Binge Eating - Kartini Clinic for Children and Families

Finding Your Sass

August 29, 2018 by Julie O'Toole

When I first thought about writing this blog I had patients with anorexia nervosa in mind. Patients with AN often struggle to find their voice, regardless of how smart, competent and encouraged they may be by others. On the other hand, our patients of high body weight for whom metabolic problems have lead to obesity, can have the same problem: shame and self-loathing has made them reluctant to use their voice, to fight back.

Unfortunately, “finding their voice”, a commonly stated treatment objective, may not be enough, both groups of kids actually have to find their sass.

Why? Because for both diagnoses there is abundant negative feedback and shaming coming from the environment, to say nothing of the negative voices coming from within.

Kids with anorexia nervosa hear that they are “superficial” “attention seeking” “and just want to look like a model” and that they are “ruining their parents’ lives”.

Kids of high body weight are told they are “lazy” “gluttonous” and “obviously don’t care about their health”. They are shamed in every way imaginable and just about everywhere they go.

But not at Kartini Clinic.

We treat kids with all conditions of disordered eating, just as another clinic might treat all conditions of disordered metabolism (endocrinology) or all conditions of childhood cancers (oncology) with no effort made to segregate these kids from each other. They are all just kids, and have a remarkable ability to find resonance with and compassion for other kids who have eating issues, even when those issues appear to be very different than their own. We adults could learn from them.

But back to finding their sass:

It is not enough to recognize how people and institutions shame you for your condition, one you did not ask to have and did not choose and one your parents did not cause, either. It is also important to learn to fight back. “Finding your voice” may be a polite way to respond to misguided comments from others, but you will discover soon enough that people fight back when their cherished beliefs about body weight, eating disorders and mental health are challenged. Why, if they are to believe that it happened to you — and that you didn’t choose it — then it could happen to them too or to someone they love, and that is scary. In the great game of “46 card draw” (aka your genome), we all get genes for complex illnesses… or not. Virtue is rarely the determining factor.

So when an adult, say a teacher, promotes messages that imply that eating disorders are a result of poor parenting or a “choice to get too thin” or that severe high body weight is caused by “poor food choices” and being “too lazy to move around”, you are going to have to call them out. How polite you are about doing this depends on who is it and where you are. You may need to be downright sassy to be heard. You may need reinforcements (parents), but you should not go quietly! I write this blog to be useful, for example, not only to help Kartini families, but also to have something concrete to give to people who need educating or at least to hear a voice with a different, informed, point of view.

To fight back you will need not only your voice, but your sass. Find it!

Christmas and a New Year

December 24, 2015 by Julie O'Toole

Everyone in our field knows that the Holiday season provides special challenges to those with eating disorders, be those restricting, bingeing and purging or predominantly bingeing eating disorders. Add to this the fact that this is typically a very important time of year to children and you have, well, a mess. It’s over in January though, and that’s the good news!

What makes it a mess? Holidays raise expectations in everyone, expectations that even for adults are often not met and sometimes engender disappointment. Families usually try to get together—a good thing, of course, but also a challenging one. For children in treatment for their eating disorder, comments by well-intended (but frankly uninformed) relatives can cause pain and even panic: “You sure look better” (read “fatter”); or, “it’s nice to see you eating again”, or even (horrors!) “why honey, you are eating more than I am! That’s great!” Tears, meltdowns and tantrums can follow. Then there’s everyone joking about bingeing, a word now popularized by streaming video (“binge watching”): bingeing on cookies, bingeing on candy canes. People also talk thoughtlessly about their dieting. Not to mention the vicarious “eating” many people with anorexia nervosa report, where they spend a great deal of time cooking, and especially baking, treats for everyone else but don’t touch them themselves. There are well intended attempts to get our kids to eat treats (“Grandma made them especially for you”) which can result in guilt and subsequent attempts to restrict food intake and/or attempts to get rid of the sweets by exercising or even vomiting. Wow. We should ask ourselves, is it worth it?

