By Domenica Angelo & Libby Parker, MS, RD, CDN, CEDS-C

Domenica is currently a graduate student at Thomas Jefferson University in their MS/RDN program. She is excited to gain the tools to become a successful dietitian and wants to make a positive impact on the health and wellness of individuals who struggle/lose their love for food. 

Did you spend any significant time learning about eating disorders (ED) in your education? No? You’re not alone. Most medical professionals spend only around one class period learning about EDs, and are supposed to treat this complex population!

It can be tricky to get the best treatment for a patient if you do not know the specific terminology and assessments used by ED specialists. This article will help medical professionals understand this terminology. Understanding what these terms mean can be crucial in any medical setting.  This is a chance to educate yourself a little more about disordered eating, treatments, and what values are important to look at when assessing an individual at risk for this mental illness.

Medical / Assessments: 

Orthostatic Vitals

Taking blood pressure at two (or three) different positions with specific timing between measurements is how we assess if an individual has orthostatic hypotension (a quick drop in blood pressure). This is done by having the patient’s blood pressure taken while in a supine position, (potentially again while sitting), then asked to stand and measure their blood pressure again. The physician should be additionally asking/making notes about the patient’s dizziness. 

Orthostatic hypotension

A condition in which your blood pressure suddenly drops at least 20 points when you stand up from a seated or lying position. Hypotension often presents as dizziness upon sitting or standing and possibly fainting from a quick change in position. This is commonly associated with anorexia nervosa.

Source: U.S. Department of Health and Human Services. (n.d.). Orthostatic hypotension. National Institute of Neurological Disorders and Stroke. https://www.ninds.nih.gov/health-information/disorders/orthostatic-hypotension#:~:text=Orthostatic%20hypotension%20is%20a%20condition,Blurred%20vision 

Why are these measurements important to eating disorder specialists?

Orthostatic hypotension is a marker of a weakened cardiovascular system due to starvation. The mechanism that maintains blood pressure is compromised due to the alteration of the autonomic nervous system, which is a result of disordered eating behaviors and should signal a need for intervention. 

Source: Graphics, C. (2019, November 25). Orthostatic hypotension-what do I need to know?. Avalon Hills. https://avalonhills.org/orthostatic-hypotension-what-do-i-need-to-know/ 

Bradycardia

Bradycardia is a slowed heart rate. An average adult’s resting heart rate is between 60 – 100 beats per minute, but with bradycardia, the resting heart rate is less than 60 beats per minute. 

Why do eating disorders cause bradycardia? 

Anorexia Nervosa (AN) is the restriction of energy intake relative to an individual’s requirements. This eating disorder has a deathly impact on the heart. The restriction of nutrients causes muscles to shrink including the heart. The impact of anorexia nervosa (AN) forces the body to reserve energy because of severe malnourishment, and the body’s response to this is a slow heart rate to conserve the energy that has been lost. 

Eating disorders are mental health disorders, while other mental health disorders normally do not affect the physical health of an individual to such an extent, eating disorders can severely damage an individual’s physical state. Anorexia Nervosa has many medical complications and cardiac issues are the most common and are accounted for most deaths. Internally, losing a significant amount of weight in a rapid period causes stress on the heart. 

Sources: Mehler, MD, FACP, FAED, CEDS, P. S. (2022, May 1). Bradycardia: How severe is too severe? understanding bradycardia in eating disorders (May 2022).

Robyn L. Goldberg. https://askaboutfood.com/bradycardia-how-severe-is-too-severe-understanding-bradycardia-in-eating-disorders-may-2022/ 

Strickland, K. (2022, September 22). 6 significant health risks of anorexia nervosa. Walden Eating Disorders. https://www.waldeneatingdisorders.com/blog/6-significant-health-risks-of-anorexia-nervosa/#:~:text=The%20malnutrition%20associated%20with%20anorexia,heart%20rate%20to%20conserve%20energy. 

Athlete’s Heart 

Patients with anorexia nervosa may indicate their low heart rate as having an “athlete’s heart.” Due to being extremely active, or even an actual athlete, the patient may believe they have the lower heart rate of a conditioned athlete. 

