Walt Kaye, M.D., believes in families

Dr. Kaye, a professor of psychiatry and director of the Eating Disorders Program at University of California-San Diego, is leading a team in one of the largest studies on eating disorders ever done. The study will include seven sites around the world and will compare two kinds of family therapy to explore the question of which kind of family therapy is best for which families.

Note to eating disorders therapists and programs: The question in this study isn't whether families should be part of e.d. recovery. It's how.

Patients will be assigned to one of two treatment types: systemic family therapy, which looks to improve relationships within the family as a means to recovery, and family-based treatment, also known as the Maudsley approach, which empowers the family to help the child recover.

One of the biggest perceived obstacles to Maudsley treatment is the notion that families have to be "perfect" in order to implement it. Well, that and the traditional notion that families cause eating disorders in the first place, and so cannot possibly be part of the solution.

The trouble is, traditional treatments stink. They condemn sufferers to years of semi-starvation, partial recovery, and inevitable relapse. So far, the Maudsley approach is the single most effective treatment for teens, with five-year recovery rates between 80 and 90 percent.

If a better treatment came along, I'd be the first to do the happy dance. What I can't stand is people who shoot down the notion of families being involved in treatment on general principle, or because it's always been done that way, or because they've always done it differently and can't make the leap to a new paradigm.

Children deserve the best treatment out there. Research shows that if someone with anorexia is ill for less than three years and then recovers, her chances of a lifetime free of this devastating illness are excellent. But those who've been chronically ill for 5 years, 10 years, 15 years, are much less likely to ever really recover.

And that's simply wrong. Especially when there are tools that can help--like the family.

Anyone who's interested in being part of the UC-San Diego trial can call 858-366-2525 or e-mail edresearch@ucsd.edu.

What does it all mean?

A reader named Moira wrote in on another thread, and I thought her comment deserved its own post:

Hi. My name is Moira, and I couldn't help noticing your comment that the BMI for overweight was lowered to 25 and obesity at 30. I've also noticed in my line of work that doctors lowered what the accepted upper limit for blood pressure should be as well, from 140/90 to 130/80. And just the other day I was called full figured for the first time in my life. What does it all mean? Is there someone out there who wants me to believe that every one of us has a problem needing intervention when we might just be fine as we are?

In a word, yes I do think that. Think about how other criteria have changed over the last decade or so, too, from cholesterol guidelines to blood sugar guidelines to weight guidelines. Ask yourself if it's really credible that most adults in the U.S. need to be on medication for cholesterol, high blood pressure, and other issues. Then ask yourself the classic question in any criminal case: Cui bono? Who benefits?

Big Pharma benefits, that's who. The health care industry benefits from the medicalization of all kinds of things, from childbirth to body size. Maybe it's useful to see the current anti-obesity hysteria as part of this overall trend toward pathologizing normal human variances and processes. After all, as soon as you identify a "normal" range of anything, you automatically create an "abnormal" range as well.

What do you all think?

Support group meeting tonight

Sorry for the late notice--the Madison, Wisconsin support group of parents of children with eating disorders is meeting tonight. This is a loose, informal group that i've convened. We share resources and support, especially around family-based treatment (the Maudsley approach). Please stop by if you're in the area. The meeting is at Barriques on Monroe Street at 7:30.

A little question of semantics

When I showed my daughter the NYT piece on the fatosphere the other day, her only comment was, "But you're not fat."

What she meant, of course, was "You're not that fat."

Put me next to, say, Ellen Pompano, and I certainly look fat. Put me next to someone who weighs 400 pounds and I don't look fat. Or I don't look as fat.

Fat and thin are words that exist mainly in relation to each other. At the extremes of each range we can certainly identify them correctly. But in the vast middle, our judgment becomes much more relative.

Semantics plays a role in the current anti-obesity hysteria. For starters, the definitions and rules changed in 1998, when the cutoff for overweight was lowered from 27.3 to 25 on the BMI chart. Bingo--instant overnight overweight for millions.

As Paul Campos has pointed out in The New Republic, the way we talk about fat and thin, oveweight and obese and underweight, is something of a shell game.