So how to navigate this mess? Well, our only defense has been to think ahead. If you are in the throes of treatment, perhaps a single Christmas should be sacrificed for the sake of merry ones to come, once your child is well. If you have an large, unruly extended family (like I do), why not skip the big get-together this year? Have a quiet time at home with fewer people: play Monopoly, Scrabble, work a puzzle, volunteer at a shelter. If that is not your plan, and you choose to have the “Christmas as usual”, don’t let the structure of the days get lost. Since school is out, this is easy to do. Stick to regular meals, no skips, no binges. Refuse to let your child engage in “vicarious eating” projects—but have something fun for them to do to take their place. If your child is precarious medically, and struggling to gain weight, remember that shopping can involve hours of walking (and miles!), without anyone really noticing. Better to do it online. Celebrating with a plan will minimize panic and believe me, I am not making this stuff up; many parents could tell you stories of “Holiday meal panic” that might have been averted with a little more forethought. Easier said than done with everything else that’s going on, of course, but still necessary.

How to make lemonade of lemons from the mess and return to the joy? Whether you celebrate Christmas or not, just about everyone can get behind the values of gratitude and giving. So this Holiday season, this Christmas, can be celebrated not as a food fest but as one where even children can reflect on their family, their friends, their pets and their good fortune. We are lucky enough to live where we do, after all. Help younger children make presents that are meaningful to their recipients. Engage older kids in ideas about how they can give to their friends and families in ways that do not involve food (or buying stuff). For example, help them to focus away from food and towards decorating the house, the tree, the garden, their rooms. Help them to understand that there are children—many of them—who do not have what they do, and consider volunteering during this season: at an animal shelter, a church or school. Even if that doesn’t happen, the discussion about gratitude and family will stay with them. This is surely the real spirit we all wish to engender. And from this spirit, the joy.

And back to January, my favorite month. By January 1st, it’s all behind us. The slate is now clean, a new year of healing, hope and growth lies ahead of us. Let’s focus on that.

Where Are The Grown-Ups?

August 5, 2015 by Julie O'Toole

I read an article on Medpage the other day – “Docs have Role in Preventing Childhood Obesity” – about recent recommendations by the American Academy of Pediatrics (AAP), which I found both annoying and discouraging in equal amounts.

First the annoying part: a prominent, almost certainly staged picture of two overweight children with their mouths open, watching TV, a huge spread of take-out food on the coffee table before them. Who allows their children to be photographed like that? And, by the way, where are the parents?

Leaving aside the flawed premise underlying the article that obesity is caused by children over-eating and under-exercising (an assumption that ignores recent scientific enquiries into epigenetic effects of environmental obesogens, including changes to the gut microbiome), I have been upset for years that “concerned physicians” have never had the courage to address the issue of childhood obesity and health with parents, who, presumably, are in charge of their children’s behavior.

Ah, but that’s the problem, they’re not.

Presumably these children didn’t use their own money to buy the food pictured in the article. It’s also unlikely that they purchased the TV (much less paid for cable, Netflix, etc.). And since no adult is in this picture we are left to assume that they walked away and left the children to eat alone, with only an electronic device as company. If the photographer had pictured the adults, what would they be doing? What would they have been eating and drinking? Why is the AAP not focusing on adult abdication of responsibility for feeding and educating children? Why is the AAP not asking: 'where, dammit, are the grown-ups!?'

I think I know why. The AAP (and all other physician organizations, for that matter) cater to doctors and their livelihood. With a problem like childhood obesity, it's far easier for a doctor to discuss “helping the child make wise snack choices” than to say to the parents, who, after all, will likely leave a practice if a doctor annoys them: 'you need to be in charge. If you don’t want your children to eat these things, don’t buy them. Period. Oh, and it will be essential for you to model different food choices yourself.' They might add that modeling limited “screen time” would also be useful for parents to do…

And such modeling or education should not be left to the schools, nutritionists, or even doctors. Schools were never intended to be in loco parentis; a school’s job is to teach us to read, write, compute, analyze, think critically and to interact socially in positive ways.

