not condone it, not praise it, but find out why. If someone cuts out soda, or takes up a healthy sport and is enjoying life, still eating with the family and eating normally, then there may be no issue at all (but PLEASE don’t give too much attention to the weight loss, instead support the healthy lifestyle as that is a good thing, and has nothing to do with weight). Be sure to take your teenager for regular doctor’s visits and ask to see the growth chart. Ask your doctor to explain it, and if your teen is falling off the growth chart, or not gaining weight, find out why. If your daughter stops having a period, or starts skipping periods, tell the doctor. But do not ever ignore weight loss in a teenager.

2. Do not make the dinner table a war zone.

If your teenager used to love your mashed potatoes and now does not want them, don’t make an issue out of it (at first). But if you notice they no longer want other foods they used to love, and insist on only grilled chicken and salad, don’t ignore it, however don’t start pressuring them at the table. The dinner table needs to be a happy place for everyone in the family. Plus, it will not work, and will most likely cause your teenager to avoid the dinner table altogether. Instead, seek out the help of a professional. Tell your pediatrician about the sudden food refusal and ask for some references for therapists who deal with eating disorders. Tell your teenager that you are worried about her eating and that she does not eat the way she used to. I explain it as an “assessment” so that is sounds less threatening. It is just to be sure everything is ok. Or, you can start with a dietitian to be sure your teenager is getting what she needs nutritionally. Sometimes, kids go through phases when they want to eat healthy, or experiment with vegetarianism, etc. and they just need a professional (and not their mother) to explain why it is ok to eat pizza or potatoes, or ice cream, or whatever because it all contributes nutrition. I have had many teens show a sign of relief that someone who “knows” gave them permission to eat ice cream again! They happily go back to mom’s potatoes. But if they don’t, typically the dietitian can also help along with the pediatrician in finding a therapist who has expertise in eating disorders.

3. Do not ignore your instincts.

Besides refusing foods they used to like, are you getting a feeling that something is just not right? Do you catch your teenager in telling little “fibs”that may not seem significant, but make you think something is up? For instance, your son says he is going to eat with his friends at the pizza joint after school, yet when you see his friends later that week, you hear them ask where he was….is he finagling his way out of meals? Or, has your daughter started a new routine, where for some reason, after eating she always has to run to the bathroom? Could she be vomiting after meals? Or have you caught your teen checking out their tummy in the mirror? Of course this can be totally normal, but if it is coupled with other “red-flag” behaviors such as food refusal, and your instincts are telling you something is wrong, don’t ignore it. Ask questions. Let your teenager know you have concerns and are wondering what is up.

4. Do not think your teenager is purposefully trying to drive you crazy.

One of the first things I always say to a parent whose teenager is newly diagnosed with an eating disorder is “they are not doing this on purpose”. Parents get very angry (at first) when their previously happy eat-you-out-of-house-and-home teenager no longer will even sit at the dinner table. Teenage years are not always the easiest as it is (having had 3 of these I can say from experience). The purple hair, the pierced eyebrows, the roller blades, loud music, protesting the rodeo……teenage years are a time of transition, so throwing in body image issues and disordered eating into the mix certainly has the potential to create some explosive scenarios.  But when it comes to an eating disorder, trust me, no one, not even a teenager, wishes the torturing mindset that comes with the disease upon themselves. What has helped me tremendously in understanding what those with eating disorders are going through is the concept of “ED”. ED is what I imagine as a monstrous little creature sitting on your teenager’s shoulder, muttering the most horrible and distorted demands into their heads that they just can’t ignore. “Don’t eat that! It will make you fat!” “Don’t listen to her, she wants to make you fat!” ” You need to skip dinner, you ate lunch, or you will get fat!” “You don’t deserve that, you were bad all week” And on and on and on. All day. Every meal. After every bite. So when your teenager has a fit, and gets mad at you, and yells and swears, just know it is not her or him. They are under the influence of something very powerful and not in their control. Not yet, until they get help. Which brings me to the last point….

5, Do not think you can go it alone.

It really is hard to commit yourself to doing what you need to do to get help. These days, we are all so busy. Both parents work, and there are more single parent households relying on only one income. Teenagers are involved in sports, getting their driving permits, there are proms to go to, it is endless. But, if ED gets control, none of that will matter in the long run because he can get such a grip on a person’s life that it will only get harder and harder to shake him off. Not only health,but lives are at risk.  No matter what it takes, rearranging work time, finding a therapist who has evening hours, getting into a program, the sooner you get help, the better. Check out the National Eating Disorders and Awareness site at NEDA for more information on eating disorders. Your teenager does not have power or control over what is going on with their eating or their body image. But you CAN help your teen by getting them help. Trust your instinct as a parent. If you think something is wrong, you are probably right.

You might wonder why I chose the beautiful photo at the beginning of this post. It is from a kayak trip down the Connecticut River, off the town of Essex. To me it symbolizes what I have learned an eating disorder is to many patients: it is something they turn to in order to deal with something else in their lives. It is a “life preserver” such as those thrown into a river when someone can’t swim.They need to learn to swim before they can let go. But there is so much to look forward to, like the beautiful sunset in the distance. They will get there.

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.