These individuals could be working out, but their malnourished/starved heart is not because of their “athletic condition.” If a physician were to ask a patient with severe anorexia nervosa to move, they would show an abnormal heart rate (orthostatic hypotension) just by standing up from a lying position. Additionally, the patient would have a spike in heart rate that a conditioned athlete would not have for the minimal exertion of going from resting to walking a short distance.

 “Moreover, ultrasound of the heart in these patients reveals small, thin heart chambers versus a normal chamber size seen in athletes. Unfortunately, few medical providers are well-trained in understanding this issue. The idea of the “athletic heart” is often accepted by healthcare professionals, whereas a trained eating disorder expert would recheck the pulse following minor exertion and recognize that bradycardia — appearing alongside a very low body weight — is a likely indication of anorexia nervosa.”(Mehler, MD, FACP, FAED, CEDS, 2022)

Mehler, MD, FACP, FAED, CEDS, P. S. (2022, May 1). Bradycardia: How severe is too severe? understanding bradycardia in eating disorders (May 2022). Robyn L. Goldberg. https://askaboutfood.com/bradycardia-how-severe-is-too-severe-understanding-bradycardia-in-eating-disorders-may-2022/ 

Contraindication of hormonal birth control (BC) when an ED client has amenorrhea 

An early sign of Anorexia Nervosa (AN) is amenorrhea, which is the absence of menstrual cycles. The result of low food intake or high physical activity disrupts the hypothalamic signals to the pituitary gland, which impacts the menstrual cycle. Since the body is enduring long periods of stress on every organ, another factor the individual with anorexia nervosa might face is a loss of BMD (bone mineral density). “The reason for bone density loss is considered to be related to the low body mass index, a low caloric intake, a low intake of calcium and vitamin D, low estrogen levels, low insulin-like growth factor 1 (IGF-1) levels, and cortisone supplements.” (Bergström et al., 2013) 

Physicians began treating patients with AN with estrogen treatment/ birth control to prevent loss of BMD, but in many studies, it was proven that oral therapies can not repair or prevent low BMD as improved nutrition is the most important factor for bone health in patients. In the studies, they all concluded that the lack of effect of estrogen on bone density is depressing the IGF-1 levels even more. Although there is a lot of evidence that hormone treatment does not prevent a loss of BMD, many clinicians still prescribe birth control to their patients, because of the induced menstrual cycles on the week “off.” These cycles give a false sense of health because they are masking the underlying issue. 

Bergström, I., Crisby, M., Engström, A.-M., Hölcke, M., Fored, M., Kruse, P. J., & Sandberg, A.-M. (2013, May 20). Women with anorexia nervosa should not be treated with estrogen or … https://obgyn.onlinelibrary.wiley.com/doi/10.1111/aogs.12178 

​​

DEXA z/t-scores

The DEXA  (Dual-Energy X-Ray Absorptiometry) score tests for an individual’s bone density, which is used to determine whether an individual has healthy bone density, osteopenia or osteoporosis.

For those ages 20-50, Z-scores less than -2 indicate low bone mineral density for age.

For those older than 50, T-scores between -1 and -2.5 denote osteopenia. Anything lower than -2.5 denotes osteoporosis. 

Bone Health & Eating Disorders. Home – InsideOut Institute. (n.d.). https://insideoutinstitute.org.au/resource-library/bone-health-eating-disorders#:~:text=The%20DEXA%20scan%20generates%20a,(Robinson%20et%20al%202019) 

Why are these scores important regarding disordered eating? 

These scores show decreased bone mineral density and strength as the eating disorder progresses. Weight is the most consistent predictor of BMD at all skeletal sites (Grinspoon et al, 2000), associating Anorexia Nervosa with low bone mineral density and an increased risk of fracture (Fazeli & Klibanski, 2018). There is a correlation in both males and females between low body weight and low bone mineral density. 

Bone Health & Eating Disorders. Home – InsideOut Institute. (n.d.). https://insideoutinstitute.org.au/resource-library/bone-health-eating-disorders#:~:text=The%20DEXA%20scan%20generates%20a,(Robinson%20et%20al%202019) 

Blind Weight

A blind weight is when the patient is unable to see, or know, their weight. Often the provider will ask the patient to step on the scale backward so they are not facing the values, or using a scale that the provider can see the weight but the patient cannot. 

