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Up to the Plate

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Food is medicine for eating disorders however there is no special kind of diet that will cure these complex illnesses Recovery from an eating disorder begins with weight restoration and normalization of eating behavior This means being able to eat enough to meet nutritional needs and energy requirements and being comfortable eating a variety of different foods Copyright by F E A S T 2015 This booklet may be reprinted and distributed by others For more information please contact F E A S T at info feast ed org

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EDITOR IN CHIEF Debra K Katzman MD FRCPC Professor of Pediatrics Senior Associate Scientist Research Institute The Hospital for Sick Children and University of Toronto Canada EDITORS Andrea K Garber PhD RD Associate Professor of Pediatrics Division of Adolescent Medicine Chief Nutritionist Eating Disorders Program at Benioff Children s Hospital University of California San Francisco Neville H Golden MD Chief Division of Adolescent Medicine The Marron and Mary Elizabeth Kendrick Professor of Pediatrics Stanford University School of Medicine Daniel Le Grange PhD Benioff UCSF Professor in Children s Health Joint Director Eating Disorders Program Departments of Psychiatry and Pediatrics University of California San Francisco Dasha Nicholls MBBS MRCPsych MD FAED Consultant Child and Adolescent Psychiatrist Feeding and Eating Disorders Service Dept of Child and Adolescent Mental Health Great Ormond Street Hospital London Graeme O Connor RD Ph D Pediatric Dietitian Great Ormond Street Hospital University College London Institute Child Health Rollyn M Ornstein MD Associate Professor of Pediatrics Interim Chief Division of Adolescent Medicine and Eating Disorders Penn State Hershey Children s Hospital Tania Turrini BSc RD Department of Clinical Dietetics Hospital for Sick Children Eating Disorders Program Hospital for Sick Children Toronto Canada F E A S T PUBLICATION TEAM Original Concept Draft by Laura Collins Lyster Mensh MS Founder Policy Director F E A S T Copy Editor Designer Leah Dean M Arch Executive Director F E A S T Chair of F E A S T Family Guide Task Force Mary Beth Krohel F E A S T Advisory Panel www feast ed org Page 1

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UP TO THE PLATE THE IMPORTANCE OF NUTRITION FOR UNDERSTANDING AND TREATING EATING DISORDERS IF EATING DISORDERS ARE MENTAL ILLNESSES WHAT DOES FOOD HAVE TO DO WITH IT Eating disorders EDs are mental illnesses in which the central anxiety has to do with food and eating And unlike a fear of flying or snakes for example eating is part of everyday life and not something that can be avoided without grave medical and psychological consequences The four main ED diagnoses include anorexia nervosa AN bulimia nervosa BN binge eating disorders BED and avoidant restrictive food intake disorder ARFID Malnutrition which is found in all EDs is a serious medical condition and nutritional rehabilitation is a fundamental component of treatment For patients with restrictive eating behaviors and weight loss weight restoration and nutritional rehabilitation are essential goals of treatment For patients with binge and or purge behaviors weight stabilization and normalization of eating behaviors are critical While the physical symptoms of starvation are fairly obvious many people do not realize that when the brain becomes malnourished it negatively affects mood behavior appetite regulation relationships and can even distort a patient s perception about their own body weight and shape The concept that malnutrition negatively affects the brain is not new but advances in science have revealed that the process is much more complex than previously understood For example researchers have discovered that genetics can influence how a person responds to malnutrition and we now believe that this plays a fundamental role in triggering and maintaining EDs in susceptible individuals Over the years research has led to promising new developments in understanding how to restore weight and health in patients with AN stop binge behaviors in BED and binge purge behaviors in BN and halt ED thoughts that are common to all of these disorders Our multidisciplinary team of health professionals has put together this guide to help families understand the relationship between EDs and the importance of nutrition Outlined below are our answers to frequently asked questions on this topic Page 2 www feast ed org