Fat qua fat is not the problem. Because, after all, we all have fat on our bodies. What's more, we need fat. Without it, your body doesn't work well and your brain sure as hell doesn't work right. I've seen the evidence up close and personal, and it's not pretty.

Think about it the next time you find yourself saying, "But I'm so fat!" or the next time you look in the mirror. Come back and tell me how it changed your perception.

We interrupt this blog to tell you

that I've had to enable comments moderation for the time being, due to an influx of ungrammatical and highly offensive comments.

Sorry for the inconvenience. I'm sure they'll find someone else to pick on soon and stop leaving their illiterate offerings, and then I'll go back to an open comments policy.

Anti-fatism up close and personal

My experience last night with the shock jock from Philly reminded me of an experience I had as a child. I went to an elementary school where we spoke English in the morning and Hebrew in the afternoon, and where pretty much everyone I knew was Jewish. My parents talked a lot about anti-Semitism, but I never encountered it.

Until I entered 7th grade at the local junior high, and one day, as I walked down the hall, a group of laughing 8th graders showered me with pennies and shouted, "Run for the pennies, kike!"

I was so naive I was more puzzled than upset. What was a kike? I didn't even know.

Once I found out, the waves of shame and humiliation took a long time to diminish.

That's how last night's radio show was for me--really the first time I've encountered fatism in such a virulent form, especially as followed up by a commenter this morning. (Alex from Philly, don't even bother. You'll be deleted and go straight to troll hell.) It's hard to take it in when you meet up with such hatred, whether it's based on the color of your skin, your religion, or the size of your waist.

Years after that day in junior high, I realized what's at the heart of all such prejudice and hatred: self-loathing.

If I were a more generous person, I'd feel compassion for all those who spew mindless hatred because they're secretly afraid they themselves don't measure up, because they hate themselves. But you know what? I'm not feeling particularly generous today, so I'll leave it at "I hope you get yourself some help."

Why talk radio sucks

I just learned Media Lesson 101: Never go on a talk radio show without asking who else is going to be on.

When the Dom Giordano Show emailed today to ask if I would come on the show this evening to talk about today's New York Times piece about the fatosphere, I figured it would be the usual five-minute radio interview, with time for a couple of comments about the piece and the fatosphere.

What they didn't tell me is that there was going to be another guest, a fitness trainer and "expert" whom they have on the show often.

Instead of a civil conversation, we had a lotta fatty mudslinging, complete with descriptions of waddling children, fatties who just want an excuse to be obese, etc. I was blindsided by the vitriolic assumptions that got tossed around. It was a classic exercise in thin entitlement and fat-bashing, all couched in the usual "Don't you know fat is unhealthy?" language.

I'm mad at myself for missing some opportunities, because my heart was banging away and my voice was shaking. Nothing like a shock jock to raise the adrenaline level. Not that it mattered--the research I was able to pull out of the air and cite (the 2005 CDC mortality study, for one) just sailed on by as if it didn't exist. And it didn't, you know, because of the waddling children and diabetic fatties who can't get off the couch. When I suggested that you can be healthy and fit even if you're fat, they practically laughed me off the show.

I feel badly about this--I could have done a better job of advocacy.

I hope the rest of you FA bloggers don't get blindsided like this. And I hope there was one person listening who heard a little something new, and might check it out.

Ugh. I'm heading upstairs to do some yoga. What an end to what a day.

Welcome new readers

Some of you have arrived here via the New York Times piece on the fatosphere. Some have come from other blogs, like Shapely Prose or Manolo for the Big Girl or Creamy Nougat Lair. However you stumbled onto this blog, I'm glad you're here.

I hope you'll take a few minutes to read up on the I Love My Body! pledge. Subversive, isn't it? Especially when you think about the messages the rest of the world gives us every single http://www.blogger.com/img/gl.link.gifday. Lose weight. You're too fat. You're worthless if you're fat. Thin = pretty. Thin = sexually attractive. Fat is repulsive, dangerous, unhealthy, ugly.