Why is this important?

Most individuals with this illness put a high value on the number on the scale, and strive to be a specific number or to have some sort of control. This number can also be a trigger for the eating disorder to resurface or intensify. The importance of taking a blind weight, and not telling the patient any descriptors of their weight can be beneficial to their recovery because the number on the scale is something that can alter their behaviors and consume their thoughts. By taking a blind weight it allows them to be able to engage more in their recovery. Because of the societal pressure on body size, blind weights can be beneficial to most patients that come through your doors, ED or not. 

Wood, C. (2023, February 23). What is a blind weight?. Christine Wood MD. https://www.christinewoodmd.com/post/what-is-a-blind-weight 

Levels of Treatment: 

Higher Level of Care (HLOC)

There is a hierarchy to disordered eating treatment. A HLOC is indicated for patients needing more than weekly sessions with eating disorder professionals, and referring to anything above outpatient level care. HLOC is for patients with more severe functional impairment and symptoms. HLOCs provide a safe and structured environment for patients who are dealing with these life-threatening disorders. 

Anderson, L. K., Reilly, E. E., Berner, L., Wierenga, C. E., Jones, M. D., Brown, T. A., Kaye, W. H., & Cusack, A. (2017, June 27). Treating eating disorders at higher levels of care: Overview and challenges – current psychiatry reports. SpringerLink. https://link.springer.com/article/10.1007/s11920-017-0796-4 

Outpatient (OP)

Outpatient care is the lowest level of care / least intensive. On a basic level, the individual will be seeing a dietitian, therapist, and possibly others on their treatment team on a regular (typically weekly) basis. Outpatient treatment may include other providers including psychiatrists, recovery coaches, and others. They should also be seeing their primary care provider on a regular basis (frequency depending on the needs of the individual). 

Intensive Outpatient Program (IOP)

This treatment is offered approximately three hours a day ranging from 3-5 days a week. This type of program will best suit patients who are ready to be more independent in their lives. IOP typically includes meal support, group therapy, individual therapy, dietary sessions, and medication management. Many programs offer both in-person and virtual options of IOP. 

Partial Hospitalization Programming (PHP)

A step up from IOP, PHP is offered  6-8 hours a day five to six days a week. This is for individuals who need more supervision to complete their meals and avoid using behaviors. In these sessions, patients are still receiving individual and group therapy, meal support, nutritional counseling, and medical monitoring. 

Simpson, C. C., Towne, T. L., Karam, A. M., Donahue, J. M., Hadjeasgari, C. F., Rockwell, R., & Kaye, W. H. (2021). Predictors of Stepping Up to Higher Level of Care Among Eating Disorder Patients in a Partial Hospitalization Program. Frontiers in psychology, 12, 667868. https://doi.org/10.3389/fpsyg.2021.667868

Residential Treatment Center (RTC)

The patient will be living at the treatment facility 24/7 for often for a month or longer, depending on the client. This treatment incorporates the same services as IOP and PHP, plus more activities and greater medical oversight. The benefit of residential is the around-the-clock supervision to ensure safety and break behavioral patterns. It is ideal for a client to step down to PHP and/or IOP following their stay at RTC. To help them integrate back into “real life.”

Inpatient hospitalization

Is designed for eating disorder patients with medical instability. In this form of treatment, patients will not receive much, if any, psychological care, the focus is to medically stabilize the patient. This may include IV fluids, tube feeding, TPN (IV nutrition), and other medical procedures. Patients will be monitored for cardiac complications and refeeding syndrome. 

Treatment Team

In the great majority of eating disorder cases, there is a need for a specialized treatment team. Because eating disorders are complex illnesses involving both the brain and the body, the team may include a primary care physician, an individual therapist, a registered dietitian, a psychiatrist, and a family therapist. The treatment must work collaboratively and communicate to give the best service to the individual. 

Ideally, all of these team members are highly experienced and specialized in the treatment of eating disorders. Finding these providers is something The Broadway Dietitian can help with at all levels of care. 