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MY DAUGHTER WANTED TO BE HEALTHY SO SHE DECIDED TO GO ON A DIET IS THAT WHAT CAUSED THE EATING DISORDER Research has shown that EDs are associated with many different factors such as genetics culture social expectations behavior psychology and biology In fact there does not seem to be one single cause to explain why people develop EDs We do know that dieting either as an attempt to lose weight or to eat healthy increases the risk of developing an ED In fact young people who diet moderately are six times more likely to develop an ED Many societies place a high value on developing a thin or muscular body and this may lead to attempts at dieting and or over exercise which can trigger an ED in those who are most vulnerable Dieting can also lead to other unhealthy or disordered eating behaviors such as bingeing and purging While not all people who go on a diet will end up with an ED we know that starting a diet is definitely a risk factor for developing an ED in adolescents For example we know that some individuals have certain personality traits that make them more prone to develop obsessive dieting or exercise patterns Most people cannot maintain dieting behaviors for too long because it is stressful and the body will respond to the need to eat normally However new research in neurobiology has found that for individuals who develop EDs behaviors such as restrictive eating bingeing and or purging may actually affect the brain in ways that relieve anxiety which then serves to support the unhealthy eating behaviors MY SON WAS DIAGNOSED WITH ANOREXIA NERVOSA WHY CAN T HE JUST EAT LIKE OTHER BOYS HIS AGE To be afraid of food and to be scared that just about any food item no matter how small or low in calories will bring about rapid weight gain cause harm or discomfort and even lead to obesity is a hallmark of AN This reaction to food is very hard for families to understand but comes from the manner in which AN disrupts the brain s normal appetite functions Whereas a healthy teen will look at a candy bar or an apple or a plate of pasta and say wow that looks good I m hungry I d like to eat that your son looks at that same food and derives no pleasure from it Instead he becomes very anxious about what that food item will do to him These fears can be very individual Whereas one patient may fear that this apple will make me fat and I don t want to be even fatter than I already am another patient may fear that eating specific foods will make them ill or sabotage their athletic performance or make them appear weak willed or unworthy to others It is important to understand that these thought patterns are irrational and disordered and are symptoms of the illness Consequently your son simply can t eat or relate to food in the same way he used to before he became ill www feast ed org Page 3

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WHAT IS THE DANGER OF EATING TOO LITTLE Eating too little can lead to serious and potentially life threatening health problems Complications can include low blood pressure heart rate and breathing rate poor growth in height and weight interruption of sexual development heart problems that can lead to abnormal heart rhythms brittle bones and risk of bone fractures abnormal electrolytes minerals in the blood or other body fluids dehydration slow emptying of the stomach constipation loss of or irregular menstrual periods dry skin hair loss and lanugo hair fine hair that can grow all over the skin inability to concentrate IS THERE A SPECIAL DIET THAT WILL CURE AN EATING DISORDER Food is medicine for EDs however there is no special kind of diet that will cure these complex illnesses Recovery from an ED begins with weight restoration and normalization of eating behavior This means being able to eat enough to meet nutritional needs and energy requirements and being comfortable eating a variety of different foods There are six nutrients that our body needs protein carbohydrate fat water vitamins and minerals Each nutrient has its own unique function and all are needed to maintain good health It is important that the patient eats a wide variety of food to ensure the body gets all the nutrients it needs Many individuals with EDs severely restrict the foods they will allow themselves to eat Some patients become overwhelmed by the fear that specific foods or entire food groups will cause them to gain weight or will harm their health The extreme anxiety associated with eating these fear foods can be very hard to overcome but gradually increasing the variety and quantity of food served will help to challenge these fears and will ensure your child is getting all the recommended nutrients MY SON IS IN TREATMENT FOR ANOREXIA WHY DOES HE HAVE TO EAT SO MUCH MORE THAN HIS PEERS AS PART OF HIS RECOVERY PLAN Basal metabolic rate BMR is the amount of energy that the body consumes at rest and supports functions like digestion breathing and maintaining body temperature When your son was at very low weight as a result of having AN his BMR slowed down to conserve as much energy as possible This is a Page 4 www feast ed org