Here at Feed Me!, we believe in Health at Every Size. When our friends make comments filled with self-loathing, we talk them off the ledge. We believe that each and every one of us deserves a joyful, competent relationship with food.

I've been researching and writing about issues of weight and body image for several years, including this story about my daughter Kitty and her struggle to recover from anorexia. I'm putting together an anthology of essays about these issues, called--what else?--FEED ME!, which will be published by Random House next December.

I'd love to hear from you. What's your relationship with food and eating and your body like? What challenges you and what brings you joy? Share it with the community here. You won't be sorry.

Love Your Body!

As Camryn Manheim said, This is for all the fat girls. And the thin girls. And the in-between girls who struggle, as so many of us do, with self-loathing.

Well, here's a way to fight back.

Print this out. Use it as a bookmark. Tape it to your fridge. Frame it for your bedside table. Say it out loud.

I promise you, someday you'll actually believe it.

In honor of MLK Day

And in the context of the ongoing discussion about fat acceptance as a civil rights movement, here are some excerpts from Dr. Martin Luther King Jr.'s "Letter From Birmingham Jail." This particular section addresses the question so often asked in the civil rights movement of the 1960s: Why not just wait, things are getting better, why push it? King's eloquent and beautiful response is moving and righteous.

We still have so long so go for racial equality in this country. And if, as you're reading King's words, you imagine the word fat everywhere he writes Negro, and thin for white, you might get a taste of the work that still needs to be done on other fronts, too.


Letter From Birmingham Jail
April 16, 1963

You may well ask: "Why direct action? Why sit-ins, marches, and so forth? Isn't negotiation a better path?" You are quite right in calling for negotiation. Indeed, this is the very purpose of direct action. Nonviolent direct action seeks to create such a crisis and foster such a tension that a community which has constantly refused to negotiate is forced to confront the issue. It seeks so to dramatize the issue that it can no longer be ignored. . . . I must confess that I am not afraid of the word "tension." I have earnestly opposed violent tension, but there is a type of constructive, nonviolent tension which is necessary for growth. Just as Socrates felt that it was necessary to create a tension in the mind so that individuals could rise from the bondage of myths and half-truths to the unfettered realm of creative analysis and objective appraisal, so must we see the need for nonviolent gadflies to create the kind of tension in society that will help men rise from the dark depths of prejudice and racism to the majestic heights of understanding and brotherhood.

The purpose of our direct-action program is to create a situation so crisis-packed that it will inevitably open the door to negotiation. . . . My friends, I must say to you that we have no made a single gain in civil rights without determined legal and nonviolent pressure. Lamentably, it is an historical fact that privileged groups seldom give up their privileges voluntarily.

We know through painful experience that freedom is never voluntarily given by the oppressor, it must be demanded by the oppressed. . . .

Let us all hope that the dark clouds of racial prejudice will soon pass away and the deep fog of misunderstanding will be lifted from our fear-drenched communities, and in some not too distant tomorrow the radiant stars of love and brotherhood will shine over our great nation with all their scintillating beauty.

Yours for the cause of Peace and Brotherhood, Martin Luther King, Jr.

Et tu, Prevention?

It's been a while since this magazine geek has looked at Prevention magazine. What I remember from the last time--maybe 10 years ago--was that Prevention was a pretty good health-related magazine, with in-depth articles, exposés, thoughtful journalism, and some reader service--the tips and tricks kinds of articles.

This evening I looked it up online; I'd been told there was an article in the current issue I should see. I got to Prevention's home page, and was immediately assaulted by the following headlines:

Kick-Start Your Metabolism!
Flat Belly Diet! Tips to Shed Pounds Fast
Eat Chocolate to Lose Weight
Calculate Your BMI
Eat Healthfully and Fight Disease
Heart-Smart Foods
Melt Fat With Every Step
Lose Up to 15 Pounds in 32 Days
Eat Up, Slim Down

Dear editors: There's more to life than obsessing over fat and weight loss. You'd think, reading this page (and this was just the home page--there's more farther in), that losing weight was the only meaningful measure of health.

Seeing it like this was a visceral reminder of our national obsession, and just how unhealthy it is.