Eating disorder treatment team: Alliance for Eating Disorders Awareness. National Alliance for Eating Disorders. (2023, July 10). https://www.allianceforeatingdisorders.com/members-of-treatment-team/ 

Treatment Philosophies

Intuitive Eating (IE)

Popularized by dietitian authors Evelyn Tribole, and Elyse Resch, Intuitive Eating is, “an adaptive form of eating characterized by a strong connection with internal physiological hunger and satiety cues. Those who eat intuitively are not preoccupied with food or dieting and do not label certain foods as ‘good’ or ‘bad’. The goal of intuitive eating is to reconnect our nature of listening to our cues of when we are hungry or full. Intuitive eating is mainly about trusting our bodies, because they will signal what is needed to fulfill our needs.”

Mauldin, K., May, M., & Clifford, D. (2022). The consequences of a weight-centric approach to healthcare: A case for a paradigm shift in how clinicians address body weight. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition, 37(6), 1291–1306. https://doi.org/10.1002/ncp.10885

Health at Every SizeⓇ (HAES)

This principle focuses on health not weight. The approach of HAES is to have confidence in every body, whether that is a larger or smaller body. HAES focuses on not using weight as a measurement for health because there are so many other factors to determine the health status of an individual. This approach strives for all individuals to enjoy a healthy-lifestyle, and to have access and dignity in healthcare. HAES focus is to allow people to trust their bodies and what needs their body is signaling.

In a nutshell, HAES is “A paradigm that supports “size- acceptance, to end weight discrimination, and to lessen the cultural obsession with weight loss and thinness” promotes “balanced eating, life-enhancing physical activity, and respect for the diversity of body shapes and sizes.” 

Mauldin, K., May, M., & Clifford, D. (2022). The consequences of a weight-centric approach to healthcare: A case for a paradigm shift in how clinicians address body weight. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition, 37(6), 1291–1306. https://doi.org/10.1002/ncp.10885

Non-Diet

The Non-Diet approach rejects diet culture/fad diets because they are typically too restrictive, and do not last long term. In fact, research shows that 95% of diets fail. By fail we mean the person cannot maintain the diet, and gains the weight back (usually plus some). This causes dieters to be on an un-ending cycle of dietitng, failing, and dieting again, leaving them defeated and unmotivated. Dieting is also the #1 precursor to developing an eating disorder. 

Instead of that, the Non-Diet approach focuses on healthy long-term habits. This is a “diet” that has no restrictions, and allows an individual to have freedom over an eating pattern. 

This approach, “emphasizes “eating in response to physiological dues, i.e. using hunger and satiety as regulators of food intake as opposed to dietary restraint, and enhancing body acceptance, regardless of whether an individual is successful at weight control.”

Mauldin, K., May, M., & Clifford, D. (2022). The consequences of a weight-centric approach to healthcare: A case for a paradigm shift in how clinicians address body weight. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition, 37(6), 1291–1306. https://doi.org/10.1002/ncp.10885

PhD, J. C. (2022, February 1). Why diets often don’t lead to long-term weight loss – what to focus on instead: Ohio State Health & Discovery. Ohio State Health and Discovery. https://health.osu.edu/wellness/exercise-and-nutrition/that-diet-probably-did-not-work#:~:text=According%20to%20the%20latest%20weight,people%20maintain%20that%20weight%20loss. 

Mindful eating

Mindful eating is relying on the body’s senses and to have the freedom to have any food choice to their desire in moderation. The term mindfulness means to be paying attention, and being present within the moment. In simple terms, mindful eating is an approach to pay more attention to the different emotions of food. By focusing on the difference between physical and emotional hunger the individual can acknowledge the emotions around food instead of judging the feelings. This approach allows the individual to become more attuned with their body, because this principle is not built on strict rules. 

“An approach to eating that supports becoming aware of “thoughts, feelings, and physical sensations related to eating, reconnecting with our innate inner wisdom about hunger and satiety.” It is conceptualized as “being aware of the present moment when one is eating, paying close attention to the effect of the food on the senses, and noting the physical and emotional sensations in response to eating.”