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protective response controlled by the brain and is sometimes referred to as a starvation state With nutritional rehabilitation the brain responds to correct for this period of starvation causing your son s BMR to increase and thus his energy intake calories consumed needs to increase dramatically In addition to the food needed to regain lost weight your son needs more food to fuel his physical development and even more energy for catching up on delayed growth Therefore your son invariably requires more food than his peers so that ongoing weight gain is achieved in a timely manner The amount of additional calories required varies for each individual patient and the best indicator that the body is receiving enough energy is adequate and sustained weight gain OUR DAUGHTER NEEDS TO REGAIN LOST WEIGHT HOW DO WE KNOW THE MOST APPROPRIATE TARGET WEIGHT FOR HER TO BE AT The appropriate weight for your daughter cannot simply be read off reference charts and it may differ from the healthy weight for someone else even of the same age and height It will also depend on her current stage of pubertal development and whether or not she has further growth potential Puberty is the time when young people have changes in their body height weight and development of sexual characteristics as they move from being a child to an adult During puberty your daughter s body will grow faster than at any other time in her life except for when she was a baby Food restriction as seen in AN can delay puberty while disordered eating behaviors as seen in BN and other EDs can compromise both short and longterm health Food is medicine for EDs and restoring full nutrition quality and quantity is critical for healthy adolescent growth and should be a priority in any ED treatment plan The appropriate target weight for your daughter will be the weight at which her body functions normally It is the weight at which she has regular menstrual periods thinks less about food and weight is able to eat a variety of foods and also gets back the personality she once had before she became ill The weight at which this is likely to happen will depend on her growth patterns before she developed the ED and the length of time she spends without restricting her caloric intake after weight restoration Continued dietary restriction even after achieving a healthy weight can lead to continued absence of menstrual periods For women with AN on average it takes about 9 months to resume menstrual periods If your daughter is still growing her progress will need to be assessed every 3 6 months and her weight target may need to be changed as she continues to grow and develop Healthy weight cannot be determined by appearance BMI or the patient s wishes Ongoing professional consultation and monitoring with an ED specialist team is critical Even among experts there are different methods and protocols www feast ed org Page 5

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OUR DAUGHTER IS A TEENAGER WHY ARE WE TREATING HER LIKE A CHILD WHEN IT COMES TO NUTRITION If your daughter is suffering from an ED she is probably malnourished As such her brain is simply not functioning well and cannot make good decisions A starved brain prevents your daughter from appreciating how unwell she is and derails her ability to eat intuitively In this state she has no way of understanding what kinds and quantities of food she needs to eat and may not even be able to recognize when her body is hungry It is really difficult for parents to appreciate the extent to which an ED overtakes the way the teen thinks and feels about all things food related It can be very confusing for parents to be guided to take over albeit for the short term all decisions related to your daughter s eating and weight when she behaves like a normal teenager in most other domains Even more confusing is that your smart and apparently rational teen will demonstrate a wealth of knowledge about nutrition in fact she may even prepare wonderful nutritious meals for the whole family that she cannot bring herself to eat Because it is normal for your daughter to resist eating what is prescribed for her you will have to emphasize the necessity of full and complete nutrition as her body heals and her brain recovers Because she may not be able to understand it at this time it is important that you as her caregiver make sure that the amount and type of food given to her is what she needs to recover regardless of what the rest of the family is eating This means that at the end of the day the job of refeeding belongs to you at home or the ED team in an inpatient setting If your child is medically stable then it s far better for your team to support you to do this job at home until your daughter is ready and capable to eat like a healthy teen once more The latter will only occur with full nutritional rehabilitation and lots of support for relearning how to eat again IS LONG TERM RECOVERY FROM AN ED POSSIBLE The short answer is yes there is always hope for a successful recovery from an ED Long term outcome studies now confirm that a good 50 60 of patients will have a full recovery Nevertheless the process is obviously quite a bit more complex and results will vary widely from patient to patient For adolescent patients we now know that if the ED is recognized early say within a few months or even a year from the time it started that they stand a better chance at full recovery compared to those with a longer duration illness e g more than 3 4 years That means that adolescents who receive proper care can go on to recover completely from their ED and lead healthy and fulfilling lives as adults While it is clear that early recognition increases success rates early and aggressive intervention is critical to recovery from an ED for all patient Page 6 www feast ed org