Finally, the discouraging, sad and counterproductive part about the article is its misplaced emphasis on “fat” rather than health. We actually have little evidence for obesity being reversible with “better eating”, but lots of evidence that health is impacted by nutrition.*

* Prevalence of malnutrition at the time of admission among patients admitted to a Canadian tertiary-care paediatric hospital. Baxter, Al-Madhaki, Zlotkin. Paediatr Child Health. 2014 Oct;19(8):413-7.

Eating Junk

June 26, 2014 by Julie O'Toole

Recently a patient of ours returned from a treatment setting where she had been presented with “challenge foods”. In her case she had been given cheetos and soda pop. Now I ask you, why on earth would someone encourage a child to eat such a thing?

A lot of ink has been spilled on teaching Americans in general and children in particular to make good food choices. Just because you have anorexia nervosa as a child, and desperately need to gain and maintain adequate weight, does not mean that you will be immune from the health effects of bad eating as you get older. This is true whether or not you get fat later on. You can be thin and unhealthy; you can destroy a lot of things by ingesting a chemical cuisine in the place of real food.

So what actually is in Cheetos? I think you’d better find out if, as a professional, you are going to request your patients take up the” challenge” of eating them.

Here’s the list, straight from Frito Lay (a dividion of Pepsico): Enriched Corn Meal (Corn Meal, Ferrous Sulfate, Niacin, Thiamin Mononitrate, Riboflavin, and Folic Acid), Vegetable Oil (Contains one or more of the following: corn, soybean, or sunflower oil), Whey, Salt, Cheddar Cheese, (Cultured Milk, Salt, Enzymes). Partially Hydrogenated Soybean Oil, Maltodextrin, Disodium Phosphate, Sour Cream (Cultured Cream, Nonfat Milk), Artificial Flavor, Monosodium Glutamate, Lactic Acid, Artificial Colors (Including Yellow 6), and Citric Acid. Contains Milk Ingredients.

Let’s see. Well, for starters I think we can agree that they flunk the famous “five ingredient rule” proposed by Michael Pollan. And for a discussion of ingredient #6 “partially hydrogenated soybean oil” see this discussion from Science in the Public Interest.org.

Regarding ingredient #7, maltodextrin (a sugar) Wikipedia says: “It is also used in snacks such as Sun Chips. It is used in “light” peanut butter to reduce the fat content but keep the texture (as in Kraft Light Smooth Peanut Butter). Research is underway at Virginia Tech to use maltodextrin with air to make a new kind of cheaper, refillable, biodegradable battery to generate electricity for cell phones, video game handhelds and other electronic gadgets.” Hmmm… does that sound like food to you?

Ingredient # 13, yellow 6 food dye, is apparently banned in Norway and Finland and is a synthetic coal tar dye made from industrial waste (coal tar). Again, from Science in the Public Interest:

“Carcinogenic contaminants: Yellow 6 may be contaminated with several carcinogens, including benzidine and 4?aminobiphenyl. The FDA set a limit of 1 part per billion (ppb) of free benzidine, but some batches of dye have contained a hundred or even a thousand times as much bound benzidine, which is likely liberated in the colon (Peiperl, Prival et al. 1995). As reported on page 3, the FDA does not test for bound benzidine. The FDA’s 1986 risk assessment (using estimates for 1990 consumption levels) estimated a risk of 3 cancers in 10 million people, which is smaller than the official “concern” level of 1 in 1 million (FDA 1986). However, that assessment failed to consider the (a) greater sensitivity of children, (b) greater consumption of Yellow 6 by children than the general population, (c) substantial increase in per capita consumption of Yellow 6 since 1990, (d) possibility that some batches of dye contain bound forms of benzidine and other contaminants (FQPA), and (e) presence of similar contaminants in Yellow 5. FDA scientists found that in 1992 one company eliminated benzidine contamination of Yellow 5, suggesting that other companies could do the same for Yellow 6 (Peiperl, Prival et al. 1995). However, a Health Canada study found that Sunset Yellow FCF (Yellow 6 in the United States) was still contaminated in 1998 (Lancaster and Lawrence 1999). With more and more chemicals being imported, it is important that dyes routinely be tested for bound contaminants.”