Mauldin, K., May, M., & Clifford, D. (2022). The consequences of a weight-centric approach to healthcare: A case for a paradigm shift in how clinicians address body weight. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition, 37(6), 1291–1306. https://doi.org/10.1002/ncp.10885

Robinson, L. (2023, March 1). Mindful eating. HelpGuide.org. https://www.helpguide.org/articles/diets/mindful-eating.htm 

Nelson J. B. (2017). Mindful Eating: The Art of Presence While You Eat. Diabetes spectrum : a publication of the American Diabetes Association, 30(3), 171–174. https://doi.org/10.2337/ds17-0015

All Foods Fit

The All Foods Fit Model is the idea that all foods can fit into a person’s daily meal planning and preparation. The model does not support the idea of categorizing foods into black or white categories–such as labeling foods as “good” vs. “bad” or “healthy” vs. “unhealthy.” The model does not support engaging in fad or elimination diets, and “legalizes” all foods that the individual is not allergic to.

Dmckenzie. (2022, May 18). The all foods fit model to prevent disordered eating < marvelous minds. Marvelous Minds. https://www.marvelousminds.net/prevent-disordered-eating/ 

This blog was just a glimpse of knowledge as to what eating disorder specialists know. As stated earlier in this blog, many of us are not educated on the many layers involving eating disorders. It is such a complex mental illness and the specialists are here to help! Understanding just a few of the different terms, treatments, and additional knowledge about eating disorders can help specialists give a patient/client a step to recovery even sooner! 

The purpose of this blog is to give more awareness to make an impact on those affected by this complex mental illness. Eating disorders can be brought to remission and prevented with the right treatment and knowledge!!

If you need help finding appropriate treatment for yourself, or a client – please reach out! I offer consultation and education to other healthcare professionals, as well.

What is therapeutic treatment consulting?

This is something I didn’t even know existed until I was already doing it! Therapeutic consulting is a specialty service in which experienced clinicians help clients find the best therapeutic program for their unique needs. 

Popular in educational consulting for therapeutic schools and for substance use programs, this type of consulting relies on the unaffiliated consultant having a large network of programs (and constantly growing that network) that they visit and check in on to see what services they offer and philosophies they use. 

Therapeutic consultants assess the clients’ needs, look at resources such as insurance and location, and provide “matchmaking” for the client and program.

As an eating disorder therapeutic consultant, the professional must have an eating disorder clinical background (for me that is a Master’s level Registered Dietitian Nutritionist, Certified Eating Disorder Specialist – Consultant credential, and over 10 years of work experience in the ED field), and knowledge of the types of treatments that work for different types of people and diagnosis. 

What does this look like more specifically in my business?

As your eating disorder therapeutic treatment consultant, I come with over 10 years of experience in the eating disorder treatment world as a certified eating disorders specialist registered dietitian who had had clients come from and go to many treatment programs. Additionally, I worked in outreach and business development and was able to form relationships with hundreds of providers and programs throughout the country.

Now I work with you to provide a high touch service, matching your unique needs for eating disorder treatment with providers and programs nationwide. 

When you work with me you will get:

• A comprehensive assessment of your unique needs for eating disorder treatment including, but not limited to: your current diagnosis, your personality, special needs (like time for school or location), your insurance plan (if applicable), etc.
• Follow-up with your current providers to get information on your case
• A plan of action based on your initial assessment (what you need)
• Program and/or provider recommendations
• Going over your questions/what to expect at this level of care
• Vetting of programs 
• Help with organizing paperwork/pre-admissions needs 
• Step-down (follow-up) planning
• Education about eating disorders (whatever is needed; this is mainly for the family members)

Why a consultant versus asking friends for recommendations?

I will ask a lot of questions (and encourage you to!) to get a thorough understanding of you or your child. This is different than asking your friend or family member for help, as I can be an available and objective sounding board who can make expert recommendations and referrals. 

From the Therapeutic Consulting Association:

Not to mention, it’s a LIFE SAVING service!

Eating disorders don’t magically “get better.” Time is of the essence, and getting the wrong treatment can actually set someone back in dangerous ways. The more times someone bounces in and out of treatment, the more likely they are to gain new disordered behaviors and medical complications. 