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populations Such interventions should include weight and or nutritional restoration stopping dangerous or disordered behaviors and psychological support to the patient and his her caregivers DO PEOPLE WITH BULIMIA NERVOSA NEED THE SAME FOOD AS THOSE WITH ANOREXIA NERVOSA Nutritional rehabilitation is the first step in recovery from both AN and BN This can be achieved by eating a wide range of foods that contain a variety of fats carbohydrate and protein In terms of the nutritional quality of the food there is very little known about what specific nutrients in what amounts are ideal for re feeding During the first stages of treatment the calorie requirements are different for people with AN compared to those with BN People with AN need to regain weight as part of their recovery and larger quantities of food are required until a healthy weight is restored and usually longer This is because AN disrupts the body s normal metabolic rate for a long period of time longer than the time it takes to regain lost weight Although calcium vitamin D and protein are necessary for regaining bone and muscle mass in people with AN overall caloric intake appears to be most important factor for successful re feeding People with BN however may not need to increase their calories if they have not lost weight Instead the focus of the nutrition therapy is on spreading the calories into a normal pattern of meals and snacks to avoid periods of fasting that may trigger bingeing and purging Stopping these disordered behaviors is critical to recovery from bulimia and people with BN may need to temporarily avoid foods that trigger their binges and purges For example if someone always binges on sweets then it might be wise to avoid such foods until they are farther along in their recovery WHAT IS THE DANGER OF BINGEING Binge eating or bingeing is when a person eats an unusually large amount of food at once in a short period of time This usually takes place in private The individual who binges often feels that they have no control over their eating during the episode They often experience feelings of guilt or shame after bingeing Some individuals may follow a binge with purging see below Binge eating is dangerous and can cause the development of serious physical and mental health problems One serious side effect of bingeing is gastric dilatation This is when the stomach becomes bloated after ingesting a large amount of food The pressure in the stomach builds up and may cause difficulty breathing or abnormal heart rhythms In addition the enlarged stomach can cut off the blood supply and cause the stomach tissue to become necrotic dies or even rupture break open Inflammation of the pancreas an organ that produces special proteins that help with digestion and hormones that control the way your body uses sugar known as pancreatitis can also develop as a result of www feast ed org Page 7

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binge eating In addition individuals who binge are at risk for mental health problems such as depression anxiety and substance abuse A person who binges may be a normal weight or overweight and may have significant weight changes from day to day Those who are obese are at risk for a number of serious and long term health problems such as high blood pressure high cholesterol type 2 diabetes and heart disease WHAT IS THE DANGER OF PURGING Purging describes any behaviors used by individuals in order to prevent weight gain Purging behaviors may follow a binge or may occur after a small snack or a normal sized meal Purging behaviours can include self induced vomiting some people use their fingers to induce vomiting and this can result in the formation of a callus on the back of the hand known as Russell s sign fasting or strict dieting excessive exercise the misuse of laxatives and diuretics drugs that promote the production and excretion of urine the misuse of diet pills or ipecac a medicine that causes one to vomit and the misuse of enemas or alternative medications Purging is dangerous and can cause medical complications that affect every organ system in the body Self induced vomiting the most common form of purging can cause tooth decay exposure to stomach acids or from bingeing on foods high in sugar and other dental problems swollen salivary glands esophageal inflammation and bleeding stomach ulcers and bleeding electrolyte abnormalities such as low potassium or sodium abnormal heart rhythms and in some cases death The use of laxatives diuretics or enemas can cause fluid and electrolyte abnormalities edema swelling caused the body holding onto fluid dehydration increased risk of kidney damage and irritation to the bowel Purging behaviors including excessive exercise can contribute to the loss of or irregular menstrual periods in young women Page 8 www feast ed org

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WE KNOW THAT OUR DAUGHTER NEEDS TO EAT MORE BUT WHEN WE TRY TO INCREASE HER MEAL SIZE SHE REFUSES TO EAT WHAT SHOULD WE DO Food refusal is a hallmark of AN As mentioned earlier patients with AN are often fearful of food eating and gaining weight In addition they are likely to feel uncomfortable overly full and bloated when they begin eating larger amounts as part of their recovery For these reasons it can be helpful to serve energy dense foods that provide a high number of calories in a relatively small volume The following methods for increasing energy can be used with many foods or recipes Increase the Fat add cream and shredded cheese to meals Eat energy dense foods first save fresh fruits vegetables and fluids until the end of the meal Consider energy dense liquids liquids are digested faster and more easily than solids and therefore smoothies shakes and formulas are good options for people who are feeling too full to eat Eliminate low calorie drinks serve whole milk or juice instead of water or diet drinks Although these strategies are helpful for some patients and families they are not sufficient to overcome all of the challenges you may run into when trying to feed your daughter Remember food is medicine for EDs therefore any nutritional therapy must be accompanied by medical monitoring and psychological interventions such as family based treatment FBT which supports both the patient and the family with tools for achieving successful meal compliance MY SON FEELS EXTREMELY FULL AFTER EATING HE COMPLAINS OF NAUSEA AND BLOATING SHOULD I GIVE HIM LESS TO EAT It is normal for your son to feel full during the initial stages of the refeeding process These feelings of fullness nausea and bloating should get better during the first couple of months with improved nutrition When very little is being eaten the stomach which is a muscle becomes smaller In addition during starvation all body processes slow down to save energy this includes the stomach and intestines As such food does not move as quickly through the digestive tract causing feelings of fullness bloating nausea and even constipation With better nutrition and more food the stomach will return to a normal size and digestion will speed up and eventually normalize No parent wants to see their child suffer and it is natural to want to compromise on food quantities under these conditions However giving your son less to eat will only prolong the amount of time until he is eating enough to reach a healthy weight and a healthy mental state www feast ed org Page 9