How you eat is also how you live

Dietitian and therapist Ellyn Satter has been writing about food and eating for years. I often think of her words when I think about my own or others' eating troubles. According to Satter, the goal for all of us is to have "a joyful, competent relationship with food." Years of research have helped her define what it means, exactly, to be a healthy, competent eater:

Competent eaters have positive attitudes about eating and therefore are relaxed about it. They enjoy food and eating and they are comfortable with their enjoyment. They feel it is okay to eat food they like in amounts they find satisfying.

These three little sentences are about as radical as the Declaration of Independence was 225+ years ago. Consider all the ways in which our culture doesn't encourage us--especially women--to enjoy food, to feel it's OK to eat food we like in amounts we find satisfying. So many of us are terrified of food and of our own appetites; this little manifesto puts the power squarely where it belongs and where it always has been: with us.

Satter's latest newsletter takes her research a step further, in a direction I find very interesting indeed:

Competent eaters do better with feeding themselves and have positive health indicators. None of that surprised me. What did surprise me, although it shouldn’t have, is that competent eaters are emotionally and socially healthier than people with low levels of eating competence. They feel more effective, they are more self-aware, and they are more trusting and comfortable with themselves and with other people.

That's right, folks: Being competent with eating correlates with emotional and social health. Not dieting. Not weight loss. Not binge eating. But maintaining that joyful, competent relationship with food and eating.

Satter goes on to explain the connection:

Consider that being emotionally and socially healthy--emotionally competent, if you will--depends on being sensitive to and comfortable with what goes on inside you--knowing what you feel, what you want, who you are--and being honest with yourself and with others about it. Your comfort and honesty with yourself allow you to act on your feelings in a rational and productive way. You can appreciate not only your own feelings and wishes but those of other people and, as a consequence, be reasonably adept at working things out. Being competent with eating depends on exactly the same processes: being sensitive to and comfortable with what goes on inside you and being honest with yourself and others about it.

Amen, sister.

Hitting a nerve

Back in October I posted about some of the marketing brochures I collected at the NEDA conference. I singled out one from Rogers Memorial Hospital, partly because it was so egregious and partly because Rogers is the closest residential treatment center to my town, and it's the place my daughter likely would have gone had we chosen in-patient treatment for her.

I've been meaning to post the follow-up to that thread, which was that I got a letter from the COO of Rogers Memorial himself. Here for your edification are some quotes from the letter, along with my commentary.

Quote: Your comments and suggestions for improving our brochure have already been received by our marketing department and will weigh in our minds when we revise our eating disorder materials in the future.

Commentary: The point wasn't a critique of the brochure; I was discussing the program. Big difference. Revising the marketing materials isn't going to change your outcomes for the real live people who go to Rogers. Point well and truly missed.

Quote: We would appreciate the consideration of sending us such criticism directly, rather than taking your complaints immediately and directly to a public forum like your website.

Commentary: I'm sure you would. And I'm sure, had I called you with my "complaints," you would have taken them very seriously indeed.

Quote: Advocates for mental health must work together to achieve greater awareness and to break down the stigma that our society attaches to mental health disorders.

Commentary: I'm with you on that one . . . though I think my notion of advocacy is probably not the same as yours. To me, advocacy means empowering patients and their families with accurate and true information, true choices, and effective treatments.

Quote: Schedule a visit to our campus and really get to know our medical staff and administrators who have trained and practice Maudsley approaches and techniques when they are applicable.

Commentary: It's those last four little words that give it away: when they are applicable. Family-based treatment is the standard of care for adolescents. It should be the norm rather than the exception.

I know there are caring staff at Rogers Memorial. I challenge them to take a hard look at their treatment protocols for teens and evaluate them in the light of evidence-based research--then come up with a new vision. You have the potential to do a lot of good. I'd love to see you doing it.

Civil rights

I just wrote this in a comment on another post, and thought it was worth repeating in a post all its own.

We need a civil rights movement for fat people.

Fat acceptance is great, but we need to go a step further. We need our own Rosa Parks and Martin Luther King, Jr. and Mahatma Gandhi. We need civil disobedience. We need to picket outside the offices of for-profit bariatric surgery clinics. We need to Act Up, not shut up.