Do it right the first time. 

If this sounds like it would be a help to you, apply for my consulting today. I only take on 3 clients at a time, so what are you waiting for?

Transcript of my interview with Amy of Dancing With Ed, on May 11, 2022. 

This is about one of my experiences with diet culture in the theatre – this was community theatre! Trigger warning: Diet talk.

Q. What made you want to do a Share My Story interview?

A. I want to tell a story that I don’t think has really been told before. The story I am going to be
telling today is not only about being a performer who has struggled and recovered from their own ED, but an ED professional and dietitian getting stuck in diet culture during a show. I don’t think that story has really been told. There aren’t very many dietitians within this type of industry that are still performing. Also, even when you know better, even when you’re doing really well, diet culture is still so pervasive that we can kind of get pulled in even when we don’t go all the way. I think it is important to say that this is a thing and that we are still susceptible to the temptation of diet culture and wanting to fit in.

Q. When did you start dancing?

A. I started dancing when I was three. My mom had been a dancer, not professionally but for fun, from her twenties on, so she wanted to make sure that I got into dance. When I was around ten she had enough knee issues that she wasn’t able to keep going anymore, but for a few years we were able to dance at the same studio. She was the helper in my class, so it was something that we got to bond over. Up until I was 13 I did tap, jazz, ballet, and lyrical, just the combo classes. Around the time I was 12/13, I was feeling ready to move on, so I took a couple years off. I was really into horses, so my whole physical activity shifted to horses. When I was 16, I was really missing dance, but I was never going to be a big bun-head type. I didn’t really want to go back to ballet. My studio was offering beginning hip hop and breakdancing. I tried that for about three months. It was not a good look for me. It was fun but ended very quickly. Then, my studio started offering ballroom classes, and that is the thing that really stuck with me. I got into ballroom. I’ve got to say, I think my first love was east-coast swing. That was the first type of dance that I really got into, especially going into high school and college. I was doing swing, ballroom, latin, and salsa. Through college, I was doing all of the social dances. I started the swing dance club, and my dance partner and I basically taught anyone that would show up. We did lots of lifts and aerials which were my specialty throughout college. This was also when I was in the midst of my ED. When I moved onto my next college, I did competitive lindy hop there and worked my way up into being the president of the salsa dance club. Moving from a small school to a large school really became part of my identity as a dancer. Being in that large school of about 60,000 students and working my way up through the club made me feel like people really truly knew me as a dancer and that was pivotal for me. When I moved to California, I knew to look for the salsa club at the university there (Cal Poly) where I could find other people to dance with.

I got married and started really getting into work so I wasn’t able to dance as much as I wanted to. Eventually my schedule opened up more and I was able to start auditioning for shows. Musical theater was really my thing. I loved the flashy tap numbers. So I got into my first show out here in 2014. This is the show I will mostly be talking about. This got me back into studio dance and even ballet classes, which I hadn’t been in for almost 16 years.

Q. Was it in your teen years when you started struggling with disordered eating?

A. I would say highschool was when I started being more aware of body image. My childhood
through middle school, I wasn’t really a popular kid by any means but I really didn’t think about my body at all. That was never a part of it for me. I know I didn’t dress like the cool kids, so that was more of an insecurity for me. For me it started more in highschool, especially my senior year and then carried into college. My first two years of college were probably the peak of my ED, which never got officially diagnosed, but was definitely a restrictive disorder. I would call it an unspecified ED (OSFED), heading towards anorexia, was what I was struggling with.

Q. Did dance challenge the body image and ED? Did it help? How did those two interact? (TW: mentions over exercise and calorie burning)

A. I don’t think dance challenged it. I don’t think my ED came from dance or being in the mirror, or other things that you would typically see with dancers. It was definitely more the comments from peers and a control issue that stemmed from the unknown of college. Dance definitely contributed as an over-exercise piece for me. At the peak of it, I remember I was dancing almost everyday. I wasn’t like an exercise person. I didn’t get into exercise or start going to the gym until the end of college and I actually became a personal trainer because of that mindset. I was definitely trying to “burn” calories. I was rehearsing a lot without fueling my body enough. After we would go out swing dancing, sometimes we would go out to a restaurant like Applebee’s, and people would order appetizers and full meals while I would get a salad or nothing. It was that kind of thing. It wasn’t that dance was the cause of it. It was more my means to restrict. Now that I work with more ED clients, I realize that I wasn’t restricting as a lot of people do. I was still getting the minimum amount that I was making sure I ate. It was not technically enough but it was more than I see a lot of people doing, but I was definitely trying to exercise it away through dance. 