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DOES MY SON NEED TO TAKE AN ORAL LIQUID NUTRITIONAL SUPPLEMENT Energy in the form of solid food is generally recommended for people with EDs because it allows for the normalization of diet and eating behaviors and the return of normal gastro intestinal function Oral supplements are high energy drinks that provide calories and micronutrients and may be helpful when used in specific circumstances such as 1 When a young person requires extremely high amounts of energy to achieve weight gain or weight maintenance such that they may not be able to meet their energy requirements from food alone 2 When a patient with an ED has a limited range of foods that they will eat meaning that some important nutrients e g calcium iron zinc are not consumed in the right quantity for the body to function well In these cases a supplement oral drink can help to boost calorie consumption and replace or top up essential nutrients Patients on liquid supplements should be monitored regularly as it is likely that their dietary intake will vary throughout treatment Finally liquid supplements should be considered a shortterm source of nutrition as full recovery cannot occur until the patient can eat real food in regular amounts to meet their energy and nutritional needs MY SON TOLD ME THAT HE FEELS FAT AT HIS TARGET WEIGHT HOW DO I RESPOND TO THIS One of the hallmark symptoms of an ED is when a person sees themselves as too fat even when their weight is dangerously low These feelings often intensify while their weight is being restored to a healthier range This is because restoring healthy brain processes that control metabolism appetite and perceptions of our weight and appearance usually takes longer than simply restoring lost weight These challenging thoughts and feelings are very real to the patient and should be discussed in a therapeutic setting so that caregivers can learn how best to respond or not respond to them For instance it is not uncommon for individuals with EDs to make negative comments about how they feel about their bodies In this state of mind even supportive comments such as you look so healthy may be misinterpreted as you look so fat It is difficult for families and friends to know how to help when patients are struggling with misperceptions about their body weight shape and size One effective strategy is for parents to avoid engaging in these types of conversations by learning to separate their child from the ED in their own minds Once a parent realizes that discussions about body size and shape will only be received as criticism by the ED it becomes easier to focus on other kinds of engagement such as commending their child for non eating related accomplishments Positive messages such as you seem so happy or that picture you sketched is beautiful or simply I love you are the things your P a g e 10 www feast ed org

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child needs to hear when they are ill and struggling with negative thoughts and feelings in their own heads SHOULD MY DAUGHTER TAKE VITAMIN D CALCIUM OR A MULTIVITAMIN Calcium is necessary for strong bones and normal muscle function Most dietary calcium comes from dairy products but other dietary sources include green leafy vegetables nuts and calcium fortified breakfast cereals If your daughter can meet her calcium requirements through her dietary intake she will not require a supplement However many young people with EDs are not able to do so and should take a supplement containing 1 000 1 200 mg calcium day Vitamin D is required for calcium absorption and without vitamin D the calcium cannot do its job Vitamin D is made in the skin when exposed to sunlight but deficiency is common in those living in northern climates and in those who spend most of their time indoors You can also get Vitamin D from foods such as fortified milk and cereal fish egg yolks and liver Vitamin D is a fat soluble vitamin which is stored in the fat tissues of the body and liver Vitamin D waits around in the body fat until the body needs it Young people who have depleted fat stores and who restrict their fat intake may become vitamin D deficient For young people with EDs most providers recommend a daily multivitamin containing 400 600 IU vitamin D day OUR SON GAINS WEIGHT ONE WEEK AND LOSES WEIGHT THE NEXT YET HE IS EATING THE SAME FOOD EVERY WEEK WHAT S GOING ON During the initial week of refeeding it is not uncommon for weight to fluctuate as there may have been excessive fluid intake prior to treatment In addition caloric needs can increase dramatically during the first month of treatment as the body s metabolism increases Because of this caregivers will usually need to increase food portions over time in order to see continued weight gain If your son has been suffering from constipation this may also cause changes in weight from week to week depending on whether he has had a recent bowel movement Caregivers also need to be aware that EDs can cause individuals to alter their weights to disguise the effects of their ED Weight checks can produce severe anxiety in ED patients for a variety of reasons For some the number itself is frightening and for others the fear of disappointing their loved ones can lead them to try to trick the scales There may also be fear of hospitalization if the acceptable weight is not met at the office visit Some young people have been known to hide coins rocks or weights under their clothes to appear heavier at weight checks Another method used to mimic weight gains is water loading drinking large amounts of water before getting weighed Water loading is very dangerous and can lead to electrolyte abnormalities abnormal heart rhythms seizures and even death www feast ed org Page 11