Gives a whole different perspective on the garish yellow coloring of those “tasty” little cheese bites, doesn’t it?

Now, for the soda and the usual concerns about encouraging consumption of high fructose corn syrup (HFCS), Science in the Public Interest has this to say:

“Modest amounts of fructose from HFCS or other sources are safe and do not boost blood glucose levels, making the sweetener attractive to diabetics. However, large amounts promote tooth decay, as well as increase triglyceride (fat) levels in blood, thereby increasing the risk of heart disease. Also, recent studies show that consuming 25 percent of calories from fructose or HFCS leads to more visceral (deep belly) fat or liver fat. Those changes may increase the risk of diabetes or heart disease. Finally, large amounts of fructose consumed on a regular basis also may affect levels of such hormones as insulin, leptin, and ghrelin that regulate appetite, thereby contributing to weight gain and obesity. The HFCS 55 that is used in most soft drinks contains about 10 percent more fructose than sucrose. That makes most soft drinks a bit more harmful than if they were made with sugar.”

OK. One soda is not “large amounts”, I’ll give you that. But we are modeling eating behavior for our children, especially those of us in authoritative roles: parents, dieticians and doctors. We have a responsibility to teach children to do what is good for them, not to imitate harmful behavior because “everybody their age does it”. How about cigarettes? When it’s “normal” among teenagers in a given child’s environment to smoke, should we offer them cigarettes?

As everyone who reads this blog probably knows, at Kartini Clinic we do not offer our patients “hyper-palatable” foods for a year following re-feeding, but we can accept that others may make a reasonable case for having birthday cake on a birthday or pumpkin pie at Thanksgiving. This is a far cry from implying that we “should” eat cheetos and pop to be “normal”. Or intuitive.

Children need our guidance, whether we are grown-up bears, rats, owls or humans. Why are we afraid to give it?

The Kartini Meal Plan De-Mystified

October 17, 2013 by Julie O'Toole

There is a common misconception out there that Kartini patients are fed on a strict meal plan for the rest of their lives. But what exactly is our meal plan? And while we talking about it, what's our approach to meals and food in general?

Well…

there’s the “parents in charge” (of all meals) thing
there’s the recording on the food journal thing
there’s the family dinners thing/ home cooking thing
there’s the whole-milk-no-low-fat thing
there’s the hyper-palatable food thing
there’s the no artificial sweeteners thing and the lots of fresh vegetables and daily salad thing
there’s the push to 100% weight restoration thing

If you are interested in more details, the links above are to specific blogs focused on individual aspects of our treatment. But for now, let’s take a brief look at these features of the meal plan one-by-one, as patients transition off the meal plan and back to whatever else works for them and their families.

Parents in charge: anorexia nervosa is a brain disorder; one with high morbidity and mortality that quite simply must be brought under control in order for a child or young person to grow and develop normally. At Kartini Clinic we put the parents in charge of food until a child is old enough to begin planning for college — and I do not mean at age 13. Parents are in charge of cooking family meals for our patients until about age 17 when the patient, if doing well, can shift focus to learning independent living skills. As I and others have written about extensively, this is a cultural shift for many modern parents who are often interested in divesting themselves of cooking for the family or sitting down to family meals as soon as they can.

It is a mistake, in our experience, to shift responsibility for their own food to a child or young person if they are not in good remission: both physical and psychological. Parents need to stay in charge until this important transition can be safely effected. And we strongly advise not below age 17, barring very unusual circumstances. After all, it is a privilege to cook for and eat with our families! We should all enjoy it while we can. Too soon our children will be grown and gone and you will be staring at an empty place.