Q. Were you aware of it at the time that you weren’t giving yourself what you needed?

A. Probably on a subconscious level, but I wasn’t letting myself get there. When I was at the peak of my restriction, I was in my second year of college. I hadn’t yet switched to my nutrition major, but I was starting to get more of an awareness of that. The reason I actually became a nutrition major was actually because of this disordered obsession with food. I was reading all of the diet articles in women’s magazines, I was reading all of the labels on nutrition facts, I was educating myself but not knowing what I was actually shooting for. So it kind of became that game of, I was tracking all of my calories, I was tracking my weight, but I didn’t know what my goals were. I wasn’t aiming for a certain number of calories or anything like that, it was more of a weird learning process? I don’t know. I just became obsessed with learning about it which then led me to become a nutrition major. Then fast forward, being a nutrition major was probably the best thing that could’ve happened to me. Which is not always the case for people. I have a lot of nutrition students as clients now. For me, I believe so strongly in science that when the facts kept getting driven into me such as: you need this many calories to survive, your body does this with food, this is how your metabolism works, this is why these different nutrients interact and do these positive things, when you are exercising this much you need to eat this much, sugar is not evil.. All the things I was learning from a scientific standpoint was probably a major major part of my recovery. Unfortunately, this isn’t the case for a lot of people that I see. The ED brain tends to push a lot of logic out the window. Maybe I wasn’t far gone enough for that to happen. I think I was really lucky. I had a lot of good social support and stuff like that which really helped. When I was deep in it, I didn’t really know what I was doing and I didn’t really have a set goal in mind. It was more just, don’t be the person that you think people will make fun of.

Q. Regarding underlying stressors, you mentioned how when you moved to California, you wanted to fit in and make friends and be part of something. So you were able to audition and get into this show. Tell us what happened from there.

A. I’m not going to mention the name of the town or the show, because I want to protect them. I don’t think what happened was anyone’s fault. It is more of a generic story, it has nothing to do with the theater company. They probably have no idea that any of this happened backstage. So when I was auditioning, it was the second show I had auditioned for, and I hadn’t really done a musical since high school. It had been eight years since I had been in a show. At that time when I was in high school I had no confidence in myself, which was probably a big reason why I hadn’t done shows in that long. The low self-esteem was probably a large part of the ED starting then as well. So for me getting into this show with a big dance role, especially after not being in studio dance for a long long time, I was both shocked and like ‘sweet, yeah I’m good! Everyone wants me!’ It was a great feeling. It boosted my confidence. And despite what I am about to talk about, I had a really great experience with the show. It was exactly what I had needed to restart a lot of passions of my life. It got me back into dance, theater, and voice lessons. I don’t know what I would be doing today if I hadn’t gotten into this show. So I am so grateful for the experience and the friends that I met.

As I begin to tell the story, I want to share the parts that are more relevant to your channel. I want to get the message across that EDs are also prevalent in spaces like musical theater, just as much as in other kinds of dance styles. We know that it is really prominent in ballet which is true, but EDs are also very prevalent in all other kinds of performing arts. I want to talk about how that falls through in musical theater and community theater.