We need to teach our own culture an essential lesson once more: That each and every person is a valuable human being, regardless of the color of his/her skin, intelligence, country of origin, gender, sexual attractiveness, or weight. Hell, we need our own song.

We're talking basic civil rights here. Who's on the bus?

Part 2: Obesity and insurance

Part 2 of my local paper's coverage of bariatric surgery starts like this:

If you smoked a pack of cigarettes every day for 20 years, you might develop lung cancer. Most insurers would pay for surgery and other cancer treatments without quibbling over it.

But if you gradually piled on weight, then developed diabetes or other problems from obesity, your health plan likely would not cover weight-loss surgery without a fight.


Shocking, isn't it? A medical condition insurance companies don't cover. (I'm putting aside for the moment the underlying assumptions here: obesity = medical condition/disease, obesity --> diabetes and other diseases, obesity is volitional.) How could this be, you wonder?

Alas, I don't have to wonder. Two years ago I fought with our insurance company--and lost--over its coverage of my daughter's treatments for anorexia. Because anorexia is considered a mental illness, and because our progressive-in-reputation-only state does not have mental health parity, our insurer got away with covering only a small percentage of the cost of my daughter's treatment.

Where were the incredulous newspaper stories then? Where was the hue and cry, the uproar at the injustice?

Uh-huh. I thought so.

Of surgery and blame

There's nothing new about bariatric surgery, even in the midwestern outpost I live in (once a New Yorker, always a New Yorker!), but this front-page story in this morning's paper made me see just how mainstream it's becoming--so mainstream that health insurers here are beginning to cover it.

The good news is that the story focuses on the risks of weight-loss surgery: internal bleeding, bowel obstructions, leaks in the new pipeline, blood clots, and cardiac complications. The local hospitals that do the procedures have complication rates about the national average--between 8 and 11 percent. (I wonder how this compares with complications rates of other kinds of surgery; anyone out there know?)

What made me sick was not just the literal description of the surgery, though that was graphic and disturbing. It was the curiously familiar rhetoric that accompanied the story's generally positive view of these procedures:

". . . some doctors [say] patients are looking at the surgery as an easy solution.

'I see a lot of people who are in a miserable situation, and they 're looking for a solution, and surgery seems like an easy solution,' said Dr. Edward Livingston, a bariatric surgeon at the University of Texas Southwestern Medical School in Dallas.

'But this is a big life change. It requires a great deal of investment on the patient 's part to make it work.'"

Sound familiar? It should. Like so many other diet pills and weight-loss plans, it comes with a heaping helping of guilt and blame: You say people are miserable and are just looking for an easy solution? How dare they! They should be made to suffer.

And suffer they will, if they have bariatric surgery. If they're lucky, like the woman profiled at the top of this story, they will get to go off their meds for diabetes, sleep apnea, etc. Assuming, of course, they were on them in the first place. If they're lucky, they won't die as a result of the surgery or have complications that cause them long-term pain and disability.

And even if they are lucky, they're still likely to face buyer's remorse. "This is a lifelong commitment, and there are going to be days when you're sorry you've made this commitment," says the woman profiled in the story.

I bet. I find the word commitment to be an odd one here. What we're really talking about is a procedure that mutilates the human body, with long-term consequences like absorbing 77 percent fewer nutrients from food--for the rest of your life. That's not a commitment; it's something you endure.

But the underlying assumption, here as elsewhere, is that there's an element of choice about being obese. And that's what I find frustrating and upsetting, that our culture assumes that whenever you deviate from the cultural norms around weight, it's your fault. Whether you're obese or anorexic, you are to blame, and you are to be punished.

If I were a therapist, I'd have to ask: How does this help us? What's the secondary gain of seeing weight as a reflection of intention, behavior, and responsibility?

These are the kinds of questions that stories like this one should be asking.

Anorexia and target weights

Doctors do a lousy job, overall, at setting target weights for people recovering from anorexia. Most set them way too low, so the patient never reaches or stays at a weight high enough to heal from prolonged malnutrition, and relapses.