A food journal: our parents record on their child’s food journal (since, after all, they are in charge of meals) for about a year, assuming treatment is successful. Somewhere after the first year of treatment is successfully completed we discuss ceasing to record intake. Why would we continue? For that matter, why do it in the first place? Well, the food journal is a bit like a check register. If you do not record the checks you write or are written (electronically or physically) you will not be able to figure out why your check bounced. In other words, the food journal will give us the data we need to analyze what might have gone wrong (or right) and what, if anything, we should do about it. It should help take the argument out of “I did too eat all of it!”, “No you didn’t…”, etc.

Family dinners: you’d think there would be no controversy about this. Even if it is honored more in the breach, pretty much everyone knows that family dinners are good for children, both nutritionally, psychologically and socially. They are good for families. They are good for combating obesity and poor intake. They let us (force us) to talk to each other and our children. Kartini Clinic patients are never released from the expectation of family meals. That doesn’t go away.

Whole milk dairy products: once children have been returned to good health, and are a year out from diagnosis, parents are free to return to eating their customary dairy products, if they insist. However, we do not advise things like a return to “low fat” products. We are aware of recommendations by the American Academy of Pediatrics (and others), but we have too often seen this behavior be the beginning of a return to eating disordered preoccupations, contributing ultimately to full-blown relapse. So why risk it? If you are eating on our meal plan, you have less than 30% of your calories from fat anyway. There is no medical need to go lower. If you are worried about your heart, try using nuts, fish and olive oil as your sources. If you eat the same number of calories but restrict the amount coming from fat, something will make up the difference, and chances are that something will be sugars.

I don’t rule the world, but if I did, low fat dairy items would be in the garbage bin along with the artificial sweeteners and diet drinks, labeled “hazardous waste”.

Hyper-palatable food thing: this is a biggie. The restriction on hyper-palatable food during the first year of treatment for kids with anorexia nervosa, bulimia nervosa and binge eating disorder is a sticking point for many people. They just don't understand it. But as far as we are concerned, it’s based on scientifically valid concerns for developing or rekindling bingeing as well as concerns for compensatory behaviors. Please do click on this link as the subject is complex and beyond the scope of this summary. The link speaks for itself in regard to bingeing, although compensatory behaviors are even more common. These are where a hyper-palatable food is eaten and the patient feels so guilty (and no, not because of our meal plan — that is a drop in the ocean of their eating disorder guilt about ‘fattening foods’) that they engage in compensatory behaviors to make up for it. Such behaviors would be an increase in exercise to “work it off”, attempts to decrease intake in subsequent meals or simple “melt-downs” and food refusal.

When a patient is doing well, about a year after diagnosis (time chosen based on Key’s evidence), the restrictions on hyper-palatable foods are removed.

I've often asked myself why some consider a refusal to eat Oreo cookies somehow “giving into eating disordered behaviors” or “not eating normally”, but a refusal to eat, say, GMO products is somehow admirable? Nothing is really lost by avoiding these foods, provided the rest of the meal plan is delivering adequate nutrition including enough calories from dietary fat.

Artificial sweeteners: our recommendations for avoiding artificial sweeteners and eating lots of vegetables, especially fresh vegetables are recommendations for life. As for fresh vegetables, see this.

100% weight restoration: why settle for less? Children need to grow, and even those teens and young adults whose linear growth may be over still have bone and brain growth. Don’t shortchange them.

So in summary, some things on the Kartini Meal Plan are in fact phased out, for example the interdiction on hyper-palatable foods, keeping a food journal, and — eventually — parents in charge of all meals. On the other hand, some things I believe are solid recommendations for life: good weight restoration, real foods, lots of vegetables, adequate fat, eaten together in a spirit of joy.

Finding Your Sass

Christmas and a New Year

Where Are The Grown-Ups?

Eating Junk

The Kartini Meal Plan De-Mystified

The Kartini Clinic Difference

Eating Disorder Quick Links

Resource Quick Links

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