It was a very dance heavy show. I was swinging for three of the leads. Meaning I was kind of like an understudy for a few parts. We have to learn all of the material for the people that we are swinging for. I was in all of the ensemble numbers and I also learned how to swing for the lead roles. I was dancing a lot. Our weekend rehearsals were like eight hours. I got in really good shape, and I was fueling myself through this. The whole rehearsal process was great. There was nothing red-flaggy throughout the rehearsal process. We were snacking and having a good time. We had a pretty good run. We had about five shows per weekend or so. I want to say we did about 28 performances. We started getting into dress rehearsals and stuff. We had really good costume fitters who made the costumes fit us really well. They were pretty tight but I felt pretty good in them. I’m trying to figure out how this happened. It wasn’t apparent that there were disordered behaviors going on. It was more the older women in the company were talking about wanting to feel their best in the costumes. Some of them proceeded to get a FaceBook group together to start working out and losing weight as a team. I am not sure why I ended up being a part of this. There were about three of four of us in total out of the very large cast along with a few others outside the cast who joined. It was like a six or eight week program that we started during tech week and it continued a little bit after the show. I totally got pulled in. I didn’t think I needed to lose weight even. It was more like I thought the diet was a healthier more inclusive program. In hindsight, I think I really wanted to make more friends and fit in, and this was a way to do that—especially with this older dancer that I really looked up to.

So at this time I was a Registered Dietitian. I knew diets didn’t work. I didn’t even have a poor mindset about my body image at the time. But there was definitely still the presence of diet culture in the rehearsal space that wasn’t overt. It didn’t come from a director telling us that we needed to lose weight, it wasn’t shaming, it was very subtle—and I still joined in.

Q. Most of the time, diet culture is very subtle. It’s the messages that it puts out that are very sneaky. It makes you believe that it is going to help you be your best self and add to your life in positive ways. But from my experience of being a “professional dieter” in my past, it always backfires. It always ended up destroying my self esteem. What I was looking for in connection, I in turn felt more isolated. So, when did you realize and decide, I don’t want to do this anymore?

A. I would say about four or five weeks into the program. At this point, I wasn’t weighing myself, I knew that wasn’t a good thing for me. I just wanted to look good in my costume and life. It started getting harder and I was working a job where I would bring food into my office. I started to feel awkward about the foods that I was bringing. Like, I’m working as a dietitian and all I’m bringing for lunch is a protein shake and a banana?! It felt kinda awkward and I didn’t want people seeing that. At home it is easier to just do what I needed to do to follow the program, but around people it felt shameful. So I started cheating on the diet and switching things around to appear more normal. It just wasn’t working for me.

Q. This sounds similar to the way we tend to form ED habits around other people to appear normal. Did this experience trigger you in any way or bring back feelings from when you struggled previously?

A. This far out, it is difficult to remember what went through my brain at that time. It was 2014 haha and now it is 2022.

Q. That totally makes sense. Maybe it’ll be easier to answer this. What was an inner strength that you accessed that helped you step back away from diet culture this time around?

A. I think it was probably two fold. One was my education background of “I had just been through all of this.” Also at this time, I hadn’t done therapy for this genre of struggle yet. That was to come later, but behaviorally I was doing well, even though there was still the mindset of the ED that was still present—which I think is why I was susceptible to this. Again, I had been well nourished at this point. I had been eating very well and I knew the science of it. So at this point the science was in the back of my head telling me that this diet wasn’t serving me well. I ended up writing about it in the FaceBook page saying that the diet went too far, encouraging others if they wanted to, to join me in a different way of eating which was closer to what our bodies needed. I was trying to help pull others out of the diet mindset as well as a way to listen to what I knew was best for myself while still trying to be a part of the group. Eventually I just had to leave because it was hard to do both. There was too much diet chatter that I couldn’t stand. I honestly don’t know where that personal strength came from because if it had been a few years prior, I would’ve really gotten stuck in it. Part of me was strong enough to pull myself out of it before the consequences snowballed. I think the other piece that helped immensely that a lot of other people don’t have, is that I started working with ED recovery patients at work which showed me glimpses of what I had gone through and what I could potentially go through if I didn’t change what I was doing. Every day I was preaching about body confidence and how to eat enough to fuel your body without restriction. And when I say those things, that is what I truly believe. I am not acting. Over the years, not just in this instance, when I talk to people about their life and how amazing they are and how their bodies deserve the best nutrition, it impacts my own perception of my body image. The more I say it to other people with full belief, the more I begin to believe it for myself.

Check back for blogs, vlogs, and follow me on instagram @thebroadwaydietitian and my YouTube channel (click image to go to it).