Now a new study published in the International Journal of Eating Disorders suggests a different measure of recovery: resumption of menstruation.

As nearly any pediatrician or parent can tell you, this is a bad idea. Really bad idea. Some girls never lose their periods no matter how much weight they lose. Some get them back while they're still significantly underweight. Getting your period back while you're in recovery is a good sign, but it's no litmus test of health.

In fact there is no single measure of restored health. Some clinics use body composition analysis, which takes into account not just a person's weight or BMI but also the percentage of lean and fat tissue in the body.

I think the best measure is mental health, and parents are well-placed to judge it. They know what their child was like before anorexia, and they know when their child is "back." I've heard countless stories of teens who reach the weight the doctor sets and still aren't better, or who get their periods back despite still being in the grip of anorexic delusions and obsessions.

When I saw my daughter's anxiety around food and eating was pretty much gone, I knew she was close to full recovery. Don't settle for anything less.

And the winners are . . .

You all could be making tons of money as high-paid marketing shills for Big Pharma. But I'm glad you're not.

And the winners of the Taranabant marketing slogan contest are:

Letitshine's "Taranabant: Because food is bad." Because, you know, that's what people really really think, deep down.

bigmovesbabe's "Taranabant: Because nothing tastes as good as anxiety feels." For its social satire of That Other Tagline.

And finally, littlem's "Taranabant: Rimonabant Duzn't Wurk On Fattiez, So We Tryz Agen" just because I think it's hilarious. And oh so true.

I'll award more prizes if you keep the entries coming. Meanwhile, congratulations to our 3 lucky winners. Send me your address and T-shirt size and I'll send you a prize. :-)

Would you rather be fat or have a mood disorder? Win a prize!

Because those are your two choices, if you listen to the hype around the latest in the slew of anti-obesity sweepstakes entrants, known generically as taranabant. Amid the hysterical buzz that's been making the rounds online, we're now beginning to see mention of "psychiatric side effects." This Scientific American article describes side effects as "nausea, vomiting, and moodiness," and goes on to explain that taranabant is what's known as a cannabinoid antagonist, meaning it blocks the receptors in the brain that are activated by cannabis sativa, or pot. So instead of giving you the munchies, this drug takes away appetite; instead of calming, it "activates," or makes people irritable and anxious.

But wait--I have a better idea. And you can win a prize! Keep reading.

Can me say first how much I hate the photo and headline that ran with this story, too? The head was "New Diet Drug in the Battle of the Bulge," and it ran with this image.

My interpretation of the phrase "battle of the bulge" is people who want to lose 10 or 20 or 30 pounds—who want to be in the lower end of their setpoint range rather than the higher end. This is hardly what even the medical profession would label "obesity." I suppose this image is better than the one that ran with a report on a site called Dogflu.ca., which I'm not going to reproduce here because it's so exploitative.

I think we need an anti-anti-obesity drug marketing campaign, and drugs like this give us the perfect material. We could start by resurrecting the old "This is your brain on drugs" ad campaign. See the fun that's possible?

Let's have a little friendly competition, in fact. You write a clever tagline to go with this new drug, and I'll send a prize to a couple of lucky winners. Ready, set, go.

Why we need to talk about food

Over at Laura Collins' blog there's a compelling debate raging about treatment for eating disorders. It started with a link to a Student Doctor Network discussion about Maudsley (also known as family-based treatment).

The forum link is a peek into the minds of some medical/psych students who dismiss Maudsley treatment as something that might work only for "the very tame cases" (has anyone out there ever seen a "very tame case" of anorexia?). Students who know nothing about it say confidently that they would "never recommend it."

I would think that given the truly abysmal rates of recovery from eating disorders, medical professionals would be thrilled to learn about a treatment with positive results and an excellent track record. I've got a couple of suggestions for where to start: With this useful Q&A on Maudsley and this article about the University of Chicago's Daniel Le Grange.

And in answer to a comment made on the Student Doctor Network, I love what Dr. Le Grange says at the end of the article: "How can you not talk about food when your daughter is starving?"