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Other ED behaviors that may interfere with proper weight gain include bingeing purging and over exercising Young people commonly hide these behaviors from their families Thus while it might seem that your son is taking in the appropriate amount of food it is important to monitor him carefully for the emergence of these other behaviors MY CHILD WATCHES ME WHEN I COOK HER MEALS AND TRIES TO TELL ME HOW TO PREPARE IT WHAT SHOULD I DO A person with an ED spends a lot of time thinking about food They may worry about what they should or should not eat the ingredients that go into their meals and portion sizes Many patients develop a set of food rules that seem irrational to caregivers but which become very important to the sufferer as a way of relieving their fear and anxiety over eating Being involved in meal preparation and serving their own food is often used as a way for the patient to control what they eat and reinforces their disordered thinking about food Remember EDs are brain disorders and a malnourished brain has a hard time making appropriate decisions regarding nutrition Needless to say many patients have difficulty feeding themselves the quantity and variety that are prescribed to them for health especially if they have been following a highly restrictive or structured set of food rules for a long period of time These patients will require a lot of support and guidance from their caregivers in order to break out of the cycle of poor nutrition that has become their normal routine Some tips for supporting patients through meals and snacks include planning meals and snacks ahead of time and keep changes to a minimum offer your child limited or no menu choices so as to reduce the anxiety related to choosing between foods which may all seem unacceptable to her do not negotiate at meal time once food has been served if necessary remove your child from the kitchen while the meal is being prepared While a non negotiable stance regarding meal planning may seem severe it is a temporary but often necessary practice until your child is further along in their recovery and able to participate in planning and eating meals in a more natural relaxed way P a g e 12 www feast ed org

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I HAVE BEEN READING CONTRADICTORY INFORMATION ABOUT EATING DISORDERS FROM BOOKS AND ON THE INTERNET HOW DO I KNOW WHO OR WHAT TO TRUST There is an increasing body of research in the ED field that informs how clinicians practice and what patients and families should expect from treatment Generally information that comes from regulated professional bodies such as the medical psychology or dietetic professions will be more reliable than information from blogs and web pages based on personal experiences of sufferers or therapist s case studies Ask yourself when looking at books and information Is this a reliable source Look for signs that what you are reading is supported by scientific evidence and that the authors reference the scientific literature You will still come across conflicting advice however because we simply do not know all the answers If you are in doubt or you have questions about whether what you have read applies to your situation you should discuss them with a qualified health care provider RESOURCES TO START WITH The Academy for Eating Disorders AED a global organization for EDs professionals committed to the integration of research and practice is a good source of information that is applicable across all health care settings Their website can be found at www aedweb org In general books recommended on the AED website have undergone scientific review by authorities in the field The AED has also published a booklet designed for health professionals titled Critical Points for Early Recognition and Medical Risk Management in the Care of Individuals with Eating Disorders This booklet is available in several languages as a PDF download from the AED s website In addition some ED advocacy groups such as F E A S T Families Empowered and Supporting treatment of Eating Disorders work with the scientific community to make sure that the information they give patients and families is based on the best available evidence F E A S T also offers support services for caregivers For more information please visit F E A S T at www feast ed org To date F E A S T has published three other Family Guide Booklets all of which are available to read and download in PDF format from the F E A S T website www feast ed org Page 13

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